Prevalence of MDR bacteria in an acute trauma hospital in Port-au-Prince, Haiti: a retrospective analysis from 2012 to 2018.

BACKGROUND: Antibiotic resistance (ABR) is recognized as an increasing threat to global health. Haiti declared ABR an emerging public health threat in 2018, however, the current surveillance system is limited. We described the microbiological data from a Médecins Sans Frontières trauma hospital, to increase knowledge on ABR in Haiti for similar facilities. METHODS: A retrospective cross-sectional analysis of routine microbiological data of samples taken from patients admitted to the inpatient ward or followed up in the outpatient clinic of the trauma hospital from March 2012 to December 2018. Resistance trends were analysed per isolate and compared over the 7 year period. RESULTS: Among 1742 isolates, the most common samples were pus (53.4%), wound swabs (30.5%) and blood (6.9%). The most frequently detected bacteria from these sample types were Staphylococcus aureus (21.9%), Pseudomonas aeruginosa (20.9%) and Klebsiella pneumoniae (16.7%). MDR bacteria (32.0%), ESBL-producing bacteria (39.1%), MRSA (24.1%) and carbapenem-resistant Enterobacteriaceae (CRE) species (2.6%) were all detected. Between 2012 and 2018 the number of ESBL isolates significantly increased from 3.2% to 42.9% (P = 0.0001), and resistance to clindamycin in MSSA isolates rose from 3.7% to 29.6% (P = 0.003). Two critical WHO priority pathogens (ESBL-producing CRE and carbapenem-resistant P. aeruginosa) were also detected. CONCLUSIONS: Over a 7 year period, a high prevalence of MDR bacteria was observed, while ESBL-producing bacteria showed a significantly increasing trend. ABR surveillance is important to inform clinical decisions, treatment guidelines and infection prevention and control practices.

Ending preventable newborn deaths in a generation.

The end of the Millennium Development Goal (MDG) era was marked in 2015, and while maternal and child mortality have been halved, MGD 4 and MDG 5 are off-track at the global level. Reductions in neonatal death rates (age <1 month) lag behind those for post-neonates (age 1-59 months), and stillbirth rates (omitted from the MDGs) have been virtually unchanged. Hence, almost half of under-five deaths are newborns, yet about 80% of these are preventable using cost-effective interventions. The Every Newborn Action Plan has been endorsed by the World Health Assembly and ratified by many stakeholders and donors to reduce neonatal deaths and stillbirths to 10 per 1000 births by 2035. The plan provides an evidence-based framework for scaling up of essential interventions across the continuum of care with the potential to prevent the deaths of approximately three million newborns, mothers, and stillbirths every year. Two million stillbirths and newborns could be saved by care at birth and care of small and sick newborns, giving a triple return on investment at this key time. Commitment, investment, and intentional leadership from global and national stakeholders, including all healthcare professionals, can make these ambitious goals attainable.

Neutrophil migration in the activation of the innate immune response to different Flavobacterium psychrophilum vaccines in zebrafish (Danio rerio).

Flavobacterium psychrophilum is a Gram-negative bacterium, responsible for the bacterial cold-water disease and the rainbow trout fry syndrome in freshwater salmonid fish. At present, there is only one commercial vaccine in Chile, made with two Chilean F. psychrophilum isolates and another licensed in Europe. The present study analyzed neutrophil migration, as a marker of innate immune activation, in zebrafish (Danio rerio) in response to different F. psychrophilum bath vaccines, which is the first step in evaluating vaccine effectiveness and efficiency in fish. Results indicated that bacterins of the LM-02-Fp isolate were more immunogenic than those from the LM-13-Fp isolate. However, no differences were observed between the same bacteria inactivated by either formaldehyde or heat. Importantly, the same vaccine formulation without an adjuvant only triggered a mild neutrophil migration compared to the complete vaccine. Observations also found that, after a year of storage at 4°C, the activation of the innate immune system by the different vaccines was considerably decreased. Finally, new vaccine formulations prepared with heat and formaldehyde inactivated LM-02-Fp were significantly more efficient than the available commercial vaccine in regard to stimulating the innate immune system.

Reducing maternal, newborn, and infant mortality globally: an integrated action agenda.

There has been increasing awareness over recent years of the persisting burden of worldwide maternal, newborn, and child mortality. The majority of maternal deaths occur during labor, delivery, and the immediate postpartum period, with obstetric hemorrhage as the primary medical cause of death. Other causes of maternal mortality include hypertensive diseases, sepsis/infections, obstructed labor, and abortion-related complications. Recent estimates indicate that in 2009 an estimated 3.3 million babies died in the first month of life and that overall, 7.3 million children under 5 die each year. Recent data also suggest that sufficient evidence- and consensus-based interventions exist to address reproductive, maternal, newborn, and child health globally, and if implemented at scale, these have the potential to reduce morbidity and mortality. There is an urgent need to put elements in place to promote integrated interventions among healthcare professionals and their associations. What is needed is the political will and partnerships to implement evidence-based interventions at scale.

Placebo effect after prefrontal magnetic stimulation in the treatment of resistant obsessive-compulsive disorder: a randomized controlled trial.

Many patients with obsessive-compulsive disorder (OCD) do not achieve satisfactory symptom improvement with conventional treatments. Here, we evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) applied over the right dorsolateral prefrontal cortex (rDLPFC) in patients with treatment-resistant OCD. This was a double-blind randomized trial involving 30 treatment-resistant OCD outpatients, allocated to have either sham or active high-frequency rTMS (over the rDLPFC) added to their treatment regimens for 6 wk, with 6 wk of follow-up. Active rTMS consisted of 30 applications (figure-of-eight coil; 10 Hz at 110% of motor threshold; 1 session/d; 40 trains/session; 5 s/train; 25-s intertrain interval). At weeks 0, 2, 6, 8, and 12, we applied the Yale-Brown Obsessive-Compulsive Scale (YBOCS), Clinical Global Impression (CGI) scale, 14-item Hamilton Anxiety Rating Scale (HAMA-14), 17-item Hamilton Depression Rating Scale (HAMD-17), and 36-item Short-form Health Survey. The primary outcome measure was a positive response (≥ 30% improvement in YBOCS score, together with a 'much improved' or 'very much improved' CGI - Improvement scale rating). One patient in each group showed a positive response (p=1.00). For YBOCS score, there was significant effect of time (F=7.33, p=0.002) but no significant group effect or group×time interaction. In treatment-resistant OCD, active rTMS over the rDLPFC does not appear to be superior to sham rTMS in relieving obsessive-compulsive symptoms, reducing clinical severity, or improving treatment response, although there is evidence of a placebo effect.

[Tuberculous pericarditis. A case reported and a brief review]. / Pericarditis tuberculosa. Informe de un caso y revisión de la literatura.

Pericarditis in patients with tuberculosis is estimated from one to eight percent. The tuberculosis is considered endemic in developing countries and tuberculous pericarditis is found frequently in patients with the Acquired Immunodeficiency Syndrome (AIDS). This entity is characterized by mediastinal or hilar lymph nodes, sternum or spine with retrograde tracheobronchial extension. Spread may also take place by the hematogenous route. The beginning can be suddenly, like an unknown pericarditis, with cough, dyspnea, chest pain, ankle edema, fever, tachycardia, and night sweats. Clinical examination shows pericardial friction rub, liver congestion, ascites, edema and low intensity cardiac noise. Chest radiograph shows cardiomegaly. The two-dimensional echocardiography verifies pericardial effusion. The PPD skin test can be negative in 30% by the presence of anergy. Definitive diagnosis is the demonstration of pericardium inflammatory granulomas and the presence of acid-alcohol resistant bacilli in the pericardial biopsy. We conclude that the tuberculous pericarditis diagnosis should be established by clinical suspicion, two-dimensional echocardiography and pericardiocentesis and later pericardiectomy must be practiced as soon as possible before receiving pharmacological treatment with triple drug therapy and steroids.

Parafuso de massa lateral do atlas para fixação da coluna cervical superior: resultados cirúrgicos / Tornillos de masa lateral del atlas para la fijación de la columna cervical superior: resultados quirúrgicos / Lateral mass screws of the atlas for upper cervical spine fixation: surgical results

OBJETIVO: Apresentar os resultados cirúrgicos de uma série de casos de estabilização da coluna cervical superior com o uso de parafusos de massa lateral do atlas. MÉTODOS: Avaliação retrospectiva dos resultados cirúrgicos de pacientes submetidos à estabilização da coluna cervical superior com o uso de parafusos de massa lateral do atlas. RESULTADOS: Seis pacientes foram operados durante o período de janeiro de 2009 a abril de 2010, quatro homens e duas mulheres. Não houve morbidade permanente ou morbidade nessa série de casos. A principal causa de instabilidade atlanto-axial foi trauma e houve apenas um caso de fratura patológica do odontoide por metástase de próstata. A fixação do áxis foi obtida com o uso de três diferentes técnicas de parafusos (pars, pedicular e de lâmina), com igual distribuição entre os pacientes. CONCLUSÃO: O uso de parafusos na massa lateral do atlas é uma importante técnica para se obter estabilidade e fusão na coluna cervical superior, e com o conhecimento da anatomia e da técnica cirúrgica, bons resultados podem ser atingidos.

OBJECTIVE: To present the surgical results of a case series of upper cervical spine stabilization with the use of lateral mass screws of the atlas. METHODS: Retrospective review of the surgical results of patients submitted to upper cervical spine stabilization with the use of lateral mass screws of the atlas. RESULTS: Six patients were operated in the period between January 2009 to April 2010, four men and two women. There was no permanent morbidity or mortality in the presented series. The main cause of atlanto-axial instability was trauma and there was just one case of odontoid pathologic fracture from a prostate metastasis. Axis fixation was achieved with the use of three different screw techniques (pars, pedicle and laminar), with equal distribution among the patients. CONCLUSIONS: The use of lateral mass screws of the atlas is an important technique to achieve fusion and stability of the upper cervical spine and with the knowledge of the anatomy and of the surgical technique good results can be achieved.

OBJETIVOS: presentar los resultados quirúrgicos de una serie de casos de estabilización con el uso de tornillos de masa lateral del atlas. MÉTODOS: evaluación retrospectiva de los resultados quirúrgicos de los pacientes sometidos a estabilización de la columna cervical superior con el uso de tornillos de masa lateral del atlas. RESULTADOS: Seis pacientes operados entre enero 2009 y abril 2010, siendo cuatro hombres y dos mujeres. No hubo mortalidad o morbilidad grave en esta serie. La principal causa de inestabilidad atlantoaxial fue traumática con apenas un caso de fractura patológica del odontoide por una metástasis de tumor de próstata. Fijación del axis fue alcanzada con el uso de tres diferentes técnicas (pars, pedicular, laminar), con dos casos cada una. Conclusión: el uso de tornillos de masa lateral en el atlas es una importante técnica para alcanzar la fusión y la estabilidad de la columna cervical, y con el conocimiento de la anatomía y de la técnica quirúrgica es posible obtenerse excelentes resultados.

Apresentação atípica de hérnia discal cervical sequestrada / Unusual presentation of sequestered cervical disc herniation

Pacientes portadores de hérnias de disco cervicais podem ser estar assintomáticos ou cursarem com quadros de radiculopatia ou mielopatia cervical. Geralmente, elas estão situadas anterior ou antero-lateralmente no espaço epidural. Apresentamos um caso de hérnia de disco cervical extrusa com migração dorsolateral no canal, mimetizando uma lesão tumoral extradural.Acredita-se que a ausência das articulações de Luschkano nível C7-T1 favoreça a migração dorsal da hérnia neste nível. O diagnóstico diferencial de lesões extradurais dorsolaterais com herniações de núcleo pulposo cervicais deve ser considerado no planejamento cirúrgico desses pacientes.

Effects of repetitive transcranial magnetic stimulation on auditory hallucinations refractory to clozapine.

OBJECTIVE: To study the therapeutic effects on auditory hallucinations refractory to clozapine with 1-Hz repetitive transcranial magnetic stimulation (rTMS) applied on the left temporoparietal cortex. METHOD: Eleven patients with schizophrenia (DSM-IV) experiencing auditory hallucinations (unresponsive to clozapine) were randomly assigned to receive either active of rTMS (N = 6) or sham stimulation (N = 5) (with concomitant use of clozapine) using a double-masked, sham-controlled, parallel design. A total of 160 minutes of rTMS (9600 pulses) was administered over 10 days at 90% motor threshold. The study was conducted from January 2003 to December 2005. RESULTS: There was a reduction in hallucination scores in both groups, which persisted during follow-up in the active group for the items reality (p = .0493) and attentional salience (p = .0360). Both groups showed similar patterns of symptomatic changes on subscales (negative symptoms, general psychopathology) and total scores of the Positive and Negative Syndrome Scale, Clinical Global Impressions scale, and Visual Analog Scale. CONCLUSION: Active rTMS in association with clozapine can be administered safely to treat auditory hallucinations, although its clinical utility is still questionable. No significant clinical effects were observed in the sample studied, possibly because it was too small and/or due to its high refractoriness.

Aplicação da estimulação magnética transcraniana de repetição no tratamento do transtorno obsessivo-compulsivo e outros transtornos de ansiedade / Repetitive transcranial magnetic stimulation as a treatment for obsessive-compulsive disorder and other anxiety disorders

A estimulação magnética transcraniana de repetição (EMTr) vem sendo amplamente investigada como ferramenta terapêutica em transtornos psiquiátricos, especialmente a depressão. Neste trabalho, compilamos as informações provenientes de estudos que investigaram as aplicações da EMTr no tratamento dos transtornos de ansiedade: transtorno do pânico (TP), transtorno de estresse pós-taumático (TEPT), transtorno de ansiedade generalizada (TAG) e especialmente o transtorno obsessivo compulsivo (TOC). Três estudos foram publicados abordando o tratamento do TOC, sendo que utilizaram metodologias e parâmetros de aplicação extremamente diversos, dificultando a obtenção de informações conclusivas sobre a efetividade deste tratamento. Quatro estudos publicados sobre TEPT e EMTr também apresentam dados conflitantes e pouco comparáveis, mas destaca-se publicação recente com desenho duplo-cego e resultados positivos. Quanto ao TP e o TAG, apenas pequenas investigações iniciais foram realizadas. Conclusão: Apesar dos estudos citados, não há dados conclusivos sobre a eficácia terapêutica da EMTr nos transtornos de ansiedade. Isto se dá especialmente devido aos estudos com amostras pequenas e desenho aberto. Portanto, devem ser realizados estudos mais aprofundados para que possamos obter estas respostas.

[New therapies for intracranial hypertension]. / Novas terapias para hipertensão endocraniana.

OBJECTIVE: The main concepts involved in the therapeutic management of intracranial hypertension are revisited, including pathophysiology, monitoring, the traditional approach, and also the presentation of recently proposed therapies. SOURCE OF DATA: The main medical literature data bases (especially Medline and Lilacs) were searched for articles published in the last 10 years, and traditional text books and dissertations focusing the subject were consulted. SUMMARY OF THE FINDINGS: Intracranial hypertension may be associated with several cerebral neurologic lesions from traumatic, infectious or metabolic origin, and in severe cases may represent an important factor for morbidity and mortality. Increases in intracranial pressure interfere with cerebral blood flow; in order to maintain an adequate cerebral perfusion pressure, it is necessary to both reduce and control intracranial hypertension and combat low blood pressure from the very beginning of treatment. Adequate monitoring is essential, and the main points addressed in conventional management include elevation of the head of bed to 30 degrees C, central positioning of the head, optimization of hypocapnia, perfect metabolic and hydro-electrolyte balance, sedation, anti-convulsive therapy, liquor drainage, and the use of barbiturics, mannitol and furosemide. New therapies currently under investigation include the use of dexanabinol, hypertonic saline solutions, moderate hypothermia, decompressive craniectomy, optimization of cerebral perfusion pressure, and reduction in cerebral microvasculature pressure (Lund therapy). CONCLUSIONS: The use of new therapies to effectively control intracranial hypertension, especially in cases that are refractory to the usual treatment, represent a promising scenario in the management of this problem.

Novas terapias para hipertensão endocraniana / New therapies for intracranial hypertension

OBJETIVOS: São revistos os principais conceitos envolvidos na abordagem terapêutica da hipertensão endocraniana, desde a abordagem tradicional até a apresentação das novas terapias preconizadas. FONTES DOS DADOS: Foram revistas as principais bases de dados da literatura médica, particularmente o Medline e o Lilacs, nos últimos 10 anos, além de livros textos consagrados e teses dedicadas ao assunto. SíNTESE DOS DADOS: A hipertensão endocraniana pode estar associada a diversas lesões neurológicas cerebrais, sejam de origem traumática, infecciosa ou metabólica, podendo, nos casos graves, se constituir em importante fator de morbimortalidade. O aumento da pressão intracraniana interfere com o fluxo sangüíneo cerebral, de modo que para se manter uma pressão de perfusão cerebral adequada, é necessário tanto a redução e o controle da hipertensão endocraniana, como o combate agressivo à hipotensão arterial, desde as fases iniciais do atendimento. A monitorização adequada é fundamental, e as principais medidas adotadas no tratamento convencional envolvem a elevação da cabeceira do leito a 30 graus, o posicionamento centrado da cabeça, a hipocapnia otimizada, o perfeito equilíbrio hidroeletrolítico e metabólico, a sedação, a terapia anticonvulsiva, a drenagem liquórica, o uso de barbitúricos, manitol e furosemida. As novas terapias que vêm sendo estudadas incluem, principalmente, o dexanabinol, as soluções salinas hipertônicas, a hipotermia moderada, a craniotomia descompressiva, a otimização da pressão de perfusão cerebral e a redução da pressão na microvasculatura cerebral (terapia de Lund). CONCLUSÕES: O uso de novas terapias para o controle eficaz da hipertensão endocraniana, particularmente em casos refratários ao tratamento usual, representam um cenário promissor na abordagem destes quadros.

Exenteración pélvica con técnica isquemica: opción terapéutica en carcinomas pélvicos avanzados o recurrentes / Pelvic exenteration withischemic technique: therapeutic option in advanced or recurrent pelvic carcinomas

Introducción: el tratamiento del carcinoma cervicouterino en etapa invasora es limitado. La exenteración pélvica se acompaña de elevada morbilidad y mortalidad.Objetivo: describir la experiencia del manejo de carcinoma pélvico avanzado o recurrente, utilizando una técnica quirúrgica de exenteración pélvica precedida de isquemia regional.Material y método: se realizó exenteración pélvica en dos tiempos, en el primero se tomaron biopsias transoperatorias de nódulos, ganglios o zonas sospechosas de actividad tumoral, tanto de cavidad abdominal como de retroperitoneo. En caso de reporte negativo, se realizó conducto ileal de Bricker o vejiga cecal, así como colostomía y se ligó la arteria mesentérica inferior y ambas arterias hipogástricas inmediatamente después de su nacimiento. Siete días después, en el segundo tiempo quirúrgico, se realizó exenteración al extraer en bloque el contenido pélvico.Resultados: se presentan los resultados de tres mujeres con neoplasia avanzada o recurrente, clínicamente desahuciadas por carcinoma vesical de células transicionales, carcinoma adenoescamoso del cérvix uterino etapa II B, y carcinoma cervical de estirpe epidermoide queratinizante de células grandes. La edad promedio fue de 51.7 ñ 10 años. No se presentaron complicaciones graves. La hemorragia promedio fue de 700 mL (500 a 1,000 mL). Dos de las pacientes se mantienen libres de actividad tumoral, con una supervivencia de 24.3 (1-60) meses.Discusión: la exenteración pélvica con técnica isquémica mejora la operabilidad y resecabilidad tumoral, abate de manera significativa la morbilidad y mortalidad, además de ofrecer una opción de tratamiento en los pacientes con tumores pélvicos avanzados o recurrentes.

Sarna: opçäo de tratamento por via oral / Scabies: via oral optin treatment

Os autores revisam o tema escabiose, dando maior ênfase ao aspecto da sarna crostosa ou norueguesa. Relatam suas experiências, reportando toda a evolução, do diagnóstico ao tratamento, comentando seu mecanismo de ação e, finalmente, sobre a droga ivermectina, com largo espectro de ação, destacando seu valor por via oral em dose única para o tratamento da escabiose em todas as suas formas e estágios