Factores asociados a colonización por enterococo sp resistente a vancomicina en una unidad de cuidados intensivos pediátricos del Paraguay: estudio transversal sobre historias clínicas / Factors associated with vancomycin-resistant enterococcus colonization in a pediatric intensive care unit of Paraguay: a cross-sectional study on hospital charts

INTRODUCCIÓN Las infecciones por Enterococcus sp resistente a la vancomicina se han diseminado y generan un desafío clínico-terapéutico en los pacientes hospitalizados. La amenaza de que la infección por enterococos intratables y la posibilidad que la resistencia a la vancomicina pueda propagarse a neumococos o estafilococos, abogan por la vigilancia atenta de las cepas resistentes. OBJETIVO Determinar los factores de riesgos asociados a la portación de Enterococcus sp resistente a la vancomicina en pacientes pediátricos ingresados en una unidad de cuidados intensivos pediátricos del Paraguay en el periodo entre enero de 2012 y junio de 2013. MÉTODOS Estudio transversal. Se analizaron las historias clínicas previas de 140 pacientes ingresados a terapia intensiva (niños de un mes a 18 años), a quienes se realizaron cultivos de hisopado rectal dentro de las 48 horas del ingreso, para determinar los factores asociados a la portación de Enterococcus sp resistente a la vancomicina en unidad de cuidados intensivos pediátricos. Se calculó el Odd ratio con sus intervalos de confianza y p < 0,05 para las variables de estudio. Posteriormente, se realizó regresión logística múltiple para las variables estadísticamente significativas. RESULTADOS La portación de Enterococcus sp resistente a la vancomicina se observó en 18,6% de los pacientes. Se identificaron como factores asociados: la hospitalización previa durante el último año (Odds ratio: 10,8; intervalo de confianza 95%: 2,43 a 47,8; p = 0,001), uso previo de antibióticos de amplio espectro (Odds ratio: 5,05; intervalo de confianza 95%: 2,04 a 12,5; p = 0,000), uso de dos o más antibióticos de amplio espectro en el último año (Odds ratio: 5,4; intervalo de confianza 95%: 1,5 a 18,4; p = 0,009), internación previa en área de alto riesgo (Odds ratio: 4,91; intervalo de confianza 95%: 1,83 a 13,2; p = 0,000), internación por igual o mayor a seis días en área de alto riesgo (Odds ratio: 5,64; intervalo de confianza 95%: 2,18 a 14,6; p = 0,000) y uso de inmunosupresores (Odds ratio: 4,84; intervalo de confianza 95%: 1,92 a 11,9; p = 0,001). La regresión múltiple señala a la utilización de dos o más antibióticos de amplio espectro (Odds ratio: 4,81; intervalo de confianza 95%: 1,01 a 22,8; p = 0,047) y a la historia de hospitalización previa dentro del año (Odds ratio: 7,84; intervalo de confianza 95%: 1,24 a 49,32; p = 0,028) como factores independientes asociados estadísticamente con la portación de Enterococcus sp resistente a la vancomicina. CONCLUSIÓN Los pacientes pediátricos ingresados en la unidad de cuidados intensivos con historia de internación previa dentro del año y la exposición a dos o más antibióticos de amplio espectro, tienen mayor riesgo de colonización por el enterococo resistente a vancomicina.

INTRODUCTION Vancomycin-resistant enterococcus (VRE) infections have become widespread and a challenge in hospitalized patients. The threat of infection by intractable enterococci and the possibility that vancomycin resistance could involve pneumococci or staphylococci advocate for careful surveillance of resistant strains. OBJECTIVE To determine the risk factors associated with VRE colonization in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU) in the period between January 2012 and June 2013. METHODS We conducted a cross-sectional study analyzing the clinical histories of 140 patients admitted to the PICU (children from 1 month to 18 years), who underwent rectal swab cultures within 48 hours of admission. We calculated the odds ratios and confidence intervals of the risk factors for VRE colonization in the PICU, and then we used multiple logistic regression for the statistically significant variables. RESULTS VRE colonization was present in 18.6% of patients. The following were identified as risk factors associated to VRE colonization: hospitalization during the previous year (odds ratio: 10.8, 95% confidence interval: 2.43 to 47.8; p = 0.001), prior use of one broad-spectrum antibiotic (odds ratio: 5.05; 95% confidence interval: 2.04 to 12.5; p = 0.000), use of two or more broad-spectrum antibiotics in the last year (odds ratio: 5.4, 95% confidence interval: 1.5 to 18.4; p = 0.009), prior hospitalization in the risk area (odds ratio: 4.91, 95% confidence interval: 1.83 to 13.2; p = 0.000), hospitalization for more than five days in high-risk area (odds ratio: 5.64, 95% confidence interval: 2.18 to 14.6; p = 0.000), and use of immunosuppressant drugs (odds ratio: 4.84, 95% confidence interval: 1.92 to 11.9; p = 0.001). In a logistic multiple regression the use of two or more broad-spectrum antibiotics (odds ratio: 4.81, 95% confidence interval: 1.01 to 22.8; p = 0.047) and the history of prior hospitalization in the last year (odds ratio: 7.84, 95% confidence interval: 1.24 to 49.32, p = 0.028) were identified as independent factors statistically associated with VRE colonization. CONCLUSION Pediatric patients admitted to the Intensive Care Unit with a history of prior hospitalization in the previous year, and exposure to two or more broad-spectrum antibiotics have a greater risk of colonization by vancomycin-resistant enterococcus.

Grado de conocimiento del idioma guaraní en estudiantes de medicina en un hospital universitario de Paraguay / Knowledge of the Guarani language in medical students at a university hospital in Paraguay

INTRODUCCIÓN: Paraguay es un país bilingüe, y el conocimiento del idioma guaraní constituye una herramienta importante de comunicación en la relación médico-paciente. OBJETIVO: Dar cuenta del grado y los factores que determinan el conocimiento del idioma guaraní, en estudiantes de medicina de último año en un hospital universitario de Paraguay. MÉTODOS: Estudio observacional, transversal y analítico. En él se aplicó una encuesta anónima con cuestionario a los alumnos de último año de medicina de un hospital universitario de Paraguay. Se realizó un estudio descriptivo de las características basales de los estudiantes de medicina y de su grado de conocimiento del idioma guaraní. Se efectuó la prueba de Chi-cuadrado para comparar variables categóricas, y se aplicó un estudio de regresión logística para determinar factores que determinan el grado de conocimiento del idioma. RESULTADOS: Fueron encuestados 264 estudiantes. El 82% provenía de la capital, 72% realizó sus estudios preuniversitarios en Asunción. El 92% estudió guaraní en la educación primaria y secundaria; 67,9% no lo interpreta correctamente. El 8,5% entienden y se expresan totalmente en guaraní; de ellos el 86% refirió que su mayor aprendizaje del idioma fue en el hogar familiar. El 75,2% de los encuestados consideró que la educación primaria y secundaria no ayudó en el aprendizaje. El grado de conocimiento del idioma (habla y entiende el idioma guaraní correctamente), varía si el estudiante proviene del interior o de la capital (31,25% versus 2,5%; OR ajustado: 0,24, intervalo de confianza 95% de 0,06 a 0,92; p=0,003); y según la localidad de la escuela primaria y secundaria: interior versus capital (25,6 y 1% respectivamente; OR ajustado: 0,08; intervalo de confianza 95% de 0,01 a 0,53; p=0,009). CONCLUSIONES: El grado de conocimiento de los estudiantes del guaraní es menor, comparado con población general. Los que mejor se expresan y comprenden el idioma, nacieron o lo estudiaron en el interior del país. La mayoría considera de poco aporte la educación primaria y secundaria para el aprendizaje del guaraní. Siendo el idioma una herramienta importante de comunicación en la relación médico­paciente, y sabiendo que el guaraní es el idioma más hablado del país; se deberían implementar estrategias para su aprendizaje.

INTRODUCTION: Paraguay is a bilingual country and knowledge of the guarani language is an important communication tool for the doctor- patient relationship. OBJECTIVE: To determine the degree of and the factors that influence the knowledge of the Guaraní language in medical students at a University Hospital in Paraguay METHODS: Observational, cross-sectional, analytical study in which an anonymous questionnaire was applied to the final year medical students of a University Hospital of Paraguay. The baseline characteristics of the medical students and their degree of knowledge of the Guarani language were described. The association between the characteristics of the students and the degree of knowledge of the Guarani language was evaluated with the Chi square association test and the logistic regression model. RESULTS: We included 264 students in the survey. Eighty two percent come from the capital, 72% made their pre-university studies in the capital; 92% studied Guaraní in primary and secondary education; 67.9% do not interpret Guarani correctly; 8.5% understand and express themselves totally in Guaraní. Of these, 86% refer to have the greater learning of the language in their home; 75.2% of respondents believe that primary and secondary education did not help in learning the language. The degree of knowledge of the language (speaks and understands the Guarani language correctly) varies according to: the origin of the student, the inland regions or the capital (31.25% vs. 2.5%, adjusted OR = 0.24, 95% confidence interval: 0.06 to 0.92, p = 0.003); the location of primary and secondary school: inland versus capital (25.6% vs. 1%, adjusted OR: 0.08, 95% confidence interval: 0.01 to 0.53, p = 0.009). CONCLUSIONS: The degree of knowledge of the Guaraní language of the students is lower compared to the general population; those who best understand and express themselves were born or studied in the interior of the country. The majority considers that primary and secondary education contribute little in the learning of Guaraní. Since language is an important communication tool in the patient-doctor relationship and knowing that Guarani is the most spoken language in the country, strategies for its learning should be implemented.

PAH fate during the anaerobic digestion of contaminated sludge: Do bioavailability and/or cometabolism limit their biodegradation?

The anaerobic removal of 13 Polycyclic Aromatic Hydrocarbons (PAHs) was measured in five continuous anaerobic digestors with different feed sludge, in which abiotic losses were neglected. These feeds were chosen to generate different levels of PAH bioavailability and cometabolism within the reactors. Based on the accurate modelling of PAH sorption in sludge, the aqueous fraction (including free and sorbed-to-dissolved-and-colloidal-matter PAHs) was demonstrated to be bioavailable, which validated a widespread assumption about micropollutants bioavailability in sludge. It was also demonstrated that bioavailability is not the only influencing factor. Indeed, PAHs biodegradation resulted from a combination of bioavailability and cometabolism. An equation adapted from Criddle (1993, The Kinetics of Cometabolism. Biotechnology and Bioengineering 41, 1048-1056) that takes into account both mechanisms was shown to fit the experimental data, with dry matter removal rate identified as the criteria for cometabolism. The existence of a threshold of dry matter cometabolism was suggested, below which PAHs removal would not be possible. The parameters of the Criddle equation were demonstrated to depend on PAH molecular structure, and the results suggest that they would also be influenced by substrate composition and microbial population. This research provided original outcomes for the assessment of micropollutants fate. Indeed, the understanding of the driving mechanisms was improved, which has implications for the optimization of micropollutants removal.

Intoxicación por plaguicidas en pacientes asistidos en el Centro Nacional de Toxicología del Ministerio de Salud Pública / Intoxication by pesticides in patients assisted at the National Center of Toxicology of the Ministry of Public Health

Se ha observado un gran incremento en el uso de plaguicidas en el Paraguay, especialmenteen el área agrícola; sin embargo la conciencia sobre el peligro del uso de las sustanciasquímicas aún tiene una historia relativamente corta, y actualmente el control está bastantelimitado. Las estadísticas no tienen un registro único, por lo que se estima un importantesubregistro de casos. El siguiente trabajo corresponde a un estudio descriptivo de cortetransversal y retrospectivo con el propósito de determinar la frecuencia de intoxicación por eluso de plaguicidas y las características demográficas de pacientes que acudieron al CentroNacional de Toxicología (CNT) del Centro de Emergencias Médicas de Asunción, Paraguay, en elperíodo de julio del 2000 a mayo del 2004. El 13,7% de 2570 intoxicaciones correspondieron aplaguicidas, siendo las más frecuentes a órgano fosforados (47,1%). El grupo etáreo másfrecuente correspondió al de 16 a 30 años (50,3%) con predominio en el sexo femenino(58.2%). Con relación a la ocupación las intoxicaciones afectaban a estudiantes de primaria ysecundaria con 61 casos (22,6%), seguidos por 49 casos domésticos (18,2%) y agricultores con31 casos (11,5%). La mayoría de los pacientes provenían del departamento Central con 190casos (53,9%). Se destaca el bajo número de casos asistidos en el CNT de los departamentosque usan mayor cantidad de plaguicidas, además del fácil acceso que estudiantes de primaria ysecundaria tienen a estas sustancias químicas

Cumplimiento (compliance) con la terapia de sustitucion hormonal durante tres años de mujeres atendidas en la Unidad de Climaterio y Menopausia del Hospital Simon Bolivar de Santafé de Bogotá / Remplace hormonal therapy compliment (compliance) during 3 years in women attending to the Climateric and Menopause Unit of Simon Bolivar Hospital in Santa fé de Bogotá

216 mujeres que acudieron a la consulta de un hospital universitario fueron seguidas durante un lapso de hasta 3 años, para investigar de manera descriptiva su cumplimiento con la THS, el tipo de terapia que recibieron y las complicaciones que presentaron con la misma. 126 (58.3 por ciento ) abandonaron el tratamiento, la mayoría de ellas por causa desconocida. 12 (5.5 por ciento ) no iniciaron la THS y 78 (36.2 por ciento ) si la continuaron. Esta última cifra refleja la tasa de cumplimiento global al final de los 3 años. 35.9 por ciento de las mujeres bajo THS tenían el antecedente de menopausia inducida quirúrgicamente. 3/4 partes de las mujeres recibieron tratamiento continuo. En general, las complicaciones presentadas con la THS no llevaron al abandono de la terapia. Se puede concluir que los datos obtenidos, que el cumplimiento sí es bastante bueno en la mujer que continúa con la THS. Pero la tasa inicial de deserción es alta, aunque similar al estándar mundial

Factors associated with discontinuation rates of the copper T380A IUD in a Peruvian public hospital.

The objectives of this study were to evaluate performance and causes of discontinuation of the Copper T380A IUD by users at the Family Planning Service at Hospital Arzobispo Loayza in Lima, Peru, during a period of three years. The study included 3167 acceptors of the CuT380A attending the service during 1992-1994. IUDs were inserted during interval timing. Follow-up was at 1, 12, 24 and 36 months after insertion. The following events were recorded: number of pregnancies, expulsions and all causes of discontinuation. The cumulative rates per 100 woman-years using the life-table method was calculated. Also calculated were the relative risks for expulsion and for pregnancy. At the end of the study, 361 women had discontinued the method for various reasons, whereas 1667 women continued using the method. The lost-to-follow-up proportion increased over time from 35.9 per 100 woman-years for the first year to 38.2 for the third year. The cumulative discontinuation rate over three years was 22.6 +/- 1.3 (cumulative rate +/- standard error) per 100 woman-years. The cumulative pregnancy rate for three years was 1.2 +/- 0.4 per 100 woman-years, whereas the cumulative rate of expulsion was 4.9 +/- 0.4 for the first, 6.4 for the second and 6.8 for the third year. The main cause of discontinuation during the first year of use was expulsion (4.9 per 100 woman-years) followed by personal reasons (2.1 per 100 woman-years). At the end of the third year, the main cause was personal reasons (11.4) and the second cause was expulsion (6.8). A higher probability of expulsion, pregnancy and discontinuation for bleeding and/or pain was associated with age less than 20 years. In conclusion, the effectiveness of the CuT380A IUD after three years of use was 98.8 per 100 woman-years, whereas continuation was 39.2, and loss to follow-up increased over time.

Oat cell carcinoma metastasis to the foot.

Initial isolation from the foot of a highly malignant primary bronchogenic carcinoma, small cell carcinoma (oat cell carcinoma), was identified via excisional biopsy from the right foot of a 42-year old nonsmoking Caucasian female. This patient denied any pertinent prior medical history, other than persistent pain in her right foot for approximately 1 year before seeking care. Incidental trauma prompted her to seek care, which consisted of immobilization via a wooden shoe. When symptoms persisted, her primary care physician referred her to my office for further evaluation.

Effects of melatonin on microtubule assembly depend on hormone concentration: role of melatonin as a calmodulin antagonist.

Melatonin may play a key role in cytoskeletal rearrangements through its calmodulin antagonism. In the present work, we tested this hypothesis by studying melatonin effects on both microtubule polymerization in vitro and cytoskeletons in situ. Microtubule assembly is a dynamic process inhibited by Ca2+/calmodulin. Calmodulin antagonists prevent the inhibition by binding to Ca(2+)-activated calmodulin, thus causing microtubule enlargement. In the presence of calmodulin (5 microM) and CaCl2 (1 mM), polymerization at equilibrium was inhibited by 40%. Complete reversal of the Ca2+/calmodulin effect on microtubules was observed with 10(-9) M melatonin or with 10(-5) M trifluoperazine or 1 microgram/ml of compound 48/80. In the absence of Ca2+/calmodulin, melatonin at 10(-5) M inhibited tubulin polymerization like 10(-4) M trifluoperazine does. Melatonin effects on microtubule assembly at both nanomolar and micromolar ranges were corroborated in cytoskeletons in situ. Therefore, it is suggested that at a low concentration (10(-9) M), cytoskeletal melatonin effects are mediated by its antagonism to Ca2+/calmodulin. At a higher concentration (10(-5) M), non-specific binding of melatonin to tubulin occurs, thus overcoming the melatonin antagonism to Ca2+/calmodulin. The results support the hypothesis that under physiological conditions, melatonin synchronizes different body rhythms through cytoskeletal rearrangements mediated by its calmodulin antagonism.

Binding of 3H-melatonin to calmodulin.

Studies in melatonin mechanism of action have suggested that one of them could be the binding of the hormone to calmodulin. We assessed calmodulin-melatonin binding by combining liposome incorporation of calmodulin with separation of free and bound 3H-Melatonin by a rapid ultrafiltration method. Specific binding to calmodulin was saturable, reversible, Ca(++)-dependent, ligand selective, and showed high affinity. Saturation as well as association-dissociation studies revealed that 3H-Melatonin binds to a single site on the calmodulin molecule with a Kd of 188 pM and a total binding capacity Bmax of 35 pM/ug of calmodulin. Displacement experiments showed that the relative order of potency of some compounds for inhibition of 3H-Melatonin was as follows: Melatonin > 6-chloromelatonin > 6-hydroxymelatonin > luzindole > trifluoperazine. The results explain our previously reported melatonin effects such as cytoskeletal rearrangements, inhibition of calmodulin dependent phosphodiesterase activity as well as the modification of Ca(++)-calmodulin electrophoretic mobility. The high affinity of melatonin binding to calmodulin suggests that the hormone is able to modulate cell activity by intracellularly binding to calmodulin at physiologically ranges. Melatonin-calmodulin binding could modulate many intracellular Ca++ functions and thus, the set-point for cell activity will follow the rhythmic circulating levels of the pineal hormone. Moreover, since calmodulin and melatonin are phylogenetically well preserved compounds, their interaction may represent a primary mechanism for both the regulation and the synchronization of cell physiology.

Melatonin modifies calmodulin cell levels in MDCK and N1E-115 cell lines and inhibits phosphodiesterase activity in vitro.

The interaction between melatonin and calmodulin was explored. Calmodulin cell levels in MDCK and N1E-115 cells cultured with 10(-9) M melatonin were increased after 3 days but decreased after 6 days. Melatonin inhibited calmodulin-dependent phosphodiesterase and when either melatonin or [3H]melatonin was preincubated with calmodulin and separated by electrophoresis, comigration of calmodulin with the radioactivity as well as modification of the Ca2+ calmodulin shift were observed. The results point out that one of the mechanisms of action of melatonin is a calmodulin-melatonin interaction.

Melatonin effects on the cytoskeletal organization of MDCK and neuroblastoma N1E-115 cells.

Despite the fact that many physiological and pharmacological actions of melatonin (MEL) have been described, its mechanism of action at the subcellular level remains unclear. It has been suggested that MEL has effects on cellular processes that involve microfilaments and microtubules. In the present study MEL effects on the cytoskeleton were evaluated in MDCK and N1E-115 cells in which the microfilaments have been shown to participate in cell morphology and dome formation (MDCK) and the microtubules in neurite outgrowths. After one day of culture with 10(-11)-10(-7) M MEL MDCK cells showed an increase in the number of elongated cells. After four days with the hormone, an increase in the incidence of MDCK cells contacting neighboring cells through long cytoplasmic elongations was observed. Actin antibody stain showed the appearance of thicker fluorescent fibres beneath the cell membrane and over the nucleus in the MEL treated cells. An increase in dome formation in confluent cells was also observed. In N1E-115 cells MEL (10(-13)-10(-5) M) induced an increase in cell with neurite processes. Neurite outgrowth is clearly seen at 24 h after plating. MEL-treated cells grow in clusters with neurites forming intricate networks. Antitubulin antibody stain showed long fluorescent neurites in the N1E-115 MEL-treated cells. A decrease in N1E-115 neurite formation was observed with either serotonin or 6-hydroxymelatonin (6OH-MEL). However, the number of MDCK cells with cytoplasmic elongations was decreased only after 6OH-MEL. We conclude that MEL action at the cellular level involves a modification of the cytoskeletal organization.

Effects of physostigmine infusion on healthy volunteers deprived of rapid eye movement sleep.

Rapid eye movement sleep (REMS) deprivation is believed to alter the sensitivity of various neurotransmitter systems. In the present article, we studied 20 healthy volunteers divided into three groups. Group A attended the sleep laboratory for three nights: acclimatization, a baseline night, and one night of physostigmine infusion. Group B attended for eight nights; acclimatization, baseline, four nights of REMS deprivation, and two recovery nights. With the exception of the first recovery night, when group C volunteers were administered physostigmine, group C's schedule was identical to group B's. The infusions received by group A and C were composed of 1.0 mg of physostigmine, dissolved in 100 ml of saline solution. These were administered 5 min after sleep onset and thereafter every hour, except when the subjects were either awake or in REMS. All of the subjects receiving the cholinomimetic infusion were given a peripheral anticholinergic. Group A experienced a great number of awakenings with a decrease in REMS percentage. Group B recovery occurred over two nights, with an increase in the average length of REMS. Group C exhibited maximum REMS rebound on the first recovery night with an increased number of REMS episodes, as well as significant reductions in the first REMS latency. Our findings suggest that physostigmine alters REMS rebound following REMS deprivation.

The effect of total sleep deprivation on plasma melatonin and cortisol in healthy human volunteers.

Twelve healthy volunteers were included in this study. Baseline curves for melatonin and cortisol were obtained after one night of adaptation to laboratory conditions. From 10:00 p.m. to 6:00 a.m., blood samples were drawn every hour. On the third night, the subjects were kept awake at the sleep unit. Curves for the two hormones were then obtained after 36 h of total sleep deprivation (SD). The levels of these hormones were evaluated by calculating the area under the curve at each hour in both situations (basal and after sleep deprivation). It was found that the melatonin levels were increased after sleep deprivation, whereas the cortisol levels remained the same. These results suggest a mechanism by which a reset of abnormal rhythms can occur in depression.

Plantar fibromatosis: surgical considerations with case histories.

Plantar fibromatosis characteristically is found in the central and medial bands of plantar fascia, although it has been reported in other areas of the foot and, through continued growth and extension, has become adherent to tendons and overlying structures. Clinically, the lesion is somewhat uncommon, usually accompanied with minimal pain and benign in nature. However, it must be distinguished from other possibly malignant lesions that may also localize in the foot. The treatment of choice is surgical extirpation of the mass. Unfortunately, the outer limits of the lesion are difficult to define, and incomplete excision often results in return of the lesion postoperatively. Therefore, a complete fasciectomy of the involved fascia is the procedure of choice in order to reduce markedly the possibility of recurrence of the fibromatosis lesion.