Entre a busca por assistência e sua efetivação: peregrinação de gestantes e puérperas com quadro de Near Miss Materno / Between the search for assistance and its realization: the peregrination of pregnant and postpartum women with Maternal Near Miss

Resumo Este estudo, de caráter misto e sequencial exploratório, objetivou identificar padrões relacionados a trajetória de mulheres gestantes e puérperas que evoluíram para situações de risco, desde sua chegada em um primeiro serviço de assistência até sua admissão em uma maternidade terciária. A fase quantitativa analisou 1.703 prontuários e registros de internação de mulheres assistidas em três maternidades terciárias da Região Metropolitana de Fortaleza, no Ceará, entre 2010 e 2019. Na fase qualitativa, realizada entre janeiro e setembro de 2020, participaram 14 mulheres sobreviventes ao Near Miss Materno (NMM), por meio da Entrevista Narrativa Autobiográfica de Schütze. Os achados desvelam como atrasos relacionados aos profissionais e ao sistema de saúde contribuíram para a peregrinação de gestantes e puérperas e, consequentemente, para os quadros de NMM. A peregrinação destas mulheres associa-se a problemas nas estruturas da rede de atenção e dos serviços de saúde. Assim, fazem-se necessários o uso de ferramentas de acompanhamento da qualidade do serviço prestado pelos profissionais de saúde, os processos assistenciais bem estabelecidos, as estruturas físicas e as Redes de Atenção à Saúde (RAS), que suportem o seguimento desses processos.

Abstract This mixed-method and sequential exploratory study aims to identify patterns related to the trajectory of pregnant and puerperal women who evolved to risk situations, from arrival in a first care service to admission to a tertiary maternity hospital. The quantitative phase analyzed 1,703 medical records and hospitalization records of women assisted in three tertiary maternity hospitals in the Metropolitan Region of Fortaleza, Ceará, from 2010 to 2019. The qualitative phase was conducted from January to September 2020 with 14 women survivors of Maternal Near Miss (MNM), using Schütze's Autobiographical Narrative Interview. The findings reveal how delays related to professionals and the health system contributed to the pilgrimage of pregnant and postpartum women and, consequently, to the MNM cases. The peregrination of these women is associated with problems in the structures of the Care Network and the services. Thus, it becomes necessary to use tools to monitor the quality of the service provided by health professionals and to provide well-established care processes, physical structures, and the healthcare networks that support the follow-up of these processes.

Antimicrobial photodynamic therapy against clinical isolates of carbapenem-susceptible and carbapenem-resistant Acinetobacter baumannii.

Infections caused by Acinetobacter baumannii have become a challenge for healthcare professionals because of the rapid increase in Gram-negative bacteria resistant to carbapenem antibiotics. The objective of this study was to evaluate the effect of antimicrobial photodynamic therapy (aPDT) against different strains of A. baumannii isolated from patients with infectious process and hospitalized at the intensive care unit of the hospitals of São Jose dos Campos, São Paulo. These isolates were obtained from the Valeclin Clinical Analysis Laboratory (SP, Brazil) and were tested for susceptibility to the carbapenems imipenem and meropenem by determination of the minimal inhibitory concentration (MIC) using the broth microdilution method. The strains susceptible and resistant to these antibiotics were submitted to aPDT using methylene blue and a low-level laser with a wavelength of 660 nm and fluence of 39.5 J/cm2 (energy of 15 J and time of 428 s). The number of colony-forming units (CFU/mL) was analyzed by ANOVA and the Tukey test. The laboratory of origin of the clinical isolates identified 1.54% of 13,715 strains tested over a period of 8 months as A. baumannii. Among the A. baumannii isolates, 58% were resistant to carbapenems by the disk diffusion test. Susceptible isolates exhibited MIC of 0.5 to 1 µg/mL and resistant isolates of 64 to > 128 µg/mL. PDT reduced the number of A. baumannii cells for all isolates tested, with this reduction ranging from 63 to 88% for susceptible isolates and from 26 to 97% for resistant isolates. The percentage of viability was dependent on the strain analyzed. In conclusion, these data indicate that PDT could be an alternative strategy for the control of infections caused by carbapenem-resistant A. baumannii.

The effect of thiamine deficiency on inflammation, oxidative stress and cellular migration in an experimental model of sepsis.

BACKGROUND: Sepsis is a prevalent condition in critically ill patients and may be associated with thiamine deficiency (TD). The aim of this study was to evaluate the effect of TD on inflammation, oxidative stress and cellular recruitment in a sepsis model. METHODS: The experimental sepsis model, cecal ligation and puncture (CLP), was utilized on mice in comparison with a sham procedure. The following four groups were compared against each other: SHAM with AIN93G complete chow, SHAM with thiamine deficient (TD) chow, CLP with AIN93G complete chow, and CLP with TD chow. Thiamine pyrophosphate (TPP) blood concentrations were determined, and blood and peritoneal fluid were evaluated for differences in TNF-alpha, IL-1, IL-6, KC and MCP-1/CCL2 levels. In addition, the levels of 4-HNE adducts in liver proteins were evaluated by Western Blot. RESULTS: The mean TPP blood concentration from the mice fed with the complete chow was 303.3 ± 42.6 nmol/L, and TD occurred within 10 days. TNF-α and MCP-1 concentrations in the peritoneal fluid were significantly greater in the CLP with TD chow group when compared with the other groups. The blood IL-1ß level, however, was lower in the CLP with TD chow group. Liver 4-HNE levels were highest in the TD chow groups. Blood mononuclear cell numbers, as well as peritoneal total leukocyte, mononuclear cell and neutrophil numbers were greater in the CLP with TD chow group. Peritoneal bacterial colony forming units (CFU) were significantly lower in the CLP with TD chow group. CONCLUSION: TD was associated with greater bacterial clearance, oxidative stress and inflammatory response changes.

Bacterial clearance in septic mice is modulated by MCP-1/CCL2 and nitric oxide.

Bacterial clearance is one of the most important beneficial consequences of the innate immune response. Chemokines are important mediators controlling leukocyte trafficking and activation, whereas reactive oxygen and nitrogen species are effectors in bacterial killing. In the present work, we used in vivo and in vitro models of infections to study the role of monocyte chemoattractant protein 1 (MCP-1)/CCL2 and nitric oxide (NO) in the bacterial clearance in sepsis. Our results show that MCP-1/CCL2 and NO levels are increased in the peritoneal cavity of mice 6 h after sepsis induced by cecal ligation and puncture. Pretreatment with anti-MCP-1/CCL2 monoclonal antibodies increased the number of colony-forming units (CFUs) recovered in the peritoneal lavage fluid. Moreover, CFU counts were increased in the peritoneal fluid of CCR2 mice subjected to cecal ligation and puncture. In vitro stimulation of peritoneal macrophages with recombinant MCP-1/CCL2 reduced CFU counts in the supernatant after challenge with Escherichia coli. Conversely, treatment with anti-MCP-1/CCL2 increased CFU counts under the same experimental condition. Stimulation of cultured macrophages with MCP-1/CCL2 and interferon had a synergistic effect on NO production. Macrophages from CCL2 mice showed a consistent decrease in NO production when compared with wild-type controls after stimulation with LPS + interferon. Finally, we showed incubation of macrophages with E. coli, and the ERK inhibitor U0126 increased CFU numbers and decreased intracellular levels of NO. In conclusion, we demonstrated for the first time that MCP-1/CCL2 has a crucial role in the clearance of bacteria by mechanisms involving increased expression of inducible NO synthase and production of NO by ERK signaling pathways.

Hemoculturas: estudo da prevalência dos microrganismos e o perfil de sensibilidade dos antibióticos utilizados em Unidade de Terapia Intensiva / Blood cultures: study of prevalence of microorganisms profile and sensitivity of antibiotics used in Intensive Care Unit

Objetivo - O trabalho apresentado tem como objetivo o estudo sobre a prevalência de hemoculturas positivas provenientes de pacientes hospitalizados em Unidade de Terapia Intensiva (UTI), e determinar os principais microrganismos presentes nessas amostras, bem como, analisar o perfil de sensibilidade dos principais antibióticos. Métodos - Durante o período de janeiro a julho de 2011, foram analisados os resultados de 512 coletas de hemoculturas, dentre elas 308 (60,2%) eram do sexo masculino e 204 (39,8%) do sexo feminino. Resultados - A positividade foi de 24%. Numa análise geral, Staphylococcus epidermidis foi o microrganismo de maior prevalência (45,5%), seguido por Staphylococcus aureus (13,0%) e Pseudomonas aeruginosa (12,2%). A resistência a antibiótico foi maior para oxacilina (80,1%). Conclusões - O estudo mostrou que Staphylococcus sp resistentes a oxacilina é uma das principais causa de bacteremia em UTI.

Objective - The work presented has goals to study about the prevalence of blood cultures from patients hospitalized in the Intensive Care Unit (ICU), and determine the main microorganisms present in these samples, as analyze the sensitivity of the main antibiotics. Methods - During the period from January to July 2011 were analyzed the results of 512 tests from blood cultures, among them 308 (60.2%) were male and 204 (39.8%) females. Results - The positivity was 24%. In a general analysis, Staphylococcus epidermidis was the microorganism most prevalent (45.5%), followed by Staphylococcus aureus (13.0%) and Pseudomonas aeruginosa (12.2%). The antibiotic resistance to oxacillin was higher(80.1%). Conclusions - The study showed that Staphylococcus sp is a main causes of bacteremia in ICU.

Binômio desnutrição e pobreza: uma meta a ser vencida pelos países em desenvolvimento / Binomial malnutrition and poverty: an objective to be achieved by underdeveloped countries / El binomio desnutrición y pobreza: una meta a ser superada por los países en desarrollo

A desnutrição pode ser de etiologia primária ou secundária. É um estado patológico originado do aproveitamento insuficiente dos nutrientes pelo organismo, levando ao comprometimento ponderal e/ou estatural. A desnutrição é uma causa importante de morbidade e mortalidade e tem sido uma importante questão nos países em desenvolvimento. Autores sugerem uma estreita relação entre desnutrição e situação socioeconômica. Adota-se como linha de pobreza a renda familiar equivalente a 0,25 salários mínimos por pessoa. No Brasil existem mais de 55 milhões de pessoas na pobreza. Nos últimos três anos, os investimentos do governo em infraestrutura atingiram o menor percentual do Produto Interno Bruto (PIB) das últimas seis décadas, comprometendo o crescimento econômico do país e, assim, piorando a realidade econômica e social da população.

Malnutrition can be of primary or secondary etiology. It is a pathologic condition originated from the insuficient use of nutrients by the organism, leading to the weight and/or stature failure. Malnutrition is an important reason for morbidity and mortality and it is a relevant issue in underdeveloped countries. Experts suggest a relationship between malnutrition and social/economic status. It is considered as poverty the family income equivalent to 0,25 minimum salaries per person. Brazil has more than 55 million poverty persons. In the last three years, government investments in the economic structure reached the lowest GDP (Gross Domestic Product) percentage in the last six decades, thus injuring the social condition of poor people.

La desnutrición puede ser de etiología primaria o secundaria. Es un estado patológico causado por el aprovechamiento inadecuado de los nutrientes por el cuerpo, poniendo en riesgo el peso y/o la altura. La desnutrición es una causa importante de morbilidad y mortalidad y ha sido un debate importante en los países en desarrollo. Algunos autores sugieren una estrecha relación entre la desnutrición y el nivel socioeconómico. Se adopta como línea de pobreza el ingreso familiar de 0,25 sueldos base por persona. En Brasil hay más de 55 millones de personas en la línea de pobreza. En los últimos tres años las inversiones del gobierno en infraestructura alcanzaron, en las últimas seis décadas, el porcentaje más bajo del Producto Interno Bruto (PIB), comprometiendo el crecimiento económico del país y empeorando, así, la realidad económica y social de la población.