A nationwide survey of Antimicrobial Stewardship in Pediatric Intensive Care Unit: implementation notes from the Brazilian underground.

A multicenter diagnostic study was conducted to investigate the implementation of an Antimicrobial Stewardship Program in Brazilian Pediatric Intensive Care Units. The analysis unveiled the main implementation impediments of the Antimicrobial Stewardship Program such as the lack of professionals and resources available to the program.

Artemisinin resistance-associated gene mutations in Plasmodium falciparum: A case study of severe malaria from Mozambique.

BACKGROUND: The effectiveness of artemisinin-based combination therapies (ACT) in treating Plasmodium falciparum, is vital for global malaria control efforts, particularly in sub-Saharan Africa. The examination of imported cases from endemic areas holds implications for malaria chemotherapy on a global scale. METHOD: A 45-year-old male presented with high fever, dry cough, diarrhoea and generalized muscle pain, following a two-week trip to Mozambique. P. falciparum infection with hiperparasitemia was confirmed and the patient was treated initially with quinine and doxycycline, then intravenous artesunate. To assess drug susceptibility, ex vivo half-maximal inhibitory concentration assays were conducted, and the isolated P. falciparum genome was deep sequenced. RESULTS: The clinical isolate exhibited elevated ex vivo half-maximal inhibitory concentration values to dihydroartemisinin, lumefantrine, mefloquine and piperaquine. Genomic analysis identified a I416V mutation in the P. falciparum Kelch13 (PF3D7_1343700) gene, and several mutations at the Kelch13 interaction candidate genes, pfkics (PF3D7_0813000, PF3D7_1138700, PF3D7_1246300), including the ubiquitin carboxyl-terminal hydrolase 1, pfubp1 (PF3D7_0104300). Mutations at the drug transporters and genes linked to next-generation antimalarial drug resistance were also present. CONCLUSIONS: This case highlights the emergence of P. falciparum strains carrying mutations in artemisinin resistance-associated genes in Mozambique, couple with a reduction in ex vivo susceptibility to ACT drugs. Continuous surveillance of mutations linked to drug resistance and regular monitoring of drug susceptibility are imperative to anticipate the spread of potential resistant strains emerging in Mozambique and to maintain effective malaria control strategies.

Mycoplasma pneumoniae Infection With Cavitated Lung Lesions: A Case Report.

Mycoplasma pneumoniae (MP) is a common etiologic agent involved in community-acquired atypical bacterial pneumonia. In severe cases, M. pneumoniae can cause cavitated lung lesions. We describe the case of a 55-year-old male seen at the emergency department with complaints of cough, fever, dyspnea, pleuritic chest pain, nausea, anorexia, asthenia, and night sweats. Cavitated lesions in the upper lobes of both lungs were documented on thoracic computed tomography (CT). An extensive investigation ruled out several infectious and non-infectious causes. The only positive result was a high immunoglobulin M (IgM) titer for M. pneumoniae. The patient was treated with azithromycin and exhibited rapid clinical improvement. Three months later, a repeat thoracic computed tomography showed the resolution of the cavitated lesions. In this rare case of M. pneumoniae pneumonia with cavitated lesions, early identification of the etiologic agent and prompt antibiotic therapy led to the resolution of the cavitated lung lesions.

Spinal Cord Infarction Presenting as Right-Sided Upper Back Pain: A Case Report.

Spinal cord infarction is a very rare event with a wide variety of symptoms at presentation. We describe the case of a 39-year-old man who presented to the emergency department with atypical chest pain. The initial investigations were non-diagnostic, and the patient was admitted for surveillance. On the second day of admission, he developed neurologic deficits; a second computed tomography showed a medullary infarction at levels C5-T2. Dual antiplatelet therapy was initiated. An extensive study on the underlying etiology was performed. It was considered to be an idiopathic event. The patient was discharged to a rehabilitation center for bladder training and motor training due to quadriplegia level D on Asia Impairment Scale with a C6 neurological level with left predominance and a hand grip deficit that disabled him to grab objects. This case report describes a rare event with a biphasic ictus at presentation. It highlights the difficulty in managing this pathology because of limited clinical data.

Isolated Left Ventricular Noncompaction Presenting With Heart Failure With Reduced Ejection Fraction and Intrahospital Cardiac Arrest: A Case Report and Literature Review.

Left ventricular noncompaction (LVNC) is characterized by a bilayered appearance of the myocardium with excessive trabeculations and deep intertrabecular recesses. Manifestations of this condition are widely variable, ranging from incidental findings in asymptomatic individuals to symptomatic heart failure, conduction abnormalities, tachyarrhythmia, and sudden cardiac death. Heart failure, ventricular arrhythmias, and systemic embolisms are the most frequent cardiovascular complications. We describe a case of a 53-year-old woman who presented to the emergency department with acute presentation of previously unknown heart failure with reduced ejection fraction and was diagnosed with LVNC. During hospitalization, the patient presented a defibrillated cardiac arrest rhythm, which was resuscitated after six minutes, and then treated with the placement of an implantable cardioverter defibrillator. After two years of follow-up with optimized medical therapy, the patient currently is asymptomatic and with a preserved ejection fraction.

Quincke's Disease Presenting After Cocaine Exposure.

Quincke's disease is a very rare form of upper airway angioedema, and it is characterized by a well-localized edematous reaction. Its epidemiology is not documented due to the rarity of this condition. Causes include allergic reactions, infectious diseases, and trauma, among others.  This article describes a rare case of a 27-year-old man who presented to the Emergency Department with isolated uvular edema associated with cocaine exposure.

Metastatic Lung Cancer with Multiorgan Thrombosis and Budd-Chiari Syndrome: A Rare Case.

Arterial thrombosis and Budd-Chiari syndrome are rare conditions in lung cancer patients. We report the case of a 53-year-old woman who presented with respiratory symptoms, lumbar pain, weight and appetite loss, and an x-ray showing a lung nodule and diffuse micro-opacities. She was diagnosed with lung neoplasia with extensive lung, liver, lymph node and bone metastases. After discharge she was readmitted with a respiratory infection, and as her condition deteriorated, computed tomography was performed and revealed ischaemic areas in the spleen and kidney, and venous thrombosis, related to Budd-Chiari syndrome, with hepatic ischaemia. Despite hypocoagulation, her clinical condition deteriorated and she died soon afterwards. LEARNING POINTS: Acute ischaemic arterial events are rare in cancer patients.Budd-Chiari syndrome associated with lung cancer is rare.Both presentations have a poor prognosis, so early diagnosis and intervention are imperative.

A Rare Case of Sarcoidosis With Urologic Symptoms As the Presenting Feature.

Sarcoidosis is a multisystem idiopathic disease that can affect virtually any organ of the human body. However, genitourinary tract involvement is rare. We describe the case of a 33-year-old man with post-coital right scrotal pain. Scrotal ultrasound showed two vascularized nodular lesions in the right testicle and one in the left. A thoracic and abdominopelvic computed tomography scan showed micronodular infiltrate in the liver, spleen, lungs, and millimetric retroperitoneal and iliac lymph nodes. Levels of alpha-fetoprotein and human chorionic gonadotropin beta were normal. On positron emission tomography, the previously documented micronodular infiltrate exhibited features suggestive of an inflammatory etiology. The aspiration cytology of an iliac ganglion was described as normal, with no malignant cells. A liver biopsy revealed non-caseating epithelioid granulomas characteristic of granulomatous hepatitis. After exclusion of other causes of granulomatous inflammation, conjugation of clinical and histological features led us to the diagnosis of sarcoidosis with pulmonary, hepatic, splenic, and genitourinary involvement. This clinical report describes one of the rare occasions when the reproductive tract is affected by sarcoidosis and is the first organ to present signs of involvement by the disease, which reinforces the importance of considering sarcoidosis in the differential diagnosis of urologic conditions. The diagnosis of testicular sarcoidosis is challenging and the issue of its impact on fertility is particularly important.

Factors associated with bronchopulmonary aspiration: a national-based study / Factores asociados con la aspiración broncopulmonar: estudio de base nacional / Fatores associados à aspiração broncopulmonar: estudo de base nacional

ABSTRACT Objectives: to determine the prevalence of bronchopulmonary aspiration in the Brazilian scenario, the factors associated with the incident and the variables associated with death. Methods: a cross-sectional and analytical study, carried out from analysis of notifications of incidents related to bronchopulmonary aspiration of the Health Surveillance Notification System, from January 2014 to December 2018. Results: of the 264,590 notifications, 553 referred to aspiration, whose prevalence rate was 0.21%. There was an association between the event and age, ethnicity, main medical diagnosis, country region, service type, health unit and consequences for patients. Furthermore, four independent predictor variables for death were found: living in the North or South regions, being elderly and receiving healthcare at night. Conclusions: the prevalence rate of bronchopulmonary aspiration was small, but with a negative impact on patients.

RESUMEN Objetivos: determinar la prevalencia de broncoaspiración en el escenario brasileño, los factores asociados al incidente y las variables asociadas a la muerte. Métodos: estudio transversal y analítico, realizado a partir del análisis de notificaciones de incidentes relacionados con la aspiración broncopulmonar del Sistema de Notificación de Vigilancia Sanitaria, de enero de 2014 a diciembre de 2018. Resultados: de las 264.590 notificaciones, 553 se refirieron a aspiración, cuya tasa de prevalencia fue del 0,21%. Hubo asociación entre el evento y la edad, etnia, diagnóstico médico principal, región del país, tipo de servicio, unidad de salud y consecuencias para el paciente. Además, se encontraron cuatro variables predictoras independientes de muerte: vivir en la región Norte o Sur, ser anciano y recibir atención médica por la noche. Conclusiones: la tasa de prevalencia de aspiración broncopulmonar fue pequeña, pero con impacto negativo en los pacientes.

RESUMO Objetivos: determinar a prevalência de aspiração broncopulmonar no cenário brasileiro, os fatores associados ao incidente e as variáveis associadas ao óbito. Métodos: estudo transversal e analítico, realizado a partir da análise das notificações de incidentes relacionados à aspiração broncopulmonar do Sistema de Notificações em Vigilância Sanitária, no período de janeiro de 2014 a dezembro de 2018. Resultados: das 264.590 notificações, 553 se referiam à aspiração, cuja taxa de prevalência foi de 0,21%. Houve associação entre o evento e idade, etnia, diagnóstico médico principal, região do país, tipo de serviço, unidade de saúde e consequência para o paciente. Ainda, verificaram-se quatro variáveis preditoras independentes para o óbito: residir na Região Norte ou Sul, ser idoso e receber atendimento à saúde no período noturno. Conclusões: a taxa de prevalência de aspiração broncopulmonar foi pequena, mas com impacto negativo para os pacientes.

Factors associated with bronchopulmonary aspiration: a national-based study.

OBJECTIVES: to determine the prevalence of bronchopulmonary aspiration in the Brazilian scenario, the factors associated with the incident and the variables associated with death. METHODS: a cross-sectional and analytical study, carried out from analysis of notifications of incidents related to bronchopulmonary aspiration of the Health Surveillance Notification System, from January 2014 to December 2018. RESULTS: of the 264,590 notifications, 553 referred to aspiration, whose prevalence rate was 0.21%. There was an association between the event and age, ethnicity, main medical diagnosis, country region, service type, health unit and consequences for patients. Furthermore, four independent predictor variables for death were found: living in the North or South regions, being elderly and receiving healthcare at night. CONCLUSIONS: the prevalence rate of bronchopulmonary aspiration was small, but with a negative impact on patients.

Nanopore Genome Sequencing and Variant Analysis of the Susceptible Candida auris Strain L1537/2020, Salvador, Brazil.

Candida auris has been reported worldwide, but only in December 2020, the first strain from a COVID-19 patient in Brazil was isolated. Here, we describe the genome sequence of this susceptible C. auris strain and performed variant analysis of the genetic relatedness with strains from other geographic localities.

Axillary Digital Thermometers uplifted a multidrug-susceptible Candida auris outbreak among COVID-19 patients in Brazil.

OBJECTIVES: To describe the first outbreak of Candida auris in Brazil, including epidemiological, clinical and microbiological data. METHODS: After the first Candida auris-colonised patient was diagnosed in a COVID-19 ICU at a hospital in Salvador, Brazil, a multidisciplinary team conducted a local C. auris prevalence investigation. Screening cultures for C. auris were collected from patients, healthcare workers and inanimate surfaces. Risk factors for C. auris colonisation were evaluated, and the fungemia episodes that occurred after the investigation were also analysed and described. Antifungal susceptibility of the C. auris isolates was determined, and they were genotyped with microsatellite analysis. RESULTS: Among body swabs collected from 47 patients, eight (n = 8/47, 17%) samples from the axillae were positive for C. auris. Among samples collected from inanimate surfaces, digital thermometers had the highest rate of positive cultures (n = 8/47, 17%). Antifungal susceptibility testing showed MICs of 0.5 to 1 mg/L for AMB, 0.03 to 0.06 mg/L for voriconazole, 2 to 4 mg/L for fluconazole and 0.03 to 0.06 mg/L for anidulafungin. Microsatellite analysis revealed that all C. auris isolates belong to the South Asian clade (Clade I) and had different genotypes. In multivariate analysis, having a colonised digital thermometer was the only independent risk factor associated with C. auris colonisation. Three episodes of C. auris fungemia occurred after the investigation, with 30-day attributable mortality of 33.3%. CONCLUSIONS: Emergence of C. auris in Salvador, Brazil, may be related to local C. auris clade I closely related genotypes. Contaminated axillary monitoring thermometers may facilitate the dissemination of C. auris reinforcing the concept that these reusable devices should be carefully cleaned with an effective disinfectant or replaced by other temperature monitoring methods.

Emergence of Candida auris in Brazil in a COVID-19 Intensive Care Unit.

In December 2020, Candida auris emerged in Brazil in the city of Salvador. The first two C. auris colonized patients were in the same COVID-19 intensive care unit. Antifungal susceptibility testing showed low minimal inhibitory concentrations of 1 µg/mL, 2 µg/mL, 0.03 µg/L, and 0.06 µg/mL for amphotericin B, fluconazole, voriconazole, and anidulafungin, respectively. Microsatellite typing revealed that the strains are clonal and belong to the South Asian clade C. auris. The travel restrictions during the COVID-19 pandemic and the absence of travel history among the colonized patients lead to the hypothesis that this species was introduced several months before the recognition of the first case and/or emerged locally in the coastline Salvador area.

Disseminated Tuberculosis: A Case of Multiple Spread Mass.

Disseminated tuberculosis is associated with significant morbidity and mortality. It results from a lymphohematogenous dissemination of mycobacterium tuberculosis (MT) and its atypical clinical presentation often delays the diagnosis. Diagnosis is established by identifying MT obtained from a biopsy sample in culture or acid-fast smear. Evidence suggests an initial two-month phase of four-drug therapy followed by a two-drug phase for six to nine months. A 61-year-old man presented with back lumbar pain. He presented two masses, a left parasternal and a left axillary masses with approximately 6 cm each. He referred a 21% weight loss, anorexia and asthenia. His computed tomography revealed recent lumbar fractures and a left paravertebral space-occupying lesion; hilum and upper lobe masses; inflammatory/infectious micronodules; mediastinal adenomegaly, hypodense lesions in the spleen, sternum and left scapula. Magnetic resonance imaging revealed lumbar vertebral fractures, an anterior epidural collection, left iliac psoas muscle liquid collection. A mass puncture and biopsy were performed, resulting in a positive detection of MT in nucleic acid amplification (NAA). The patient started on quaternary antibacillary therapy with isoniazid, rifampin, pyrazinamide and ethambutol. Bronchofibroscopy revealed an hypervascularized and infiltrated submucosa. Later, histopathology was compatible with chronic granulomatous inflammatory process and bronchial lavage molecular test was positive for MT. At the moment, he is under two-drug antibacillary therapy with isoniazid and rifampin and masses are regressing.

The Protagonism of the Brazilian Health Regulatory System in the Evolution of Patient Safety in the Country: History, Dilemmas, and Current Challenges.

OBJECTIVE: This article aims to identify and analyze the legal and regulatory frameworks with an interface with patient safety, considering the historical path of the patient safety policy in Brazil. METHODS: This is a historical review based on the relevant literature to the topic such as papers, legislation, and official documents with an interface with public health policies from 1988 to 2019. We also performed a documentary search to include data from the Brazilian Health Regulatory Agency (ANVISA) such as normative and nonnormative regulatory instruments. After organizing the data, the process of content analysis was performed. RESULTS: We debated initially the historical aspects of sanitary surveillance of health services in addition to main actions taken by the Brazilian Health Regulatory System, which includes sanitary regulation and patient safety challenges. We identified a diversity of regulations published by ANVISA in the past decade related to patient safety, in addiction to sanitary actions. These initiatives culminated in the establishment of the National Patient Safety Program in 2013, followed by other health improvements, such as surveillance, incidents monitoring, and safe practices self-assessment. CONCLUSIONS: The regulation and sanitary actions directed to patient safety in Brazil have increased after the creation of ANVISA. In the face of this activities, the social role played by the Brazilian Health Regulatory System toward the advancement in the field of risk minimization in health services can be highlighted as a protagonist in the process of promoting patient safety.

Efficient synthesis of enantiopure amines from alcohols using resting E. coli cells and ammonia.

α-Chiral amines are pivotal building blocks for chemical manufacturing. Stereoselective amination of alcohols is receiving increased interest due to its higher atom-efficiency and overall improved environmental footprint compared with other chemocatalytic and biocatalytic methods. We previously developed a hydrogen-borrowing amination by combining an alcohol dehydrogenase (ADH) with an amine dehydrogenase (AmDH) in vitro. Herein, we implemented the ADH-AmDH bioamination in resting Escherichia coli cells for the first time. Different genetic constructs were created and tested in order to obtain balanced expression levels of the dehydrogenase enzymes in E. coli. Using the optimized constructs, the influence of several parameters towards the productivity of the system were investigated such as the intracellular NAD+/NADH redox balance, the cell loading, the survival rate of recombinant E. coli cells, the possible toxicity of the components of the reaction at different concentrations and the influence of different substrates and cosolvents. In particular, the cofactor redox-balance for the bioamination was maintained by the addition of moderate and precise amounts of glucose. Higher concentrations of certain amine products resulted in toxicity and cell death, which could be alleviated by the addition of a co-solvent. Notably, amine formation was consistent using several independently grown E. coli batches. The optimized E. coli/ADH-AmDH strains produced enantiopure amines from the alcohols with up to 80% conversion and a molar productivity up to 15 mM. Practical applicability was demonstrated in a gram-scale biotransformation. In summary, the present E. coli-ADH-AmDH system represents an important advancement towards the development of 'green', efficient and selective biocatalytic processes for the amination of alcohols.

Reflexão em torno da adesão ao tratamento em pacientes recebidos através do Centro de Atendimento Psicanalítico da SBPdePA / Reflection about the adhesion to treatment in patients received via the Center of Psychoanalytical Treatment of the SBPdePA / Reflexión sobre la adhesión al tratamiento en pacientes recibidos a través de la Clínica de Tratamiento Psicoanalítico de la SBPdePA

Os analistas participantes do Centro de Atendimento Psicanalítico da Sociedade Brasileira de Psicanálise de Porto Alegre deparam-se, frequentemente, com a questão de por que alguns pacientes aderem ao tratamento psicanalítico e muitos outros, não. Neste trabalho, é feita uma reflexão em torno de alguns fatores do paciente e do analista que possam estar implicados nessa questão, envolvendo vicissitudes da transferência e da contratransferência. Os dados levantados em relação à adesão ao tratamento referem-se ao período de janeiro de 2012 a janeiro de 2013.

The analysts participating in the Center of Psychoanalytical Treatment of the Brazilian Society of Psychoanalysis of Porto Alegre frequently face the problem of why some patients adhere to the psychoanalytical treatment and many do not. In this paper, a reflection is made about some factors regarding both the patient and the analyst; these factors may be implicated in this matter, involving vicissitudes of transference and countertransference. The data collected in relation to the adhesion to the treatment refers to the period from January 2012 to January 2013.

Los analistas participantes en la Clínica de Tratamiento Psicoanalítico de la Sociedad Brasilera de Psicoanálisis de Porto Alegre enfrentan la cuestión de por qué algunos pacientes adhieren al tratamiento psicoanalítico y muchos, en cambio, no. En este trabajo, se hace una reflexión sobre algunos factores del paciente y del analista que puedan estar relacionados a esta cuestión, involucrando vicisitudes de la transferencia y de la contratransferencia. Los datos obtenidos en relación a la adhesión al tratamiento se refieren al período de enero de 2012 a enero de 2013.