Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation / Mortalidad en pacientes con COVID-19 grave sometidos a traqueostomía por ventilación mecánica prolongada

BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

ANTECEDENTES: La utilidad de la traqueostomía en pacientes COVID-19 sometidos a ventilación mecánica invasiva (VMI) prolongada ha sido cuestionada. OBJETIVO: Comparar la mortalidad a 90 días en estos pacientes, con y sin traqueostomía. MATERIAL Y MÉTODOS: Estudiamos una cohorte histórica de 92 pacientes COVID-19 con VMI prolongada (>10 días). El desenlace prima-rio fue mortalidad a 90 días. Se consideraron desenlaces secundarios los días en VMI, estadía hospitalaria/UCI, frecuencia de infecciones nosocomiales, y eventos trombóticos. Mediante regresión logística se ajustó el efecto de la traqueostomía en la mortalidad, por SOFA y días de VMI. RESULTADOS: Cuarenta y seis pacientes de 54 a 66 años (72% hombres) fueron traqueostomizados. Ellos tenían una mediana de dos comorbilidades, y recibieron el procedimiento luego de una mediana de 20,5 días en VMI (rango intercuartílico: 17-26). En el análisis crudo, la mortalidad a 90 días fue menor en los pacientes con traqueostomía que en el grupo control (6,5% vs. 32,6%; p < 0,001). No obstante, luego de controlar por factores de confusión, no se encontraron diferencias en mortalidad (riesgo relativo 0,303; p = 0,233). Las infecciones asociadas a la atención de salud y la estadía en hospital/UCI fueron mayores en los pacientes traqueostomizados que en los controles. Los eventos trombóticos ocurrieron en el 42,4% de los pacientes, sin diferencias entre grupos. No hubo casos de COVID-19 en el personal de salud que realizó las traqueostomías. CONCLUSIONES: En pacientes con COVID-19 sometidos a VMI prolongada, la realización de una traqueostomía no se asocia a un exceso de mortalidad, y es un procedimiento seguro para el personal sanitario.

Prácticas nacionales de analgesia, sedación y delirium en las Unidades de Cuidados Intensivos de adultos en Chile / Analgesia, sedation, neuromuscular blockade and delirium management practices in Chilean intensive care units

Background: The appropriate use of analgesia, sedation, neuromuscular blockade and the diagnosis and prevention of delirium (ASBD) are associated with better outcomes in critically ill patients at Intensive Care Unit (ICUs). Aim: To know the practices about analgesia, sedation, delirium, and neuromuscular blockade use among healthcare professionals working in adult ICUs in Chile. Material and Methods: An electronic survey was sent to 812 professionals working in ICUs using a previously published instrument, which was adapted and authorized by the author. Results: We received 278 surveys. Fifty two percent of respondents were physicians, 34% nurses and 11% physical therapists. Their age ranged between 30 and 39 years in 43% and was over 50 years in 9%. Eighty four percent evaluated pain routinely, but only 26% use a validated scale. Sedation was routinely evaluated with a validated scale and 73% referred to have a protocol. Neuromuscular block is seldom used, and little monitoring occurs (43%). Delirium is routinely evaluated by 48% of respondents, usually using the CAM-ICU scale. Conclusions: There is a heterogeneous adherence to the ASBD recommended practices. The main gaps are in the assessment of pain, monitoring of neuromuscular blockade and diagnosis of delirium through validated instruments.

Development of a caspase-3 antibody as a tool for detecting apoptosis in cells from rainbow trout (Oncorhynchus mykiss)

Background: Apoptosis is an active cell death process mediated by caspases activation, in which different extrinsic or intrinsic signalling pathways result in direct activation of effector caspases. Caspase-3 is considered to be the most important of the executioner caspases, which cause the morphological and biochemical changes detected in apoptotic cells. Different bacterial and virus pathogens have developed different strategies to survive inside the host and overcome natural protections, one of them is inducing apoptotic death in infected cells. We have demonstrated previously that Piscirickettsia salmonis activates this process in monocytes/macrophages from salmonid RTS11 cell line both by morphological and caspase detection assays; nevertheless, recognition of caspase activation by western blot was impossible since most of the commercially available antibodies for mammalian caspases are not cross-reacting. Results: We have generated a monospecific polyclonal antibody directed to an epitope region of salmonid caspase-3; the selected epitope present high homology with caspase-3 from others teleost species and includes the active site of the enzyme. The peptide was designed using bioinformatics tools and was chemically synthesized using the Fmoc strategy, analysed by RP-HPLC, its molecular weight confirmed by mass spectrometry and its structure analyzed by circular dichroism. The synthetic peptide was immunized and antibodies from ascitic fluid were enriched for immunoglobulins using caprylic acid and then purified by activated affinity columns. The anti-peptide activity of purified antibodies was verified by ELISA, and the ability of the anti-peptide to recognize salmonid caspase-3 activation was demonstrated with the molecule in P. salmonis RTS11 infected cells by western blotting, ELISA and immunocytochemistry. Conclusions: This is the first antibody available for a fish caspase, specifically for trout caspase-3...

Immunological strategy for detecting the pro-inflammatory cytokine TNF-alpha in salmonids

Background: Tumour necrosis factor-alpha (TNF-alpha) is a pro-inflammatory cytokine which exerts a variety of immunological functions in vertebrates. TNF-alpha has been identified and cloned in a number of teleost fish species; nevertheless, the functions displayed by this cytokine in fishes remain poorly understood, given that the low sequence identity compared to their mammalian counterpart, limit fish TNF-alpha detection using mammalian antibodies. Then, for fish immune response characterization is fundamental the production of specific fish anti-TNF-alpha antibody. Results: We have developed a monoespecific antibody against the pro-inflammatory molecule TNF-alpha of salmonid fish. TNF-alpha epitope region was identified and characterized using bioinformatic tools. The epitope sequence was chemically synthesized using Fmoc strategy, analyzed by RP-HPLC and its molecular weight confirmed by mass spectrometry. The synthetic peptide was used to immunize mice and antibodies from ascitic fluid were purified. The resulting antibody was used for molecular and histochemical detection in gut samples from salmonid fishes treated with different food. By ELISA, we detected a differential expression of TNF-alpha, the western blot analysis shows recognition of the whole TNF molecule and by immunohistochemistry TNF-alpha positive cells were observed. Conclusions: We provide an immunological tool, validated through classical immunological assays, which can be a useful tool for characterizing fish TNF-alpha function.

Invasive pneumococcal disease in a third level pediatric hospital in Mexico City: epidemiology and mortality risk factors / Enfermedad neumocócica invasora en un hospital pediátrico de tercer nivel en la Ciudad de México: características epidemiológicas y factores de riesgo asociados con mortalidad

Objective. To assess the epidemiologic characteristics of invasive pneumococcal diseases (IPD) among a population in a pediatric hospital in Mexico City and analyze mortality-related risk factors, serotype distribution and antibiotic susceptibility related to S.pneumoniae. Material and Methods. We performed a retrospective review of IPD cases at a third level pediatric hospital between 1997-2004. Results. A total of 156 patients were included. The mortality rate was 27.5 percent and was associated with six pneumococcal serotypes: 14, 6B, 23F, 6A, 19F and 19A. There was no relationship between mortality and antimicrobial susceptibility pattern. A total of 28.2 percent of isolates were resistant to penicillin and 24.6 percent were resistant to cefotaxime. A statistically significant relationship was observed between mortality and previous underlying disease (CI 95 percent; 2.5-18.3; p< 0.05) using a multivariate logistic regression model. Conclusions. Our outcomes show that IPD mortality in our population is closely related to underlying disease and to six serotypes, five of which are included in the 7-valent pneumococcal conjugate vaccine.

Objetivo. Conocer la epidemiología de la enfermedad neumocócica invasora (ENI) en un hospital pediátrico y analizar los factores de riesgo relacionados con la mortalidad, la distribución de serotipos y el patrón de susceptibilidad de S. pneumoniae. Material y métodos. Revisión retrospectiva de los casos de ENI en un hospital pediátrico de tercer nivel, entre 1997 y 2004. Resultados. En 156 pacientes la mortalidad fue de 27.5 por ciento. Los serotipos de neumococo más frecuentemente relacionados con la mortalidad fueron: 14, 6B, 23F, 6A, 19F y 19A; no hubo relación de mortalidad con la resistencia a antibióticos. El 28.2 por ciento mostró resistencia a penicilina y 24.6 por ciento a cefotaxima. A través del modelo multivariado, se encontró una relación estadísticamente significativa entre la mortalidad y enfermedad previa (IC 95 por ciento; 2.5-18.3; p<0.05). Conclusiones. La mortalidad asociada a la ENI tuvo relación significativa con antecedente de una enfermedad previa y con seis serotipos, cinco incluidos en la vacuna neumocócica conjugada 7-valente.

Streptococcus pneumoniae isolates in healthy children attending day-care centers in 12 states in Mexico

OBJECTIVE: The aim of this study was to determine the prevalence of asymptomatic nasopharyngeal carriage of Streptococcus pneumoniae, which is a major factor in the transmission of this bacterium. MATERIAL AND METHODS: Nasopharyngeal cultures were performed on children attending 32 day-care centers in 12 states in Mexico. RESULTS: Streptococcus pneumoniae was isolated from the nasopharynx of 829 out of 2 777(29.9 percent) subjects aged two months to six years. All children lived in urban areas and 80 percent spent more than six hours daily in a day-care center. Streptococcus pneumoniae serotypes most frequently identified were: 19F (23 percent), 6B (15.6 percent), 23F (11.2 percent) and 6A (14.9 percent). Thirty-six percent of the isolates were susceptible to penicillin. CONCLUSIONS: Serotype distribution suggests the possible benefits that could be obtained from the heptavalent pneumococcal conjugate vaccine.

OBJETIVO: La intención de este estudio fue determinar la prevalencia de portadores nasofaríngeos asintomáticos de Streptococcus pneumoniae, el cual es el principal factor en la transmisión de esta bacteria. MATERIAL Y MÉTODOS: Los cultivos nasofaríngeos fueron realizados en niños que asisten a 32 estancias infantiles en 12 estados de México. RESULTADOS: Streptococcus pneumoniae fue aislado de la nasofaringe de 829 (29.9 por ciento) niños de los 2 777 incluidos en el estudio con un rango de edad de 2 meses a 6 años. Todos los niños vivían en áreas urbanas y 80 por ciento permanecían más de seis horas diarias en la estancia infantil. Los serotipos de Streptococcus pneumoniae más frecuentemente identificados fueron: 19F (23 por ciento), 6B (15.6 por ciento), 23F (11.2 por ciento) y 6 A (14.9 por ciento). Treinta y seis por ciento de los aislamientos fueron susceptibles a penicilina. CONCLUSIONES: La distribución de serotipos nos da una idea de los posibles beneficios que podrían obtenerse de la vacuna neumocóccica conjugada heptavalente.

Evaluación de rasgos depresivos en estudiantes de Medicina, su conocimiento y manejo / Evaluation of depressive features in medical students, his knowledge and management

Evaluar la presencia de rasgos depresivos, nivel de conocimiento y métodos utilizados para enfrentar la depresión. Conocer el uso de los servicios de orientación y consejería que ofrece la Facultad de Medicina. Planteamiento : Los estudiantes de medicina son personas vulnerables a presentar rasgos depresivos, de ahí la importancia de este estudio. Metodología : Estudio descriptivo, prospectivo. Se exploran rasgos patológicos, conocimiento por semestre, y manejo sintomático; además, el uso del Servicio de Consejería. Del universo de 1 054, se utilizan 122 estudiantes (51,6 por ciento hombres y 48,4 por ciento mujeres); z= 1,65 (90 por ciento), c= 7 por ciento. Resultados: 78,7 por ciento estudiantes no tuvieron rasgos depresivos, 14,8 por ciento rasgos depresivos leves, 5,7 por ciento rasgos moderados, y 0,8 por ciento rasgos depresivos graves. Respecto a conocimiento de la depresión 72,1por ciento posee un conocimiento promedio, 21,3 por ciento tiene poco conocimiento y 5,7 por ciento tiene buen conocimiento. 51,8 por ciento prefiere hablar con personas de confianza como manejo sintomático, 1,8 por ciento consume drogas y/o alcohol, 23,2 por ciento realiza actividades deportivas, 5,3 por ciento se automedica, 7,1 por ciento consulta libros de autoayuda y 10,8 por ciento maneja sus síntomas consultando a médicos u otros profesionales de la salud. 73,8 por ciento no acude y 20,5 por ciento ha acudido por servicios de orientación psicológica. Un elevado porcentaje de estudiantes de medicina presenta rasgos depresivos; existe un conocimiento promedio sobre la depresión; la mayoría prefiere métodos no profesionales para el manejo de síntomas depresivos; la orientación psicológica es pobremente utilizada

Carriage of antibiotic-resistant pneumococci in a cohort of a daycare center

OBJECTIVE: To define epidemiologic relationships to determine the prevalence and potential risk factors for nasopharyngeal colonization by antibiotic-resistant pneumococci, their serotypes and their antibiotic susceptibility patterns in children attending a daycare center (DCC). MATERIAL AND METHODS: A prospective cohort study was conducted among children (n = 53) attending the DCC at Hospital Infantil de MÚxico Federico Gómez, which is staffed by 20 employees. Patients were enrolled in the study during a two-year period from September 1997 to September 1999. All the participants were followed prospectively, swabbing them every four months. The strains recovered were typed and screened for susceptibility to several antibiotics. The daycare records were reviewed also. Odds ratios and fisher's exact test: or chi square test of significance were computed from contingency tables as appropriate. Exact 95 confidence intervals were computed for odds ratios. Data analysis was performed using Epi statistics program version 6.04 a. RESULTS: Pneumococci were recovered from 45/53 of the infants at one or more visits. A total of 178 isolates were carried. The carriage rate was 47. Only 7 adults acquired pneumococci during the study. Types 6, 14, 19 and 23 were prevalent and represented 77 of the total. Antibiotic-resistant strains were higher to penicillin and erythromycin. CONCLUSIONS: Children were frequent carriers of pneumococci, the rate of carriage was high in infancy and tended to decrease with age. The types commonly carried by children were the same as those causing invasive disease. There is a high proportion of carriers with antibiotic-resistant S. pneumoniae strains. Children who have had frequent antimicrobial courses are at particular risk.