Species distribution and antifungal susceptibility of bloodstream fungal isolates in paediatric patients in Mexico: a nationwide surveillance study.

OBJECTIVES: To establish the species distribution and in vitro susceptibilities of 358 bloodstream fungal isolates from paediatric patients in Mexico. METHODS: Isolates were collected during a 2 year surveillance programme in 14 medical centres in 10 Mexican states. A molecular approach was used to determine the Candida parapsilosis species complex. In vitro susceptibility to amphotericin B, fluconazole, voriconazole, itraconazole, posaconazole, caspofungin, anidulafungin and micafungin was determined according to CLSI procedures. Species-specific clinical breakpoints for fluconazole, voriconazole and echinocandins were applied. RESULTS: Candida spp. accounted for 98.33% of fungaemias, including 127 Candida albicans isolates, 127 C. parapsilosis complex isolates (121 C. parapsilosis sensu stricto, 4 Candida orthopsilosis and 2 Candida metapsilosis strains) and 72 Candida tropicalis isolates. C. albicans and C. parapsilosis complex were the species predominant in neonates (48 cases each; 41.02%). C. parapsilosis complex was also the predominant species in patients 1 month to <2 years of age (P = 0.007). In contrast, C. albicans was the most frequent species in patients aged 2 to <12 years (P = 0.003). Antifungal resistance was rare among the subset of isolates. Candida glabrata showed the highest resistance rate to amphotericin B (1/9 isolates), fluconazole (1/9 isolates) and itraconazole (2/9 isolates). CONCLUSIONS: The species distribution differed with the age of the patients, with C. albicans and C. parapsilosis complex being the most commonly isolated species. C. glabrata showed the highest resistance rate to amphotericin B, fluconazole and itraconazole. This is the first study of fungaemia episodes in Mexican children.

Oral thromboprophylaxis in pelvic trauma: a standardized protocol.

BACKGROUND: Thromboprophylaxis for deep vein thrombosis (DVT) after lower-extremity trauma could include rivaroxaban, an oral medication that does not need laboratory monitoring. OBJECTIVE: To assess rivaroxaban's efficacy in preventing DVTs after pelvic trauma compared to its historical incidence. MATERIALS AND METHODS: All patients admitted with pelvic fractures in a 12-month period followed a standardized thromboprophylaxis protocol: 1) rivaroxaban 10 mg/day within 24 h of injury or upon hemodynamic stability; 2) pre-operative, post-operative, and 30-day extremity ultrasound; 3) ventilation-perfusion scintigraphy for clinical signs of pulmonary embolus; and 4) a 45-, 90-, and 120-day re-evaluation. Rivaroxaban administration ceased the day of surgery and restarted 12 h post-operatively or upon hemodynamic stability, continuing for 30 days. Excluded patients had severe neurological or hepatosplenic injuries, heparin hypersensitivity, or hemodynamic instability. RESULTS: Of 113 patients assessed, 84 patients (66 males), average age 46.6 years (range 19-69 years), were included. They had isolated pelvic trauma (n = 37), associated lower limb injuries (n = 47), average Injury Severity Score 21.4 (range 16-50), and average Glasgow Coma Scale score 13.6 (range 9-15). Patients receiving thromboprophylaxis soon after their fracture (n = 64) had a lower incidence of DVT than those receiving delayed thromboprophylaxis (n = 20) (p = 0.02). One patient (1.2%) died from a pulmonary embolus; 13 had asymptomatic below-the-knee DVTs. Rivaroxaban did not increase intra- or post-operative bleeding in surgical wounds. CONCLUSIONS: DVT incidence after pelvic fractures is reduced by administering antithrombotics within 24 h of injury or, if the patient is hemodynamically unstable, 24 h after stabilization. Rivaroxaban is a safe and effective method of providing this thromboprophylaxis.

Single fascia iliaca compartment block for post-hip fracture pain relief.

Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37-96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block's efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.

Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

PURPOSE: Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients. METHODS: The Acute Kidney Injury-Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge. RESULTS: A total of 1032 ICU patients out of 1802 [57.3%; 95% confidence interval (CI) 55.0-59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage 1 = 1.679 (95% CI 0.890-3.169; p = 0.109), stage 2 = 2.945 (95% CI 1.382-6.276; p = 0.005), and stage 3 = 6.884 (95% CI 3.876-12.228; p < 0.001). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) in 47.7% (95% CI 43.6-51.7) versus 14.8% (95% CI 11.9-18.2) in those without AKI, p < 0.001. CONCLUSIONS: This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.

Measuring intrabladder pressure with the head of the bed elevated 30°: evidence to support a change in practice.

BACKGROUND: A 30° head-of-bed elevation is recommended for most critically ill patients. Measuring intrabladder pressure with the patient in this position is controversial. OBJECTIVE: To assess the feasibility of measuring intrabladder pressure with a 30° head-of-bed elevation. METHODS: A prospective, randomized, and experimental study. Patients had intrabladder pressure measured first while positioned supine with a 30° head-of-bed elevation and 25 mL of saline instilled into the bladder and again after the patients were randomly repositioned to supine without any head-of-bed elevation (flat) or with a 30° head-of-bed elevation while supine or in right lateral or left lateral position with either 25, 50, or 200 mL of saline instilled into the patient's bladder. RESULTS: Intrabladder pressures measured with the patient in all 3 head-of-bed elevated positions were higher than pressures measured with patients supine and flat after instillation of 25 mL of saline into the bladder, but intrabladder pressure did not differ between the 30° head-of-bed elevated positions and the supine and flat positions when 50 or 200 mL of saline was instilled into the bladder. Two-way analysis of variance showed a significant interaction between volume of saline instilled (P = .05), patient's position (P = .007), and bladder instill volume and position interaction (P = .004). CONCLUSION: It is feasible to measure intrabladder pressure with a 30° head-of-bed elevation, and that position could be an alternative to supine positioning of patients for measurement of intrabladder pressure.

Reliability of intrabladder pressure measurement in intensive care.

BACKGROUND: The reliability of intrabladder pressure measurements obtained in nonsupine patients is unknown. OBJECTIVES: To investigate the reliability of measurements of intrabladder pressure obtained with 30 degrees head-of-bed elevation. METHODS: With patients supine, 30 degrees head-of-bed elevation, and instillation of 0 and 25 mL physiological saline, intrabladder pressure was measured in 10 patients: twice by one nurse to assess intraobserver reliability and once by a different nurse to assess interobserver reliability. Data were analyzed by using paired t tests, Pearson correlation, and Bland-Altman analysis. RESULTS: For intraobserver reliability, measurements obtained with no instillation (mean difference, -1.8; 95% confidence interval [CI], -4.9 to 1.3; P = .22) and with instillation of 25 mL (mean difference, -0.6; 95% CI, -1.8 to 0.6; P = .28) did not differ significantly. Pearson r values were 0.74 and 0.81, respectively. Estimated Bland-Altman bias and limits of agreements were -1.8 and -10.3 to 6.7 mm Hg and -0.6 and -3.82 to 2.62 mm Hg, respectively. For interobserver reliability, measurements obtained with no instillation (mean difference, 1.0; 95% CI, -2.2 to 4.2; P = .49) and with instillation of 25 mL (mean difference, -0.7; 95% CI, -2.45 to 1.05; P = .39) did not differ significantly. Pearson r values were 0.78 and 0.82, respectively. Estimated Bland-Altman bias and limits of agreement were 1.0 and -7.76 to 9.76 mm Hg and -0.7 and -5.5 to 4.0 mm Hg, respectively. CONCLUSIONS: Reliability of intrabladder pressure measurements obtained with 30 degrees head-of-bed elevation is strong.

Lista de cotejo de Caprini modificada como una estrategia para la aplicación de un programa de seguridad del paciente en la prevención de la enfermedad tromboembólica / Modified Caprini's checklist as a strategy to apply a safety program for the patient in the prevention of thromboembolic disease

Objetivo: Evaluar si la lista de cotejo de Caprini modificada para la valoración de factores de riesgo en la enfermedad tromboembólica venosa es útil para la práctica quirúrgica cotidiana y evaluar el estado actual del conocimiento de la tromboprofilaxis. Sede: Encuentro Nacional de Cirujanos 2009, Hacienda de San Miguel Regla Hgo. Asociación Mexicana de Cirugía General, A.C. Diseño: Estudio prospectivo, transversal, comparativo, observacional. Análisis estadístico: Porcentajes como medida de resumen para variables cualitativas y chi cuadrada con corrección de Yates. Material y métodos: Se realizó un estudio con 93 líderes de opinión de la cirugía general de todo el país y se utilizó una presentación destacando los conocimientos y evidencias más importantes en tromboprofilaxis. Luego, en pequeños grupos, se presentaba un caso clínico típico y se aplicaba la lista de cotejo de Caprini modificada que se discutía en cada mesa de trabajo y para cada caso clínico durante 2 ó 3 minutos para dar respuesta, de acuerdo a la evidencia clínica. Este ejercicio se efectuó en cinco ocasiones con diversos casos, todos ellos quirúrgicos y con diferente magnitud de dificultad. Al final del ejercicio se efectuó una encuesta de percepción acerca de la adquisición del conocimiento, con dos preguntas, a fin de averiguar si el cirujano tiene presente, y con actualización continua, el tema y en una tercera pregunta se exploró si la herramienta es o no útil para su práctica diaria. Resultados: Se entregaron 93 cuestionarios, que correspondieron al 100% de los asistentes, 66 se resolvieron completos. El instrumento de cotejo proporcionado pareció un instrumento útil en el 97%. Se realizó una comparación entre las respuestas de las preguntas que exploraban si el participante habría obtenido conocimiento o sólo reafirmado el mismo. Encontramos una diferencia estadísticamente significativa, pues ante la primera pregunta más de la mitad de los encuestados indicaban que no habían obtenido nuevos conocimientos; sin embargo, al responder si la práctica realizada les habría hecho recordar dichos conocimientos la mayoría aceptó esta situación (P < 0.001) Conclusión: Debe mantenerse una educación médica continua sobre tromboprofilaxis y se acepta la lista de cotejo de Caprini modificada para la práctica cotidiana.

Objective: To assess whether the modified Caprini risk stratification list for the evaluation of risk factors in venous thromboembolic disease is useful for the daily surgical practice and to evaluate the current status of knowledge on thromboprophylaxis. Setting: National Meeting of General Surgeons-2009, Hacienda de San Miguel Regla, Hgo. Mexican Association of General Surgery, A.C. Design: Prospective, cross-sectional, comparative, observational study. Statistical analysis: Percentages as summary measure for qualitative variables and Yates' chi-square test. Material and methods: We performed a study with 93 opinion leaders in Surgery of the whole country, and a presentation was used to point out the knowledge and most important evidences regarding thromboprophylaxis. Thereafter, in small groups, a typical clinical case and the modified Caprini risk assessment list were presented and discussed in each working table and for each clinical case for 2 to 3 min to provide an answer, based on clinical evidence. This exercise was performed five times with diverse cases; all surgical in nature and with different grades of difficulty. At the end of the exercise, a perception interview was performed regarding knowledge acquisition with two questions, aimed at finding out if the surgeon is aware and is continuously updated on the subject, and a third question to explore whether the tool is or not useful for the surgeon's daily activity. Results: We delivered 93 questionnaires, corresponding to 100% of the attendants; 66 were solved completely. The validation tool seemed to be useful in 97%. A comparison was made between the questions exploring whether the participant had obtained new knowledge or had only up-dated it. We found statistically significant difference, since to the first question more than half of the surveyed participants indicated that they did not acquire new knowledge; however, when responding to whether the performed exercise had refreshed that knowledge, most responses were positive (P < 0.001). Conclusion: A continuous medical education on thromboprophylaxis must be maintained and it is accepted that the modified Caprini risk assessment list is useful for the daily practice.

Nutritional concerns related to Roux-en-Y gastric bypass: what every clinician needs to know.

Weight loss surgery, particularly the Roux-en-Y gastric bypass (REYGB), has become a popular treatment strategy for obesity. Often the only measure of success is the amount of weight lost following surgery. Unfortunately the nutritional adequacy of the postoperative diet has frequently been overlooked, and in the months to years that follow, nutritional deficiencies have become apparent, including protein-calorie malnutrition and various vitamin and mineral deficiencies contributing to medical illnesses and limiting optimal health. Therefore, patients require close monitoring following REYGB, with special regard to the rapidity of weight loss and vigilant screening for signs and symptoms of subclinical and clinical nutritional deficiencies. Several specific nutrients require close surveillance postoperatively to prevent life-threatening complications related to deficient states. This article addresses nutritional concerns associated with REYGB with fastidious focus on recognition and treatment of the nutritional deficiencies and promotion of nutritional health following REYGB. Recommendations regarding nutritional intake following REYGB are based on available scientific data, albeit limited. In cases where data do not exist, expert or consensus opinion is provided and recommendations for future research are given. Ultimately, clinical application of this information will contribute to the prevention of nutrition-related illness associated with REYGB.

Probing the accumulation history of the voluminous Toba magma.

The age and compositional zonation in crystals from the Youngest Toba Tuff record the prelude to Earth's largest Quaternary eruption. We used allanite crystals to date and decipher this zoning and found that the crystals retain a record of at least 150,000 years of magma storage and evolution. The dominant subvolcanic magma was relatively homogeneous and thermally stagnant for approximately 110,000 years. In the 35,000 years before eruption, the diversity of melts increased substantially as the system grew in size before erupting 75,000 years ago.