The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated.

Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p = 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p = 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated / O número relativo de linfócitos é menor quando o agente etiológico da doença de Pott é isolado com sucesso

Abstract Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p= 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p= 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

Resumo Objetivo Descrever as características clínico-epidemiológicas, laboratoriais e radiológicas da espondilodiscite tuberculosa na população brasileira e avaliar se há diferenças entre pacientes em que o agente etiológico da doença de Pott foi isolado ou não. Métodos Os pacientes diagnosticados com tuberculose (TB) da coluna (doença de Pott) foram acompanhados em um hospital quaternário entre 2009 e 2019 e divididos em 2 grupos: isolamento positivo (IP) do agente etiológico (por baciloscopia, cultura ou teste rápido molecular positivo) e isolamento negativo (IN) do agente etiológico. Resultados De um total de 26 pacientes com diagnóstico de TB da coluna, 21 (80,7%) eram do sexo masculino, e a média de idade era de 40 ± 22,5 anos. As contagens médias de linfócitos foram maiores no grupo IN (25,35 ± 13,08; p= 0,025) do que no grupo IP (14,18 ± 7,48). Além disso, a relação monócito/linfócito foi menor no grupo IN (0,39 ± 0,22; p= 0,009) do que no grupo IP (0,89 ± 0,65). O número relativo de linfócitos maior ou igual a 16,7 teve sensibilidade de 76,9% e especificidade de 62,5% no grupo IN. A razão monócito/linfócito maior ou igual a 0,58 teve sensibilidade de 84,6% e especificidade de 75,0% no grupo IN. Conclusão Não observamos diferenças em relação às características clínico-epidemiológicas e radiológicas entre os dois grupos experimentais. No entanto, o grupo IN apresentou maior número de linfócitos e menor razão monócito/linfócito.

Experiência de reforma curricular com participação da comunidade acadêmica e ensino baseado em competências / Curricular Reform Experience with Academic Community Participation and Competency-Based Education

Resumo: Introdução: Repensar os processos de ensino-aprendizagem é tarefa contínua dentro da escola médica, devendo haver aplicação das melhores evidências. Embora as necessidades de mudanças sejam amplamente conhecidas, os meios para realizá-las não o são. Por isso, este relato objetiva descrever a metodologia utilizada por uma faculdade tradicional do ensino em medicina durante seu processo de reforma curricular, o qual contou com a participação ativa da comunidade acadêmica. Relato de experiência: Para a reforma da matriz, foi nomeada uma comissão composta por alunos, docentes e funcionários. Seguindo os princípios do Design Thinking, organizaram-se os conhecimentos prévios e estruturaram-se os processos de escuta dos diferentes sujeitos. Optou-se por desenvolver uma matriz baseada em competências, com disciplinas integradas horizontalmente e priorização de atividades práticas, de modo a permitir uma redução da carga horária global do curso. As reformas implementadas exigiram alterações institucionais complexas para além da matriz, como a mudança da cultura avaliativa, a implementação do portfólio e outras questões de currículo oculto. Discussão: Superou-se o desafio de criar processos flexíveis e sustentáveis porque a comunidade foi capacitada para colaborar na gestão do ensino. Para além de coordenadores e diretores, todos os agentes do processo de aprendizagem devem ser reunidos de forma horizontal com participação ativa na proposição de mudanças. Barreiras e distanciamentos em relação à literatura podem ser enfrentados, devendo-se admitir as limitações para preservar identidades próprias e garantir projetos viáveis. Conclusão: A formação de profissionais competentes é o objetivo dos currículos em medicina, que devem ser revistos continuamente. A reforma descrita permitiu o fortalecimento de vínculos com a comunidade, entregando um projeto representativo e adequado à realidade específica.

Abstract: Introduction: Rethinking the teaching-learning process is a continuous task in medical training, with the constant requirement of applying the best evidence. Although the needs for change are widely known, the means to carry them out are not. Therefore, this report aims to describe the methodology used by a traditional medical school during its curricular reform process, which had the active participation of the academic community. Experience: A committee for curricular reform was appointed, including students, academic and professional staff. Following the principles of Design Thinking, prior knowledge was organized and listening processes were structured. A competency-based matrix was developed, with horizontally integrated disciplines and prioritization of practical activities, allowing for reduced total class hours of the course. The implemented reforms required complex institutional changes beyond the matrix, such as changing the evaluative culture and the implementation of the portfolio, in addition to other hidden curricular issues. Discussion: The challenge of creating flexible and sustainable processes seems to be overcome by empowering the community to collaborate with the educational management. In addition to coordinators and directors, all agents of the learning process must be brought together horizontally with active participation in proposing changes. Barriers and distances in relation to literature can be faced, and limitations must be admitted in order to preserve appropriate identities and guarantee viable projects. Conclusion: Training competent professionals is the goal of curricula, which must be continually reviewed. The reform described allowed for the strengthening of ties between the community, delivering a representative project that was adequate to the specific reality.

Women engaged in prostitution and COVID-19: why are they excluded from socially vulnerable groups?

This study analyzed the exposure of women engaged in prostitution in downtown São Paulo to COVID-19. This cross-sectional study had a convenience sample selected in May 2021. We interviewed 219, mostly black, middle-aged, poor women with comorbidities. Among them, 61 had shown COVID-19 symptoms, 23, tested positive for the disease, seven underwent hospitalization, and four reported post-COVID-19 complications. Only 26 (30.2%) had been vaccinated. In addition to gender, race, and class inequalities, these women suffer both from a higher risk of contracting COVID-19 due to their working conditions and from the subsequent worsening of that disease due to age and lack of vaccination.

Women engaged in prostitution and COVID-19: why are they excluded from socially vulnerable groups? / Mulheres em situação de prostituição e covid-19: por que excluídas dos grupos vulneráveis?

ABSTRACT This study analyzed the exposure of women engaged in prostitution in downtown São Paulo to COVID-19. This cross-sectional study had a convenience sample selected in May 2021. We interviewed 219, mostly black, middle-aged, poor women with comorbidities. Among them, 61 had shown COVID-19 symptoms, 23, tested positive for the disease, seven underwent hospitalization, and four reported post-COVID-19 complications. Only 26 (30.2%) had been vaccinated. In addition to gender, race, and class inequalities, these women suffer both from a higher risk of contracting COVID-19 due to their working conditions and from the subsequent worsening of that disease due to age and lack of vaccination.

RESUMO Esta pesquisa analisou a exposição de mulheres em situação de prostituição no centro de São Paulo à covid-19. Este estudo transversal contou com amostra de conveniência selecionada em maio de 2021. Entrevistou-se 219 mulheres majoritariamente negras, de meia idade, pobres e com comorbidades. Dentre essas mulheres, 61 tiveram sintomas de covid-19, 23 com teste positivo,7 foram internadas e 4 relataram complicações pós-covid-19. Somente 26 (30,2%) haviam sido vacinadas. Além das desigualdades de gênero, raça e classe, essas mulheres são expostas a um maior risco de contraírem covid-19, devido às condições de trabalho e por apresentarem doença grave relacionada à idade e falta de vacinação.

Correlation of postoperative infection with the etiology of the disease in spinal surgery with instrumentation / Correlação da infecção pós operatória com a etiologia da doença na cirurgia de coluna instrumentada / Correlación de la infección postoperatoria con la etiología de la enfermedad en cirugía espinal instrumentada

ABSTRACT Objective: To evaluate the epidemiological characteristics of postoperative infection in surgeries of the spine with instrumentation in our service, and whether there is a correlation between the rate of postoperative infection and the etiology of the indication for the primary surgical procedure. Methodology: A retrospective search through medical records of patients who underwent spinal surgery with instrumentation in our hospital between 2015 and 2019 was performed, and the ones that evolved with acute or chronic postoperative infection with need for surgical cleaning to resolve it were selected. Cases of non-instrumented surgery, primary infection of the spine (osteomyelitis and spondylodiscitis) and superficial infection of the surgical wound without the need for surgical cleaning were excluded. Results: The rate of postoperative infection was 11.6%. In this group of patients who evolved with this complication, most were submitted to surgery primarily for trauma (38.9%), followed by degenerative disease (30.8%), neoplasm (19.2%), and deformity (15, 4%). However, when we analyzed these patients comparing them with the total number of cases of spinal surgery with instrumentation performed in the period, we obtained a higher prevalence of infection in patients operated for deformity (17.6%), followed by degenerative disease (13%), neoplasm (11.4%) and trauma (9.9%). This difference did not prove to be statistically significant (p = 0.79), nor the correlation with sex and age. Conclusion: In our study, proportionally, there was a difference in the prevalence of postoperative infection according to the etiological indication, being higher in cases operated for deformity, mainly due to neuromuscular disease. Level of evidence IV; A case series therapeutic study.

RESUMO Objetivo: Avaliar as características epidemiológicas da infecção pós-operatória nas cirurgias com instrumentação da coluna vertebral no nosso serviço, assim como se há correlação entre a taxa de infecção pós-operatória e a etiologia da indicação do procedimento cirúrgico primário. Metodologia: Foi realizada uma busca retrospectiva por meio dos prontuários de pacientes submetidos a cirurgia da coluna vertebral com instrumentação em nosso hospital entre 2015 e 2019, e que evoluíram com infecção pós-operatória aguda ou crônica com necessidade de limpeza cirúrgica para sua resolução. Foram excluídos os casos de cirurgias não instrumentadas, casos de infecção primária da coluna (osteomielite e espondilodiscite) e casos de infecção superficial da ferida operatória sem necessidade de limpeza cirúrgica. Resultados: A taxa de infeção pós-operatória foi de 11,6%. Deste grupo de pacientes que evoluíram com essa complicação a maioria foi submetida a cirurgia primariamente por trauma (38,9%), seguido de doença degenerativa (30,8%), indicação oncológica (19,2%), e deformidade (15,4%). Porém quando analisamos esses pacientes comparando-os com o total de casos de cirurgia na coluna vertebral com instrumentação realizadas no período, obtivemos uma prevalência maior de infecção em pacientes operados por deformidade (17,6%), seguido de doença degenerativa (13%), doença oncológica (11,4%) e trauma (9,9%). Essa diferença não mostrou ser estatisticamente significativa (p=0,79), assim como a correlação com sexo e idade. Conclusão: Em nosso estudo, proporcionalmente, houve diferença na prevalência de infecção pós-operatória de acordo com a indicação etiológica, sendo maior nos casos operados por deformidade, principalmente em decorrência de doença neuromuscular. Nível de evidência IV; Estudo terapêutico de série de casos.

RESUMEN Objetivo: evaluar las características epidemiológicas de la infección postoperatoria en cirugías de columna con instrumentación en nuestro servicio, así como si existe una correlación entre la tasa de infección postoperatoria y la etiología de la indicación para el procedimiento quirúrgico primario. Metodología: se realizó una búsqueda retrospectiva a través de los registros médicos de pacientes que se sometieron a cirugía de columna con instrumentación en nuestro hospital entre 2015 y 2019, y que evolucionaron con infección postoperatoria aguda o crónica con necesidad de una limpieza quirúrgica para resolverlo. Se excluyeron los casos de cirugía no instrumentada, infección primaria de la columna (osteomielitis y espondilodiscitis) y infección superficial de la herida quirúrgica sin necesidad de limpieza. Resultados: la tasa de infección postoperatoria fue del 11,6%. De este grupo de pacientes que evolucionaron con esta complicación, la mayoría fueron sometidos a cirugía principalmente por trauma (38.9%), seguidos de enfermedad degenerativa (30.8%), neoplasia (19.2%) y deformidad (15, 4%). Sin embargo, cuando analizamos a estos pacientes comparándolos con el número total de casos de cirugía de columna con instrumentación realizada en el período, obtuvimos una mayor prevalencia de infección en pacientes operados por deformidad (17,6%), seguido de enfermedad degenerativa (13%), neoplasia (11.4%) y trauma (9.9%). Esta diferencia no resultó ser estadísticamente significativa (p = 0,79), así como la correlación con el sexo y la edad. Conclusión: En nuestro estudio, proporcionalmente, hubo una diferencia en la prevalencia de infección postoperatoria según la indicación etiológica, siendo mayor en los casos operados por deformidad, principalmente debido a enfermedad neuromuscular. Nivel de evidencia IV; Estudio terapéutico de serie de casos.

Formação docente no curso de Medicina: como podemos melhorar? / Faculty development in medical school: how can it be improved?

Resumo: Introdução: As instituições de ensino superior (IES) têm valorizado progressivamente a educação permanente do corpo docente. Mudanças no perfil de aprendizado, o amplo acesso digital ao conhecimento e novas competências exigidas aos médicos pela sociedade induzem necessidades de atualizações nas práticas docentes, especialmente durante a pandemia de Covid-19. Objetivo: Este estudo teve como objetivo avaliar as necessidades de desenvolvimento, as práticas educacionais utilizadas e a visão sobre o ensino na perspectiva de docentes de graduação em Medicina. Método: Trata-se de estudo transversal, com amostra de conveniência formada por coordenadores de disciplinas de graduação de uma IES paulistana, com dados coletados entre agosto e setembro de 2020 por meio de questionário eletrônico. Os dados foram analisados por meio de proporções e teste do qui-quadrado e teste exato de Fischer. O nível de significância foi de 5%. Resultado: Do total de 68 coordenadores de disciplina da IES, participaram 47 (69,1%). Destes, 26 (55,3%) se declararam do gênero feminino e 21 (44,7%) do gênero masculino, 17 (36,2%) eram de disciplinas do primeiro biênio, 20 (42,6%) do segundo biênio e dez (21,1%) do terceiro biênio (internato). A maioria dos coordenadores (93,6%) relatou motivação para participar de ações de formação docente, especialmente para inclusão de inovações em suas disciplinas (85,1%). Relataram maior necessidade para atualização em métodos de ensino e de avaliação. As mulheres citaram, com maior frequência, a necessidade de formação em avaliação (p = 0,04). Nas práticas educacionais relatadas, as mulheres incorporaram mais atitudes (p = 0,02) e habilidades no planejamento educacional (p = 0,007), assim como relataram utilizar mais avaliação formativa (p = 0,03) e maior formação prévia para uso de metodologias ativas (p = 0,02). Apesar de a valorização do diálogo com os estudantes ser apontada pela maioria dos docentes, práticas centradas no estudante foram descritas em menor percentual das respostas Conclusão: Há motivação de os coordenadores de disciplinas se engajarem em ações de formação docente, tendo sido identificadas diversas necessidades quanto às práticas educacionais, contudo observaram-se algumas diferenças entre os gêneros. Embora a maioria apresente uma visão dialógica do processo ensino-aprendizagem, essa concepção ainda não está implementada na prática relatada em suas disciplinas.

Abstract: Introduction: Faculty development in medical education has shown an increasing focus on universities. Changes in the learning style, the broad access to digital knowledge and new society demands in terms of medical competences have induced the need for updates in teaching practices, especially during the Covid-19 pandemic. Objective: To evaluate the needs of faculty development, reported educational practices and the view on teaching and learning from medical teachers' perspectives. Methods: this study has a cross-sectional design with a convenience sample of undergraduate medical teachers from a medical school in São Paulo, who coordinate educational units in the curricula. Data collection took place between August and September 2020, by completing an electronic questionnaire. The data were analyzed using proportions, the chi-square test or Fisher's exact test, with p <0.05 being considered significant. Results: There were 68 medical teachers coordinating curricula units and 47 (69.1%) accepted to participate. Of the total of 47 participants, 26 (55.3%) are female and 21 (44.7%) are male, 17 (36.2%) teachers taught disciplines from first biennium, 20 (42.6%) from the second biennium and 10 (21.1%) from the third biennium. Most of medical teachers reported being motivated to participate in faculty development courses (93.6%), with focus on the inclusion of innovations in their educational practice (85.1%). They reported the need to update teaching and assessment methods. The women reported more frequently the need for training in assessment methods (p = 0.04). In the reported educational practices, women incorporate more attitudes (p = 0.02) and skills in educational planning (p = 0.007), as well as the use of formative assessment (p = 0.03) and more previous training in the use of active methodologies (p = 0.02). Although the recognition of the importance of the dialogue with students being reported by most teachers, student-centered practices were described in a lower percentage of responses. Conclusion: Teachers are motivated to engage in faculty development actions, with several needs regarding educational practices being identified, with differences being observed between genders. Although they reported a dialogic view of the teaching-learning process, this concept is not yet implemented in the reported practice in their disciplines.

The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive.

BACKGROUND: In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. METHODS: Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. RESULTS: Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). CONCLUSIONS: In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).

Perfil do mal de pott em um serviço de referência sul-americano / The profile of pott's disease in a south american reference service / Perfil de la enfermedad de pott en un servicio de referencia sudamericano

ABSTRACT Objective: Tuberculosis (TB) represents one of the top ten causes of death in the world. Its insidious onset and nonspecific symptoms usually result in delayed diagnosis. The objective is to evaluate the characteristics of patients with tuberculous spondylodiscitis in follow-up at a South American reference hospital. Method: Retrospective evaluation of the medical records of patients of both sexes and between 0 and 80 years of age diagnosed with tuberculosis of the spine between 2009 and 2018. The variables were analyzed based on groups: epidemiological, clinical, laboratorial, microbiological, imaging tests and treatment. Results: Total of 26 cases, about 80.8% male, mean age 41.6 ± 22.46 years. Axial pain was the most prevalent symptom (84.6%), the VAS score was 6.85 ± 2.87. The mean time between symptom onset and diagnosis was 23.8 ± 24.1 weeks (4-96). The most affected region was the thoracic spine (50% of the cases). Most participants (61.4%) had no change in neurological function (Frankel D and E) at the beginning of treatment and after 6 months, and 84.5% improved. During treatment 34.6% required surgery and the main indication was isolated neurological deficit (55.5%). The most frequently performed procedure was decompression and arthrodesis (55.5%). The average time to cure was 12.0 ± 8.8 months (8-48). Conclusion: Disease with insidious onset, nonspecific symptoms, high frequency of negative microbiological tests in cases with the disease. A small number of the cases required surgical treatment and most of them achieved good neurological recovery. Level of evidence IV; Case series.

RESUMO Objetivo: A tuberculose (TB) é uma das dez principais causas de morte no mundo. O início insidioso e os sintomas inespecíficos geralmente resultam em atraso do diagnóstico. O objetivo é avaliar as características dos pacientes com espondilodiscite tuberculosa em acompanhamento, em um hospital de referência sul-americano. Método: Avaliação retrospectiva de dados de prontuários, diagnóstico de tuberculose da coluna vertebral entre 2009 e 2018, de ambos os sexos, entre 0 e 80 anos de idade. As variáveis foram analisadas com base em grupos: epidemiológicas, clínicas, laboratoriais, microbiológicas, exames de imagem e tratamento. Resultados: Total de 26 casos, cerca de 80,8% do sexo masculino, média de idade de 41,6 ± 22,46 anos. A dor axial foi o sintoma mais prevalente (84,6%), o escore da EVA foi de 6,85 ± 2,87. A média de tempo entre o início dos sintomas e o diagnóstico foi de 23,8 ± 24,1 semanas (4-96). A região mais acometida foi a coluna torácica (50% dos casos). A maioria (61,4%) dos participantes apresentou função neurológica inalterada (Frankel D e E) no início do tratamento e 6 meses depois, sendo que 84,5% obtiveram melhora. No tratamento, 34,6% necessitaram de cirurgia, e a principal indicação foi déficit neurológico isolado (55,5%). O procedimento mais realizado foi descompressão e artrodese (55,5%). O tempo médio até a cura foi de 12,0 ± 8,8 meses (8-48). Conclusão: Doença de início insidioso, sintomas inespecíficos, grande frequência de exames microbiológicos negativos em casos com a doença. A menor parte dos casos necessitou de tratamento cirúrgico e a maioria apresentou boa recuperação neurológica. Nível de evidência IV; Série de casos.

RESUMEN Objetivo: La tuberculosis (TB) es una de las diez principales causas de muerte en el mundo. El inicio insidioso y los síntomas inespecíficos generalmente resultan en atraso del diagnóstico. El objetivo es evaluar las características de los pacientes con espondilodiscitis tuberculosa en acompañamiento en un hospital de referencia sudamericano. Método: Evaluación retrospectiva de datos de historiales clínicos, diagnóstico de tuberculosis de la columna vertebral entre 2009 y 2018, de ambos sexos, entre 0 y 80 años de edad. Las variables fueron analizadas con base en grupos: epidemiológicas, clínicas, de laboratorio, microbiológicas, exámenes de imagen y tratamiento. Resultados: Total de 26 casos, cerca de 80,8% del sexo masculino, promedio de edad de 41,6 ± 22,46 años. El dolor axial fue el síntoma más prevalente (84,6%). El puntaje de la EVA fue de 6,85 ± 2,87. El promedio de tiempo entre el inicio de los síntomas y el diagnóstico fue de 23,8 ± 24,1 semanas (4-96). La región más acometida fue la columna torácica (50% de los casos). La mayoría (61,4%) de los participantes presentó función neurológica inalterada (Frankel D y E) al inicio del tratamiento y seis meses después, siendo que 84,5% obtuvo mejora. En el tratamiento, 34,6% precisó cirugía, y la principal indicación fue déficit neurológico aislado, (55,5%). El procedimiento más realizado fue descompresión y artrodesis (55,5%). El tiempo promedio hasta la cura fue de 12,0 ± 8,8 meses (8-48). Conclusión: Enfermedad de inicio insidioso, síntomas inespecíficos, alta frecuencia de exámenes microbiológicos negativos en casos con la enfermedad. La menor parte de los casos requirió tratamiento quirúrgico y la mayoría presentó buena recuperación neurológica. Nivel de evidencia IV; Serie de casos.

Use of biologic agents and risk of tuberculosis in Brazil, a tuberculosis high-burden country.

BACKGROUND: Brazil is a country with a high burden of tuberculosis (TB). The immunomodulatory effect of biological therapies is associated with an increased risk of infection. This study evaluated the frequency of TB infection in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), juvenile idiopathic arthritis (JIA), and psoriatic arthritis (PsA) after the use of biologic agents in a single center of rheumatology. METHODS: In this observational study, 161 consecutive adult patients with RA, JIA, AS, and PsA using biological therapy were followed up during 55 months to evaluate the occurrence of TB infection throughout treatment. All patients were screened for latent TB infection (LTBI), and TB disease was excluded before introduction of biological therapy. Patients with LTBI received prophylaxis with isoniazid before the start of biological treatment. RESULTS: Of 161 patients on biologics, 31 (19.25%) had positive tuberculin skin test (TST) and received LTBI treatment. Eleven (6.8%) cases of TB were detected in patients on biologics, six (54.5%) had AS, one had PsA (9.09%), two had RA (18.18%), and two had JIA (18.18%). Regarding the use of different biologics, six (54.5%) patients received adalimumab, three (27.2%) infliximab, one (9.09%) etanercept, and one (9.09%) tocilizumab. CONCLUSION: In this study, the frequency of TB infection among 161 patients on biologics, during 55 months of follow-up, was 6.8%. Compared with the national registry of patients receiving biologics (BiobadaBrasil - January 01, 2009 to May 31, 2013), a higher incidence of TB (6.8 versus 0.44%) was found in this sample of patients receiving biological therapy. This study highlights that in a country with high TB burden, the possibility of TB infection in a patient receiving biological therapy should always be considered, even after prophylaxis with isoniazid.

Chronic skull osteomyelitis due to Cryptococcus neoformans: first case report in an HIV-infected patient.

Osteomyelitis due to Cryptococcus neoformans are described in mostly 10% of patients with disseminated cryptococcosis, being direct inoculation even more uncommon. We report the case of an HIV-infected patient with history of recurring itching on his scalp and repetitive local trauma. For eighteen months, he noticed a painful and slow growing lump on his scalp. He was submitted to an excisional biopsy of the lesion but no etiological diagnosis was identified. After this procedure, the post-surgical wound never completely healed. At admission, the patient presented nausea and headache for three days and an open orifice into his skull. Investigations confirmed meningitis and skull osteomyelitis caused by Cryptococcus neoformans. He was treated with bone debridement and combined systemic antifungals, showing good clinical and laboratorial outcome. Cryptococcal disease should be included in the differential diagnoses of chronic osteomyelitis in HIV-infected patients and trauma is a possible source of infection.

Interferon-γ release assay as a sensitive diagnostic tool of latent tuberculosis infection in patients with HIV: a cross-sectional study.

BACKGROUND: In developing countries, tuberculosis (TB) is a major public health problem and the leading cause of death among patients with HIV (Human Immunodeficiency Virus). Until 2001, the tuberculin skin test (TST) was the only available tool for the diagnosis of latent tuberculosis infection (LTBI), but false-negative TST results are frequently reported. Recently, the interferon-γ (IFN-γ) release assay (IGRA) has gained ground because it can detect the IFN-γ secreted by circulating lymphocytes T cells when stimulated by specific TB antigens. However, the role of IGRA in the diagnosis of LTBI in HIV-infected patients has not been well established. METHODS: This cross-sectional study compared the accuracy of TST (performed by the Mantoux method) and IGRA (QuantiFERON-TB Gold In-Tube, Cellestis, Carnegie, Australia) on the diagnosis of LTBI among patients with HIV. LTBI is defined by LTBI risk and at least one positive test (TST or IGRA), without clinical evidence of active TB. We also assessed the accuracy of TST and IGRA among HIV patients with high and low risk for LTBI. RESULTS: Among 90 HIV patients, 80 met the study criteria for LTBI, fifty-nine (73.7%) patients were TST positive, 21 (26.2%) were negative, whereas 75 patients (93.7%) were IGRA positive, and five (6.2%) were negative. TST showed poor agreement with the diagnosis of LTBI (Kappa: 0.384), while IGRA demonstrated good agreement (Kappa: 0.769). Among 69 patients with high risk and 21 with low risk for LTBI, TST was positive in 48 (69.5%) and 11 (52.4%), while IGRA was positive in 68 (98.5%) and 7 (33.3%) patients, respectively. There were no association between TST and the level of risk (P = 0,191). Conversely, we observed a strong association between the IGRA and risk for LTBI (p < 0.001). CONCLUSIONS: Compared to TST, IGRA positivity is consistent with the risk of TB infection and seems to be a better diagnostic tool for LTBI in HIV-infected patients.

Chronic skull osteomyelitis due to Cryptococcus neoformans: first case report in an HIV-infected patient

ABSTRACT Osteomyelitis due to Cryptococcus neoformans are described in mostly 10% of patients with disseminated cryptococcosis, being direct inoculation even more uncommon. We report the case of an HIV-infected patient with history of recurring itching on his scalp and repetitive local trauma. For eighteen months, he noticed a painful and slow growing lump on his scalp. He was submitted to an excisional biopsy of the lesion but no etiological diagnosis was identified. After this procedure, the post-surgical wound never completely healed. At admission, the patient presented nausea and headache for three days and an open orifice into his skull. Investigations confirmed meningitis and skull osteomyelitis caused by Cryptococcus neoformans. He was treated with bone debridement and combined systemic antifungals, showing good clinical and laboratorial outcome. Cryptococcal disease should be included in the differential diagnoses of chronic osteomyelitis in HIV-infected patients and trauma is a possible source of infection.

Cutaneous atypical mycobacteriosis with sporotrichoid clinical presentation caused by automotive accident

Abstract: Atypical mycobacterial infections are caused by mycobacteria other than those from the M. tuberculosis complex and M. leprae. Its incidence has increased progressively, with considerable increase of scientific publications on the subject. Only 10% of the cases present with cutaneous infections, most of them related to surgical interventions and aesthetic procedures. We present a case of mycobacteriosis due to automotive accident that presented a diagnostic challenge due to its clinical presentation with lesions of sporotrichoid progression in the lymphatic system.

Cutaneous atypical mycobacteriosis with sporotrichoid clinical presentation caused by automotive accident.

Atypical mycobacterial infections are caused by mycobacteria other than those from the M. tuberculosis complex and M. leprae. Its incidence has increased progressively, with considerable increase of scientific publications on the subject. Only 10% of the cases present with cutaneous infections, most of them related to surgical interventions and aesthetic procedures. We present a case of mycobacteriosis due to automotive accident that presented a diagnostic challenge due to its clinical presentation with lesions of sporotrichoid progression in the lymphatic system.

In vitro antibacterial activity of bioactive glass S53P4 on multiresistant pathogens causing osteomyelitis and prosthetic joint infection.

BACKGROUND: Conventional local treatment for medullary osteomyelitis (OM) includes insertion of antibiotic-loaded polymethylmethacrylate (PMMA) cement. Nevertheless, PMMA may delivery irregular concentration of antibiotic to surrounding tissue. We aimed to compare the in vitro antibacterial activity of Bioactive Glass (BAG) S53P4, which is a compound showing local antibacterial activity, to that of antibiotic-loaded PMMA against multidrug resistant bacteria from OM isolates. METHODS: We studied convenience samples of multidrug resistant (MDR) microorganisms obtained from patients presenting OM and prosthetic joint infection (PJI). Mixtures containing tryptic soy broth (TSB) and inert glass beads (2 mm), BAG-S53P4 granules (0.5-0.8 mm and < 45 mm) and Gentamicin or Vancomycin-loaded PMMA beads were inoculated with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative Staphylococcus (MR-CoNS), Pseudomonas aeruginosa or Klebsiella pneumoniae isolates. Glass beads (2.0 mm) were used as a control. Antibacterial activity was evaluated by means of time-kill curve, through seeding the strains on blood agar plates, and subsequently performing colony counts after 24, 48, 72, 96, 120 and 168 h of incubation. Differences between groups were evaluated by means of two-way analysis of variance (ANOVA) and Bonferroni's t test. RESULTS: Inhibition of bacterial growth started soon after 48 h of incubation, reached zero CFU/ml between 120 and 168 h of incubation for both antibiotic-loaded PMMA and BAG S53P4 groups, in comparison with inert glass (p < 0.05). No difference regarding time-kill curves between antibiotic-loaded PMMA and BAG S53P4 was observed. CONCLUSIONS: BAG S53P4 presented antibacterial properties as much as antibiotic-loaded PMMA for MDR bacteria producing OM and PJI.

Microbial investigation of biofilms recovered from endotracheal tubes using sonication in intensive care unit pediatric patients

Abstract Objectives To compare cultured microorganisms identified on endotracheal tubes biofilms through sonication technique with traditional tracheal aspirate collected at extubation of pediatric intensive care unit patients. Methods Demographic and epidemiological data were analyzed to identify factors possibly related with the microbiological profile of the two collection methods. Associations between categorical and continuous variables were analyzed using the chi-square or Fisher's exact test, or Student's t test. p-Value <0.05 were considered significant. Results Thirty endotracheal tubes and tracheal aspirates samples from 27 subjects were analyzed. Only one patient presented the clinical diagnosis of ventilator-associated pneumonia. Overall, 50% of bacteria were Gram-negative bacilli, followed by Gram-positive bacteria in 37%, and fungi in 10%. No statistically significant difference on the distribution of Gram-positive or Gram-negative bacteria (p = 0.996), and fungi (p = 0.985) were observed between the collection methods. Pseudomonas spp. was the most frequent microorganism identified (23.8%), followed by Streptococcus spp. (18.5%), Acinetobacter spp. (15.9%), coagulase-negative staphylococci (11.2%), and Klebsiella spp. (8.6%). Concordant results between methods amounted to 83.3%. Pseudomonas aeruginosa and Acinetobacter baumannii showed carbapenem resistance in 50% and 43.7% of the isolates, respectively. In general, cultures after endotracheal tubes sonication (non-centrifuged sonication fluid and centrifuged sonication fluid) yielded bacteria with higher rates of antimicrobial resistance compared to tracheal aspirates cultures. Additionally, in 12 subjects (40%), we observed discrepancies regarding microbiologic profiles of cultures performed using the collection methods. Conclusions Our study demonstrated that sonication technique can be applied to ET biofilms to identify microorganisms attached to their surface with a great variety of species identified. However, we did not find significant differences in comparison with the traditional tracheal aspirate culture approach.

Microbial investigation of biofilms recovered from endotracheal tubes using sonication in intensive care unit pediatric patients.

OBJECTIVES: To compare cultured microorganisms identified on endotracheal tubes biofilms through sonication technique with traditional tracheal aspirate collected at extubation of pediatric intensive care unit patients. METHODS: Demographic and epidemiological data were analyzed to identify factors possibly related with the microbiological profile of the two collection methods. Associations between categorical and continuous variables were analyzed using the chi-square or Fisher's exact test, or Student's t test. p-Value <0.05 were considered significant. RESULTS: Thirty endotracheal tubes and tracheal aspirates samples from 27 subjects were analyzed. Only one patient presented the clinical diagnosis of ventilator-associated pneumonia. Overall, 50% of bacteria were Gram-negative bacilli, followed by Gram-positive bacteria in 37%, and fungi in 10%. No statistically significant difference on the distribution of Gram-positive or Gram-negative bacteria (p=0.996), and fungi (p=0.985) were observed between the collection methods. Pseudomonas spp. was the most frequent microorganism identified (23.8%), followed by Streptococcus spp. (18.5%), Acinetobacter spp. (15.9%), coagulase-negative staphylococci (11.2%), and Klebsiella spp. (8.6%). Concordant results between methods amounted to 83.3%. Pseudomonas aeruginosa and Acinetobacter baumannii showed carbapenem resistance in 50% and 43.7% of the isolates, respectively. In general, cultures after endotracheal tubes sonication (non-centrifuged sonication fluid and centrifuged sonication fluid) yielded bacteria with higher rates of antimicrobial resistance compared to tracheal aspirates cultures. Additionally, in 12 subjects (40%), we observed discrepancies regarding microbiologic profiles of cultures performed using the collection methods. CONCLUSIONS: Our study demonstrated that sonication technique can be applied to ET biofilms to identify microorganisms attached to their surface with a great variety of species identified. However, we did not find significant differences in comparison with the traditional tracheal aspirate culture approach.

Concentration of Sonication Fluid through Centrifugation Is Superior to Membrane Filtration for Microbial Diagnosis of Orthopedic Implant-Associated Infection.

Microbial identification of orthopedic implant-associated infections using sonication fluid (SF) submitted to a concentration step by membrane filtration (SMF) was compared with the standard centrifugation (SC) method. Among 33 retrieved infected implants, sonication identified microorganisms in 26 (78.8%). The sensitivity of SC was higher than that of SMF (78.8% versus 30.3%; P < 0.001).

Tratamento de infecção após artroplastia total de joelho / Treatment of infection after total knee arthroplasty

Objetivos: Comparar as taxas de sucesso das modalidadesterapêuticas utilizadas no tratamento de infecções associadas aartroplastia total de joelho (ATJ), e avaliar o desfecho funcionale de dor nas modalidades por meio de escores de qualidadede vida. Métodos: Avaliamos todos os indivíduos que desenvolveraminfecção após ATJ em nosso serviço, entre 1º de janeirode 2008 e 31 de dezembro de 2010. Resultados: Neste período,29 pacientes com ATJ tiveram infecção, e 12 deles foram submetidosa desbridamento e retenção da prótese (D+R), sete acirurgia de troca da prótese em dois estágios, seis a cirurgia emum estágio, e quatro receberam terapia antibiótica supressivapor não poderem ser submetidos a nova cirurgia. Conclusão: Astaxas de sucesso de D+R, da revisão em um, e em dois está-gios foi de 75%, 83,3% e 100%, respectivamente. Os melhoresresultados referente à qualidade de vida e função ocorreramnos pacientes submetidos a D+R. Em contraste, os piores resultadosforam observados em pacientes tratados com cirurgiade revisão em dois estágios. Nível de Evidência II, EstudosPrognósticos- Investigação do Efeito de Característica deum Paciente Sobre o Desfecho da Doença.

Objectives: To identify and compare the rate of success of therapeuticmodalities applied in surgeries for the treatment of infectionsassociated with total knee arthroplasty (TKA), and to evaluate thefunctional outcome and pain in different therapeutic modalities bymeans of quality of life scores. Methods: We evaluated all patientswho developed periprosthetic infection after TKA for primary orsecondary osteoarthritis, in the period from January 1st, 2008 toDecember 31st, 2010. Results: In the study period, 29 patients withTKA had infection, and 12 of these underwent debridement andretention of the prosthesis (D+R), seven received two-stage and sixone-stage exchange arthroplasties, and four patients were treatedwith suppressive antibiotic therapy because they could not undergoanother surgical procedure. Conclusion: The D+R , one-stagerevision and two-stage revision success rates were 75%, 83.3%,and 100%, respectively. The best results of quality of life (QoL) andfunction occur in patients undergoing D+R. In contrast, the worstQoL and functional results were obtained in patients treated withtwo-stage revision arthroplasty. Level of Evidence II, PrognosticStudies - Investigating the Effect of a Patient Characteristicon the Outcome of Disease.