Manejo anestésico perioperatorio de la deficiencia de acil-coenzima A deshidrogenasa de cadena muy larga / Perioperative anesthetic management of very long-chain acyl-coenzyme a dehydrogenase deficiency

La deficiencia de acil-coenzima A deshidrogenasa de cadena muy larga (VLCADD) es un trastorno infrecuente del metabolismo de β-oxidación de los ácidos grasos que origina susceptibilidad a hipoglucemia, fallo hepático, cardiomiopatía y rabdomiólisis durante las situaciones catabólicas. Reportamos el caso de un varón de 10 años de edad programado para la colocación de catéter venoso central totalmente implantado durante su hospitalización por rabdomiólisis, que fue exitosamente gestionada con anestesia general con óxido nitroso, sevoflurano y remifentanilo. No se produjo hipoglucemia y los niveles de creatina quinasa no se incrementaron durante el periodo perioperatorio. Describimos las dificultades a que nos enfrentamos, y las estrategias utilizadas para evitar mayor descompensación de la enfermedad debida al estrés quirúrgico.(AU)

Very long-chain acyl-coenzyme A dehydrogenase deficiency (VLCADD) is a rare disorder of β-oxidation fatty acid metabolism that results in susceptibility to hypoglycemia, liver failure, cardiomyopathy and rhabdomyolysis during catabolic situations. We report the case of a 10-year-old male undergoing a totally implanted central venous catheter placement during hospitalization for rhabdomyolysis, who was successfully managed with general anesthesia with nitrous oxide, sevoflurane and remifentanil. No hypoglycemia occurred and creatine kinase levels did not increase in the perioperative period. We describe the challenges encountered and the strategies used to avoid further decompensation of the disease due to surgical stress.(AU)

Perioperative anesthetic management of very long-chain acyl-coenzyme a dehydrogenase deficiency.

Very long-chain acyl-coenzyme A dehydrogenase deficiency is a rare disorder of ß-oxidation fatty acid metabolism that results in susceptibility to hypoglycemia, liver failure, cardiomyopathy and rhabdomyolysis during catabolic situations. We report the case of a 10-year-old male undergoing a totally implanted central venous catheter placement during hospitalisation for rhabdomyolysis, who was successfully managed with general anesthesia with nitrous oxide, sevoflurane and remifentanil. No hypoglycemia occurred and creatine kinase levels did not increase in the perioperative period. We describe the challenges encountered and the strategies used to avoid further decompensation of the disease due to surgical stress.

Interfaz entre formación en enfermería y actividades artístico-culturales en el espacio académico: visión de los estudiantes / The interface between the nursing formation process and artistic-cultural activities within the academic space: the students' perspective / A interface entre formação de enfermagem e atividades artístico-culturais no espaço acadêmico: visão dos estudantes

Objetivo Analizar la percepción de los estudiantes en relación con las contribuciones de su inserción en actividades artístico-culturales en el espacio universitario para la formación en enfermería. Método Investigación cualitativa, guiada por la epistemología de Fleck. Participaron 17 estudiantes de enfermería integrantes de movimientos artístico-culturales existentes en una institución de enseñanza superior, a saber: Grupo teatral, grupo musical y grupo de Maracatú. Los datos fueron recolectados por medio de entrevista semiestructurada y organizados por la técnica del discurso del sujeto colectivo. Resultados: Los estudiantes destacaron entre las ventajas de las actividades artístico-culturales el estímulo para estudiar, sentirse relajado y más preparado para las actividades académicas, así como propiciar el desarrollo de sensibilidad y competencias que puedan transformar los escenarios de la práctica clínica de enfermería. Fueron indicadas como dificultades, la credibilidad de estas actividades en la academia, frente a la lógica de la formación curativa. Conclusiones: Integrar actividades artísticas y culturales con la formación académica permite al alumno protagonizar modos renovados de pensar en el cuidado de enfermería y fortalecer conexiones con los diferentes conocimientos necesarios para la práctica del cuidado holístico.

Objective To analyze the students' perceptions of the impact which their participation in artistic-cultural activities within the university space has on their nursing-formation process. Method: This is a qualitative research guided by the epistemology of Fleck. Seventeen nursing students from a high level school, and also members of artistic-cultural movements such as theater, music and Maracatu groups, participated in this study. Data were collected through semi-structured interviews and then organized following the collective subject discourse technique. Results: Related to the positive influence of their artistic-cultural activities, the students highlighted their stimulus to study, feeling relaxed, and being more prepared for the academic activities including those which can help them develop competences and sensibilities to improve the clinical nursing practice scenarios. A remark on the academia who doubts the credibility of these activities and who follows a model in which health is only viewed as the absence of illness was also highlighted. Conclusions: The integration of artistic and cultural activities into the nursing formation process allows the students to develop renewed modes of thinking which can strengthen the links among their knowledge areas, and thus prepare them better for a holistic care practice

Objetivo Analisar a percepção dos estudantes em relação às contribuições da sua inserção em atividades artístico-culturais no espaço universitário para a formação em enfermagem. Método: Investigação qualitativa, guiada pela epistemologia de Fleck. Participaram 17 estudantes de enfermagem, integrantes de movimentos artístico-culturais existentes em uma instituição de ensino superior, a saber: Grupo teatral, grupo musical e grupo de Maracatú. Os dados foram coletados por médio da entrevista semiestruturada e organizados pela técnica de discurso do sujeito coletivo. Resultados Os estudantes destacaram de entre as vantagens das atividades artístico-culturais, o estímulo para estudar, sentir-se relaxado e mais preparado para as atividades acadêmicas, bem como propiciar o desenvolvimento de sensibilidade e competências que pudessem transformar os cenários da prática clínica de enfermagem. Foram indicadas como dificuldades, a credibilidade destas atividades na escola, perante à lógica da formação curativista. Conclusões Integrar atividades artísticas e culturais na formação acadêmica, permite ao aluno protagonizar modos renovados de pensar no cuidado de enfermagem e fortalecer conexões com os diferentes conhecimentos necessários para a prática do cuidado holístico.

Referral pattern of leptospirosis cases during a large urban epidemic of dengue.

During heavy seasonal rainfall in 1996, concurrent epidemics of dengue and leptospirosis occurred in an urban center in northeastern Brazil. We interviewed 110 cases of leptospirosis hospitalized a median of seven days after the onset of illness to evaluate the impact of the dengue epidemic on the triage of suspected leptospirosis from ambulatory clinics to the infectious disease reference hospital. Within the first three days of illness, 46 (42%) cases sought their first medical evaluation, and 28 (61% of 46) received a diagnosis of dengue. Dengue diagnoses were associated with a median of five days delay in referral to the infectious disease hospital. Patients who reported initial diagnoses of dengue were more likely than other patients to have required admission to the intensive care unit (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 0.8-9.5) and to have died during hospitalization (OR = 5.1, 95% CI = 0.8-55.0). These findings indicate that diagnostic confusion between the early symptoms of leptospirosis and dengue may have contributed to the high mortality observed during the leptospirosis epidemic.

Latex agglutination test for the detection of urinary antigens in visceral leishmaniasis.

This paper describes a new latex agglutination test ('KATEX') for the detection of leishmanial antigen in the urine of patients with visceral leishmaniasis. In preliminary laboratory trials, using urine collected from well-defined cases and controls from Brazil, Yemen and Nepal, the test had 100% specificity and a sensitivity between 68 and 100%. When used in a time-course experiment in cotton rats infected with Leishmania donovani, the test became positive 1 week after inoculation and antigen levels in urine declined rapidly after chemotherapy (the test was negative before the end of the course of treatment). Finally, in an integrated study performed in Sudan, KATEX was compared to microscopy and four different serological tests in a group of 73 patients having presented with clinical manifestations suggestive of visceral leishmaniasis. Compared to microscopy, KATEX performed better than any single serological test in predicting positivity and a particularly good result was obtained by combining KATEX and the direct agglutination test (DAT).

Clonally related penicillin-nonsusceptible Streptococcus pneumoniae serotype 14 from cases of meningitis in Salvador, Brazil.

Active hospital-based surveillance in the city of Salvador, Brazil, from December 1995 through October 1998, identified 221 patients with confirmed pneumococcal meningitis. Of these 221 patients, 29 (13%) had isolates with intermediate-level resistance to penicillin. Infection with these penicillin-nonsusceptible isolates was significantly associated with age of <2 years (P<.0019), previous antibiotic use (P<.0006), and coresistance to trimethoprim-sulfamethoxazole (P<.0000). Serotype 14 was the most prevalent serotype (55.2%) of penicillin-nonsusceptible isolates. Strain typing by repetitive element BOX polymerase chain reaction (PCR) analysis showed that penicillin-nonsusceptible serotype 14 isolates had closely related BOX PCR patterns, whereas penicillin-susceptible serotype 14 isolates each had distinct, unrelated patterns. Penicillin-nonsusceptible serotype 14 isolates from Salvador and other Brazilian cities had similar BOX PCR patterns. These observations indicate that in Brazil a large proportion of cases of penicillin-nonsusceptible pneumococcal meningitis appear to be caused by a closely related group of serotype 14 strains that may have disseminated to widely separate geographic areas.

Urban epidemic of severe leptospirosis in Brazil. Salvador Leptospirosis Study Group.

BACKGROUND: Leptospirosis has, traditionally, been considered a sporadic rural disease. We describe a large urban outbreak of leptospirosis. METHODS: Active surveillance for leptospirosis was established in an infectious-disease referral hospital in Salvador, Brazil, between March 10 and Nov 2, 1996. Patients meeting case criteria for severe manifestations of leptospirosis were recruited into the study. The diagnosis was confirmed in the laboratory with the microagglutination test and identification of leptospires in blood or urine. Risk factors for death were examined by multivariate analyses. FINDINGS: Surveillance identified 326 cases of which 193 (59%) were laboratory-confirmed (133) or probable (60) cases. Leptospira interrogans serovar copenhageni was isolated from 87% of the cases with positive blood cultures. Most of the cases were adult (mean age 35.9 years [SD 15.9]), and 80% were male. Complications included jaundice (91%), oliguria (35%), and severe anaemia (26%). 50 cases died (case-fatality rate 15%) despite aggressive supportive care including dialysis (in 23%). Altered mental status was the strongest independent predictor of death (odds ratio 9.12 [95% CI 4.28-20.3]), age over 37 years, renal insufficiency, and respiratory insufficiency were also significant predictors of death. Before admission to hospital, 42% were misdiagnosed as having dengue fever in the outpatient clinic; an outbreak of dengue fever was taking place concurrently. INTERPRETATION: An epidemic of leptospirosis has become a major urban health problem, associated with high mortality. Diagnostic confusion with dengue fever, another emerging infectious disease with a similar geographic distribution, prevents timely intervention that could minimise mortality.

The direct agglutination test: a non-specific test specific for the diagnosis of visceral leishmaniasis?

Serology has an important role to play in the diagnosis of the severe clinical syndrome of visceral leishmaniasis (VL). The direct agglutination test (DAT), a simple agglutination test which requires no laboratory facilities, has become the preferred test, particularly for field studies. The nature of the antigens responsible for the agglutination of leishmanial promastigotes by the serum of VL patients is not known. A series of experiments which provide some clues to the molecular basis for the test and which indicate that there might be more in DAT than meets the eye is reported.

Synthetic peptide-based enzyme-linked immunosorbent assay for serodiagnosis of visceral leishmaniasis.

Synthetic peptides, derived from the amino acid sequence of a Leishmania donovani clone, were used to develop an enzyme-linked immunosorbent assay (ELISA) for detecting antibodies against L. donovani. For this purpose, five peptides were conjugated to a protein carrier, human serum albumin (HSA), by using a heterobifunctional reagent, epsilon-maleimidocaproic acid N-hydroxysuccinimide ester, to obtain a well-defined product. The sensitivity and the specificity of the peptide-specific ELISA were determined with a panel of 106 serum samples from individuals living in areas where visceral leishmaniasis is endemic; sera from post-kala azar dermal leishmaniasis-infected patients and from individuals suffering from other infectious diseases were also included. ELISAs were performed with either a single peptide-HSA conjugate or a mixture of two peptide-HSA conjugates. Ninety-seven percent of the serum samples from patients with visceral leishmaniasis had detectable antibodies to one or more of the single synthetic peptides. ELISA with a single peptide-HSA conjugate proved to be less sensitive (less than 71%) but more specific (up to 93%) than ELISA with crude promastigote antigens (80% sensitivity and 79% specificity); when a combination of two different peptide-HSA conjugates was used, the test increased both in sensitivity and in specificity. Chemically defined peptide-protein conjugates improve the reproducibility and reliability of ELISA for the serodiagnosis of L. donovani infection.