Motor Pathways Reorganization following Surgical Decompression for Degenerative Cervical Myelopathy: A Combined Navigated Transcranial Magnetic Stimulation and Clinical Outcome Study.

(1) Background: Degenerative cervical myelopathy is one of the main causes of disability in the elderly. The treatment of choice in patients with clear symptomatology and radiological correlation is surgical decompression. The application of navigated transcranial magnetic stimulation (nTMS) techniques has the potential to provide additional insights into the cortical and corticospinal behavior of the myelopathic cord and to better characterize the possible extent of clinical recovery. The objective of our study was to use nTMS to evaluate the effect of surgical decompression on neurophysiological properties at the cortical and corticospinal level and to better characterize the extent of possible clinical recovery. (2) Methods: We conducted a longitudinal study in which we assessed and compared nTMS neurophysiological indexes and clinical parameters (modified Japanese Orthopedic Association score and nine-hole pegboard test) before surgery, at 6 months, and at 12 months' follow-up in a population of 15 patients. (3) Results: We found a significant reduction in resting motor threshold (RMT; average 7%), cortical silent period (CSP; average 15%), and motor area (average 25%) at both 6 months and 12 months. A statistically significant linear correlation emerged between recruitment curve (RC) values obtained at follow-up appointments and at baseline (r = 0.95 at 6 months, r = 0.98 at 12 months). A concomitant improvement in the mJOA score and in the nine-hole pegboard task was observed after surgery. (4) Conclusions: Our results suggest that surgical decompression of the myelopathic spinal cord improves the neurophysiological balance at the cortical and corticospinal level, resulting in clinically significant recovery. Such findings contribute to the existing evidence characterizing the brain and the spinal cord as a dynamic system capable of functional and reversible plasticity and provide useful clinical insights to be used for patient counseling.

The importance of confirmatory assays in testing blood donors for human T-cell lymphotropic virus.

BACKGROUND AND OBJECTIVES: Serological HTLV-1/2 screening is mandatory for blood donor candidates in Brazil. Our objective was to analyse HTLV test results in blood donors submitted for screening and confirmatory assays in a Brazilian blood bank. MATERIALS AND METHODS: Retrospective analysis (2017-2022) results of chemiluminescence immunoassays and confirmatory tests for HTLV-1/2 in reactive donors were performed. During the analysed period, three sets of assays were used: (1) Architect rHTLV-I/II + HTLV Blot 2.4 (Western blot [WB]); (2) Alinity s HTLV I/II Reagent Kit + INNO-line immunoassay (LIA) HTLV I/II Score (LIA); (3) Alinity + WB. RESULTS: The analysed period comprised a total of 1,557,333 donations. The mean percentage of HTLV reactive donors using the Architect assay was 0.14%. With the change to the Alinity assay, that percentage dropped 2.3-fold (0.06%). The reactivity rate in the confirmatory tests (1064 samples) ranged from 13.5% to 30.2%, whereas 58.3%-85.9% of samples were non-reactive. The highest rates of positive (30.2%) and indeterminate (11.5%) results were seen using LIA. Considering all analysed samples, those with signal/cut-off ratio (S/CO) >50 were positive in confirmatory tests (positive predictive value, PPV = 100%), whereas samples with S/CO ≤6 are very unlikely to be truly positive (PPV = 0). CONCLUSION: The use of the Alinity assay reduced the frequency of false-positive results. Confirmatory tests are important to identify true HTLV infection in blood donors, because more than 58% of initially reactive individuals are confirmed as seronegative. Categorizing S/CO values is useful for assessing the likelihood of true HTLV-1/2 infection.

Functional Approaches to the Surgery of Brain Gliomas.

In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one hand, it has been solidly demonstrated the impact of gross total resection on life expectancy. On the other hand, the paradigm shift from classical cortical localization of brain function towards connectomics caused by the resurgence of awake surgery and the advent of tractography has permitted safer surgeries focused on subcortical white matter tracts preservation and allowed for surgical resections within regions, such as Broca's area or the primary motor cortex, which were previously deemed inoperable. Furthermore, new asleep electrophysiological techniques have been developed whenever awake surgery is not an option, such as operating in situations of poor compliance (including paediatric patients) or pre-existing neurological deficits. One such strategy is the use of intraoperative neurophysiological monitoring (IONM), enabling the identification and preservation of functionally defined, but anatomically ambiguous, cortico-subcortical structures through mapping and monitoring techniques. These advances tie in with novel challenges, specifically risk prediction and the impact of neuroplasticity, the indication for tumour resection beyond visible borders, or supratotal resection, and most of all, a reappraisal of the importance of the right hemisphere from early psychosurgery to mapping and preservation of social behaviour, executive control, and decision making.Here we review current advances and future perspectives in a functional approach to glioma surgery.

Impact of private use of the 13-valent pneumococcal conjugate vaccine (PCV13) on pneumococcal carriage among Portuguese children living in urban and rural regions.

In Portugal, the 13-valent pneumococcal conjugate vaccine (PCV13) was commercially available between 2010 and 2015, following a decade of private use of PCV7. We evaluated changes on serotype distribution and antimicrobial susceptibility of pneumococci carried by children living in two regions of Portugal (one urban and one rural). Three epidemiological periods were defined: pre-PCV13 (2009-2010), early-PCV13 (2011-2012), and late-PCV13 (2015-2016). Nasopharyngeal samples (n = 4,232) were obtained from children 0-6 years old attending day-care centers. Private use of PCVs was very high in both regions (>75%). Pneumococcal carriage remained stable and high over time (62.1%, 62.4% and 61.6% (p = 0.909) in the urban region; and 59.8%, 62.8%, 59.5% (p = 0.543) in the rural region). Carriage of PCV7 serotypes remained low (5.3%, 7.8% and 4.3% in the urban region; and 2.5%, 3.7% and 4.8% in the rural region). Carriage of PCV13 serotypes not targeted by PCV7 decreased in both the urban (16.4%, 7.3%, and 1.6%; p < 0.001) and rural regions (13.2%, 7.8%, and 1.9%; p < 0.001). This decline was mostly attributable to serotype 19A (14.1%, 4.4% and 1.3% in the urban region; and 11.1%, 3.6% and 0.8% in the rural region, both p < 0.001). Serotype 3 declined over time in the urban region (10.1%, 4.4%, 0.8%; p < 0.001) and had no obvious trend in the rural region (4.2%, 6.7%, 2.4%; p = 0.505). Serotype 6C decreased in both regions while serotypes 11D, 15A/B/C, 16F, 21, 22F, 23A/B, 24F, 35F, and NT were the most prevalent in the late-PCV13 period. Intermediate resistance to penicillin and non-susceptibility to erythromycin decreased significantly in both regions (19.5%, 13.3%, and 9.3%; and 25.4%, 25.9%, and 13.4%; both p < 0.001, respectively in the urban region; and 12.4%, 11.1%, and 2.8% (p < 0.001); and 15.3%, 14.7%, and 9.2% (p = 0.037), respectively, in the rural region). In conclusion, private use of PCV13 led to significant changes on the pneumococcal population carried by children in Portugal.

Efetividade de procedimentos não farmacológicos para o alívio da dor de parturientes: contribuições para a enfermagem obstétrica / Effectiveness of non-pharmacological procedures for pain relief in parturients: contributions to obstetric nursing

Estudo que apresentou como objeto o uso de procedimentos não farmacológicos para alívio da dor em parturientes. O objetivo geral foi conhecer a efetividade de três procedimentos não farmacológicos: o uso do gelo; o uso da água aquecida através do banho; e o uso da massagem na região lombar de gestantes, quanto à sua capacidade de produzir o alívio da dor na fase ativa do trabalho de parto. E os objetivos específicos: medir, a intensidade da dor autoreferida pelas parturientes antes, durante e após cada aplicação dos procedimentos não farmacológicos; analisar os escores numéricos referentes ao alívio da dor e descrever as avaliações das parturientes sobre os efeitos produzidos pelos procedimentos não farmacológicos. A tese é: O uso do gelo, da água aquecida através do banho de aspersão ou da massagem na região lombar de gestantes, quando empregados como procedimentos não farmacológicos na fase ativa do trabalho de parto são eficazes em produzir o alívio da dor. Ao mesmo tempo, contribui para a evolução fisiológica do trabalho de parto e parto. Baseou-se nos princípios da desmedicalização e no emprego de procedimentos não farmacológicos recomendados pela Organização Mundial de Saúde e ratificados pelo Ministério da Saúde no Brasil. Trata-se de um estudo clínico de intervenção prospectivo, não randomizado, que utilizou uma escala numérica como instrumento para medir a dor autorreferida de parturientes antes, durante e após cada aplicação de um dos procedimentos não farmacológicos. Os resultados evidenciaram que: A maioria das parturientes preferiu a aplicação da massagem na região lombar (21) e banho de aspersão (17). O uso de gelo foi realizado em 7 parturientes. Foi possível observar que a quantidade mulheres que referiram de aumento da dor não ultrapassou a quantidade de mulheres que referiram alívio, principalmente quando a dilatação está em 9cm. Pode-se observar, pela descrição dos comportamentos das parturientes, que poucas referiram medo e grande parte se disse confiante e sentindo-se bem. Algumas mulheres cochilaram e a maioria caminhou livremente. Apenas oito parturientes (17,7%) solicitaram interrupção após a aplicação da intervenção na primeira vez e a grande maioria (91,1%) referiu satisfação com o procedimento aplicado. Em relação ao bebê, em nenhum caso foi necessário realizar aspiração, reanimação com emprego de oxigênio, intubação traqueal, massagem cardíaca ou medicação para reanimação. Não foi detectado nenhum caso de bradicardia ou desaceleração dos batimentos cardíacos do feto. Após o parto, todas as parturientes foram encaminhadas ao Alojamento Conjunto com seus bebês sem necessidade de atendimentos de urgência, ou de internação em setores de atendimento a situações de risco. Confirmando a tese proposta, o estudo concluiu que os procedimentos não farmacológicos foram efetivos em produzir o alívio da dor das parturientes, e que são instrumentos facilitadores da ação fisiológica e natural do organismo feminino, no trabalho de parto.

This study approached the use of non-pharmacological procedures for pain relief in parturients. The general objective was to know the effectiveness of three non-pharmacological procedures: the use of ice; the use of heated water through the bath; and the use of lumbar region massage in pregnant women, regarding its ability to produce pain relief in the active phase of labor. The specific objectives were: to measure the self-reported pain intensity by parturients before, during and after each application of non-pharmacological procedures; to analyze numerical scores related to pain relief and to describe the evaluations of parturients about the effects produced by non-pharmacological procedures. The thesis is: The use of ice, warm water through a shower bath or massage in the lower back of pregnant women, when employed as non-pharmacological procedures in the active phase of labor, are effective in producing pain relief. At the same time, it contributes to the physiological evolution of labor and delivery. It was based on the principles of de-medicalization and the use of non-pharmacological procedures recommended by the World Health Organization and ratified by the Ministry of Health in Brazil. This is a prospective, nonrandomized intervention clinical study that used a numerical scale as a tool to measure self-reported pain in parturients before, during and after each application of one of the non-pharmacological procedures. The results showed that: Most of the parturients preferred the application of lumbar massage (n=21) and spray bath (n=17). The use of ice was performed in seven parturients. It was observed that the amount of owmen who described increasing pain did not exceed those who described pain relief, mainly when the cervical dilation was at 9cm. It can be observed from the description of the behaviors of the parturients that few mentioned fear and most of them said they were confident and feeling well. Some women dozed off and the majority walked freely. Only eight parturients (17.7%) asked for interruption after the intervention was applied for the first time and the vast majority (91.1%) reported satisfaction with the procedure applied. Regarding the baby, none of them needed aspiration, oxygen resuscitation, tracheal intubation, cardiac massage or medication resuscitation. No cases of bradycardia or deceleration of the fetal heartbeat were detected. After delivery, all parturients were referred to the rooming-in with their babies with no needs for urgent care or hospitalization in risk care sectors. Confirming the proposed thesis, the study concluded that non-pharmacological procedures were effective in producing pain relief of parturients, and are instruments that facilitate the physiological and natural action of the female organism in labor.

Procedimentos invasivos no cuidado à parturiente sob a perspectiva de gênero / Invasive procedures in midwifery care from a gender perspective / Procedimientos invasivos en el cuidado a la parturiente en la perspectiva de género

Objetivo: refletir sobre o uso de procedimentos obstétricos invasivos e dolorosos sob a perspectiva de gênero na saúde da mulher. Método: trata-se de reflexão desenvolvida a partir de estudos sobre a dor do parto, encontrados nas bases: LILACS, MEDLINE e SciELO. A busca compreendeu o período de 2005 a 2015, tendo como critérios de inclusão relatos de estudos qualitativos, em português, cujo conteúdo tivesse depoimentos de mulheres sobre a dor sentida durante o parto. Foram analisados 27 depoimentos extraídos dos 11 estudos selecionados. Resultados: identificaram-se como grupo temático central 'as relações desiguais de gênero manifestadas através de procedimentos dolorosos', permeando as relações de poder e na atenção à parturiente. Conclusão: quando as inter-relações são de domínio/submissão, as parturientes, inconsciente e involuntariamente, assimilam os valores e a visão de mundo dos profissionais tornando-se cúmplices da ordem estabelecida.

Objective: to reflect on the use of invasive and painful obstetric procedures from a gender perspective in women's health. Method: it is a reflection developed from studies on labor pain, found in the bases: LILACS, MEDLINE and SciELO. The search comprised the period from 2005 to 2015. The inclusion criteria were reports of qualitative studies in Portuguese, the content of which had statements from women about the pain experienced during childbirth. We analyzed 27 statements from the 11 selected studies. Results: it was identified as the central thematic group 'unequal gender relations manifested through painful procedures', permeating relations of power and care for the parturient. Conclusion: when the interrelationships are of domain/submission, the parturients, unconsciously and involuntarily, assimilate the values and the worldview of the professionals becoming complicit in the established order.

Objetivo: reflexionar sobre el uso de procedimientos obstétricos invasivos y dolorosos desde una perspectiva de género en la salud de la mujer. Método: es una reflexión desarrollada a partir de estudios sobre dolor de parto, encontrados en las bases: LILACS, MEDLINE y SciELO. La búsqueda incluyó el período comprendido entre 2005 y 2015. Los criterios de inclusión fueron estudios cualitativos en portugués, cuyo contenido contenía declaraciones de mujeres sobre el dolor experimentado durante el parto. Se analizaron 27 extractos de entrevistas de 11 estudios seleccionados. Resultados: se identificó como el grupo temático central "relaciones de género desiguales manifestadas a través de procedimientos dolorosos", permeando las relaciones de poder y cuidado de la parturienta. Conclusión: cuando las interrelaciones son de dominio/sumisión, las parturientas, inconsciente e involuntariamente, asimilan los valores y la cosmovisión de los profesionales y se hacen cómplices en el orden establecido.

The impact of private use of PCV7 in 2009 and 2010 on serotypes and antimicrobial resistance of Streptococcus pneumoniae carried by young children in Portugal: Comparison with data obtained since 1996 generating a 15-year study prior to PCV13 introduction.

In Portugal, the 7-valent pneumococcal conjugate vaccine (PCV7) was not introduced in the national immunization plan but was commercially available between 2001 and 2010. We studied serotype distribution and antibiotic susceptibility of Streptococcus pneumoniae carried by children in 2009 and 2010. Vaccination with PCV7 was extracted from children's immunization bulletins and information on recent antimicrobial consumption was obtained through a questionnaire. For comparison, we included data from previous studies conducted since 1996: 1996-1999, 2001-2003, 2006-2007. Pneumococci were isolated from nasopharyngeal samples of 1092 children up to six years old attending day-care in an urban area. Among these, 76% (819/1070) were vaccinated and 62% (677/1092) carried pneumococci. In 2009-2010, serotype replacement was extensive. Carriage of PCV7 serotypes was 4.9% and 5.8%, in 2009 and 2010, respectively, with the majority being of serotype 19F (carried by 4.3% and 4.6% of all participants, respectively). Colonization by serotype 19F was associated with vaccine status (7.7% (19/248) of non-vaccinees vs. 3.5% (29/818) of PCV7-vaccinees, p=0.010). Carriage of serotype 19A was high in 2009 and 2010 (8.6% of all participants) consistent with values already observed in 2007; carriage of serotype 6A was <1% (10/1092), indicating a major decline after 2007 (5.8% or 31/538, p<0.001). Non-vaccine serotypes increased and serotype 6C became the most frequently carried serotype in 2010 (11.2% (54/481)). High-level resistance to penicillin (MIC ≥2mg/L) showed a decreasing trend (p<0.001), whereas resistance to both penicillin and erythromycin increased (p<0.001) and was detected in 15-20% of all isolates in 2009-2010, most of which were non-vaccine serotypes. Antimicrobial use decreased over time (p<0.001). In conclusion, widespread private use of PCV7 has impacted on colonization leading to near elimination of all PCV7 serotypes except for serotype 19F. Antimicrobial consumption declined but it may be too soon to observe generalized changes in antimicrobial resistance rates.

Rendimiento en el proceso de acreditación de hospitales públicos de Minas Gerais/Brasil: influencias para la calidad asistencial / Performance em processo de acreditação de hospitais públicos de Minas Gerais/Brasil: influências para a qualidade da assistência / Performance in the process of accreditation of public hospitals in Minas Gerais/ Brazil: influences on the quality of care

El objetivo es analizar las no conformidades relacionadas con la dirección de la acreditación de los hospitales públicos de Minas Gerais y sus influencias en la calidad del proceso de atención. Estudio descriptivo, cuantitativo y de investigación documental realizada en ocho hospitales públicos que participan en el Programa de Fortalecimiento y Mejora de la Calidad de los Hospitales de la MG Único de Salud (Pro - Hosp). Los datos fueron recogidos a partir de informes de Diagnóstico Organizacional de la Organización Nacional para la Acreditación de hospitales que autorizaron el estudio y clasificados en estructura, proceso y resultado. La estructura NC más frecuente se relaciona con "definir y ejecutar la política institucional para la gestión de riesgos clínicos y no clínicos, la contemplación de las acciones preventivas y correctivas". La NC de proceso más frecuente fue "fortaleciendo la metodologia de la comunicación institucional contemplando la capilarización de la información necesaria para garantizar la calidad y seguridad de la atención." Las NC de resultados encontradas no fueron cuantitativamente representativas. Llegamos a la conclusión de que las NC están principalmente relacionadas con la estructura y los procesos, porque los hospitales de este estudio se encuentran en una etapa temprana del proceso de mejora continua. Por lo tanto, es necesario el desarrollo de planes de acción para mitigar estas NC (AU)

Objetiva-se analisar as não conformidades relacionadas à direção em processo de acreditação de hospitais públicos de Minas Gerais e suas influências na qualidade da assistência. Pesquisa descritiva, quantitativa e documental realizada em oito hospitais públicos participantes do Programa de Fortalecimento e Melhoria da Qualidade dos Hospitais do Sistema Único de Saúde de MG (Pro-Hosp). Os dados foram coletados dos relatórios de Diagnóstico Organizacional da Organização Nacional de Acreditação dos hospitais que autorizaram o estudo e classificados em Estrutura, Processo e Resultado. A NC mais frequente relacionada à estrutura foi "definir e implantar política institucional para gerenciamento de riscos clínicos e não clínicos, contemplando ações preventivas e corretivas". A NC de processo mais frequente foi "reforçar a metodologia de comunicação institucional contemplando a capilarização das informações necessárias para a garantia da qualidade e segurança da assistência". As NC de resultados encontradas não foram representativas quantitativamente. Conclui-se que as NC estão relacionadas principalmente à estrutura e processos, isso porque os hospitais em estudo estão em uma fase inicial do processo de melhoria contínua. Então, é necessário a elaboração de planos de ação para a mitigação dessas NC

The objective is to analyze the non-conformities related to the direction of accreditation of public hospitals in Minas Gerais and its influences on quality of care process. Descriptive, quantitative and desk research conducted in eight public hospitals participating in the Program for Strengthening and Improving the Quality of Hospitals of the Unified Health MG (ProHosp). Data were collected from reports of Organizational Diagnosis of the National Organization for Accreditation of hospitals who authorized the study and categorized into Structure, Process and Outcome. The most frequent NC structure was related to "define and implement institutional policy for managing clinical and non-clinical risks, contemplating preventive and corrective actions”. NC The most frequent case was "strengthening institutional communication methodology contemplating capillarization of the information needed to guarantee the quality and safety of care". The NC found the results were not quantitatively representative. We conclude that the NC are mainly related to the structure and processes, because hospitals in this study are at an early stage of the process of continuous improvement. So, the development of action plans to mitigate these NC is required (AU)

Low prevalence of pneumococcal carriage and high serotype and genotype diversity among adults over 60 years of age living in Portugal.

Pneumococcal disease is frequent at the extremes of age. While several studies have looked at colonization among young children, much less is known among the elderly. We aimed to evaluate pneumococcal carriage among elderly adults living in Portugal. Between April 2010 and December 2012, nasopharyngeal and oropharyngeal swabs of adults over 60 years of age, living in an urban area (n = 1,945) or in a rural area (n = 1,416), were obtained. Pneumococci were isolated by culture-based standard procedures, identified by optochin susceptibility, bile solubility and PCR screening for lytA and cpsA, and characterized by antibiotype, serotype, and MLST. Associations between pneumococcal carriage, socio-demographic and clinical characteristics were evaluated by univariate analysis and multiple logistic regression. The global prevalence of carriage was 2.3% (95% CI: 1.8-2.8). In the multiple logistic regression analysis, smoking, being at a retirement home, and living in a rural area increased the odds of being a pneumococcal carrier by 4.4-fold (95% CI: 1.9-9.2), 2.0-fold (95% CI: 1.1-3.6) and 2.0-fold (95% CI: 1.2-3.5), respectively. Among the 77 pneumococcal isolates, 26 serotypes and 40 STs were identified. The most prevalent serotypes were (in decreasing order) 19A, 6C, 22F, 23A, 35F, 11A, and 23B, which accounted, in total, for 60.0% of the isolates. Most isolates (93.5%) had STs previously described in the MLST database. Resistance to macrolides, non-susceptibility to penicillin and multidrug resistance were found in 19.5%, 11.7%, and 15.6% of the isolates, respectively. We conclude that the prevalence of pneumococcal carriage in the elderly, in Portugal, as determined by culture-based methods, is low. Serotype and genotype diversity is high. Living in a rural area, in a retirement home, and being a smoker increased the risk of pneumococcal carriage. This study contributes to the establishment of a baseline that may be used to monitor how novel pneumococcal vaccines impact on colonization among the elderly.

Crioterapia: tecnologia não-invasiva de cuidado da enfermeira obstétrica para alívio da dor em parturientes / Cryotherapy: non-invasive technology of midwife care for pain relief in parturients

Pesquisa piloto de intervenção com dados prospectivos, grupo único de intervenção, cujo desfecho é a medida da dor de mulheres em trabalho de parto. Apresenta como objetivo discutir os efeitos da crioterapia no alívio da dor das parturientes. Como referencial teórico este trabalho apresentou o descrito por Soares e Low, onde se encontra que os mecanismos de ação do gelo para alívio da dor propiciam o decréscimo da transmissão das fibras de dor, a diminuição da excitabilidade nas terminações livres, a redução no metabolismo tecidual aumentando o limiar das fibras de dor e a liberação de endorfinas. Baseou-se ainda nos princípios da desmedicalização e do emprego de tecnologias não-invasivas de cuidado de enfermagem obstétrica conforme descritos por Vargens e Progianti. A pesquisa foi realizada no Centro Obstétrico do Hospital Municipal Maternidade Carmela Dutra, no Rio de Janeiro de abril a agosto de 2011. O gelo foi aplicado, utilizando-se para tal uma bolsa-cinta ajustável à região tóraco-lombar de 36 gestantes. A bolsa/cinta é descartável, de tecido TNT, com abertura na parte superior para introdução de gelo picado envolto em plástico. As aplicações se deram aos cinco centímetros de dilatação do colo uterino; e/ou aos sete centímetros de dilatação do colo uterino; e/ou aos nove centímetros de dilatação uterina, totalizando ao final das três aplicações um tempo de 60 minutos, que corresponde ao somatório de 20 minutos para cada uma. O gelo foi produzido em fôrma exclusiva para o projeto, em freezer da unidade. Os dados referentes à avaliação da dor foram coletados através de entrevista estruturada guiada por formulário previamente elaborado...

This pilot intervention study, with prospective data and a single intervention group, the outcome of which was the pain measured in women in labour, was designed to discuss the pain relief effects of cryotherapy in childbirth. The theoretical framework for this study was as described by Soares & Low, in which the mechanisms of the pain-relief action of ice foster decreased pain fibre transmission, reduced free nerve ending excitability, reduced tissue metabolism, increased pain fibre threshold and release of endorphins. It also drew on the principles of de-medicalisation and non-invasive obstetric nursing techniques as described by Vargens & Progianti. The study was conducted at the Obstetrics Centre of the Carmela Dutra Municipal Maternity Hospital, in Rio de Janeiro, from April to August 2011. Ice was applied using an adjustable belt-bag to the lumbar/thoracic region of 36 expectant mothers. The disposable TNT fabric belt-bag has an opening at the top for introducing plastic-wrapped ground ice. Applications were given at five centimetres cervical dilation; and/or at seven centimetres cervical dilation; and/or at nine centimetres cervical dilation: to a total of three applications over a 60-minute timespan, corresponding to the sum of 20 minutes each. The ice was produced exclusively for the project in the unit’s freezer. Pain assessment data were collected by structured interview guided by a previously prepared script...

Clonal evolution leading to maintenance of antibiotic resistance rates among colonizing Pneumococci in the PCV7 era in Portugal.

The introduction of the seven-valent pneumococcal conjugate vaccine (PCV7) in Portugal led to extensive serotype replacement among carriers of pneumococci, with a marked decrease of PCV7 types. Although antimicrobial resistance was traditionally associated with PCV7 types, no significant changes in the rates of nonsusceptibility to penicillin, resistance to macrolides, or multidrug resistance were observed. This study aimed to investigate the mechanisms leading to maintenance of antimicrobial resistance, despite marked serotype replacement. We compared, through molecular typing, 252 antibiotic-resistant pneumococci recovered from young carriers in 2006 and 2007 (era of high PCV7 uptake) with collections of isolates from 2002 and 2003 (n=374; low-PCV7-uptake era) and 1996 to 2001 (n=805; pre-PCV7 era). We observed that the group of clones that has accounted for antimicrobial resistance since 1996 is essentially the same as the one identified in the PCV7 era. The relative proportions of such clones have, however, evolved substantially overtime. Notably, widespread use of PCV7 led to an expansion of two Pneumococcal Molecular Epidemiology Network (PMEN) clones expressing non-PCV7 capsular variants of the original strains: Sweden(15A)ST63 (serotypes 15A and 19A) and Denmark(14)ST230 (serotypes 19A and 24F). These variants were already in circulation in the pre-PCV7 era, although they have now become increasingly abundant. Emergence of novel clones and de novo acquisition of resistance contributed little to the observed scenario. No evidence of capsular switch events occurring after PCV7 introduction was found. In the era of PCVs, antimicrobial resistance remains a problem among the carried pneumococci. Continuous surveillance is warranted to evaluate serotype and clonal shifts leading to maintenance of antimicrobial resistance.

Multiple-locus variable number tandem repeat analysis for Streptococcus pneumoniae: comparison with PFGE and MLST.

In the era of pneumococcal conjugate vaccines, surveillance of pneumococcal disease and carriage remains of utmost importance as important changes may occur in the population. To monitor these alterations reliable genotyping methods are required for large-scale applications. We introduced a high throughput multiple-locus variable number tandem repeat analysis (MLVA) and compared this method with pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). The MLVA described here is based on 8 BOX loci that are amplified in two multiplex PCRs. The labeled PCR products are sized on an automated DNA sequencer to accurately determine the number of tandem repeats. The composite of the number of repeats of the BOX loci makes up a numerical profile that is used for identification and clustering. In this study, MLVA was performed on 263 carriage isolates that were previously characterized by MLST and PFGE. MLVA, MLST and PFGE (cut-off of 80%) yielded 164, 120, and 87 types, respectively. The three typing methods had Simpson's diversity indices of 98.5% or higher. Congruence between MLST and MLVA was high. The Wallace of MLVA to MLST was 0.874, meaning that if two strains had the same MLVA type they had an 88% chance of having the same MLST type. Furthermore, the Wallace of MLVA to clonal complex of MLST was even higher: 99.5%. For some isolates belonging to a single MLST clonal complex although displaying different serotypes, MLVA was more discriminatory, generating groups according to serotype or serogroup. Overall, MLVA is a promising genotyping method that is easy to perform and a relatively cheap alternative to PFGE and MLST. In the companion paper published simultaneously in this issue we applied the MLVA to assess the pneumococcal population structure of isolates causing invasive disease in The Netherlands before the introduction of the 7-valent conjugate vaccine.

Analysis of invasiveness of pneumococcal serotypes and clones circulating in Portugal before widespread use of conjugate vaccines reveals heterogeneous behavior of clones expressing the same serotype.

To estimate the invasive disease potential of serotypes and clones circulating in Portugal before extensive use of the seven-valent pneumococcal conjugate vaccine, we analyzed 475 invasive isolates recovered from children and adults and 769 carriage isolates recovered from children between 2001 and 2003. Isolates were serotyped and genotyped by pulsed-field gel electrophoresis, and a selection of isolates were also characterized by multilocus sequence typing. We found that the diversities of serotypes and genotypes of pneumococci responsible for invasive infections and carriage were identical and that most carried clones could also be detected as causes of invasive disease. Their ability to do so, however, varied substantially. Serotypes 1, 3, 4, 5, 7F, 8, 9N, 9L, 12B, 14, 18C, and 20 were found to have an enhanced propensity to cause invasive disease, while serotypes 6A, 6B, 11A, 15B/C, 16F, 19F, 23F, 34, 35F, and 37 were associated with carriage. In addition, significant differences in invasive disease potential between clones sharing the same serotype were found among several serotypes, namely, 3, 6A, 6B, 11A, 14, 19A, 19F, 22F, 23F, 34, and NT. This heterogeneous behavior of the clones was found irrespective of the serotype's overall invasive disease potential. Our results highlight the importance of the genetic background when analyzing the invasive disease potential of certain serotypes and provide an important baseline for its monitoring following conjugate vaccine use. Continuous surveillance should be maintained, and current research should focus on uncovering the genetic determinants that contribute to the heterogeneity of invasive disease potential of clones sharing the same serotype.

Denmark14-230 clone as an increasing cause of pneumococcal infection in Portugal within a background of diverse serotype 19A lineages.

Pneumococci of serotype 19A are increasingly found to be the cause of infection in various geographic regions. We have characterized the serotype 19A isolates (n = 288) found among pneumococci responsible for infections (n = 1,925) and pneumococci recovered from asymptomatic carriers (n = 1,973) in Portugal between 2001 and 2006. We show that despite the existence of serotype 19A clones that have a greater potential to cause invasive disease or an enhanced colonization capacity, the lineage that is increasing as a cause of infection in Portugal is a multiresistant clone that is competent at both. The expanding Denmark(14)-230 clone found in Portugal is disseminated in other Mediterranean countries, where it is also increasingly responsible for invasive infections in both children and adults. The lineages driving the rise of serotype 19A infections in Asia and the United States (sequence type 320 [ST320] and ST199) are either absent or account for only a small proportion of isolates in Portugal. These data highlight the importance of locally circulating clones with the ability to compete in the nasopharyngeal niche in the emergence of the serotype 19A lineages which are an increasing cause of infection in various geographic regions.

Streptococcus pneumoniae nasopharyngeal carriage in children attending day-care centers in the central region of Portugal, in the era of 7-valent pneumococcal conjugate vaccine.

The 7-valent pneumococcal conjugate vaccine became available in Portugal in 2001. Although not included in the national immunization program, vaccination coverage is high (over 60%). We studied for the first time the rates of nasopharyngeal (NP) carriage of pneumococci, antibiotic resistance patterns and serotypes among children attending day-care centers (DCCs) in Coimbra, a city in the Central Region of Portugal. Between January and February 2007, a cross-sectional study was conducted among children aged 6 months to 6 years attending eight DCCs. NP swabs were obtained from 507 children: 76.7% had received at least one dose of 7-valent pneumococcal conjugate vaccine and 64.3% were age-appropriately vaccinated. The global pneumococcal carriage rate was 61.3%. Colonization proportions varied with age and number of children attending each DCC. Serotyping revealed that 20.7% of the pneumococci were vaccine types (VTs), 70.8% were non-VTs, and 8.5% were nontypeable. Serotype 19F was the second most frequent serotype being detected in 10.5% of the samples. While global NP carriage was not associated with vaccination status, non-VTs were predominant among vaccinated children, who had significantly lower prevalence of VT. Of all isolates, 15.7% had penicillin minimum inhibitory concentrations that ranged between 0.12 and 2 microg/ml. The proportion of resistant strains was significantly higher among VT and unvaccinated children. In conclusion, the rates of vaccination and prevalence of pneumococcal NP were high. Rates of antimicrobial resistance were similar to those found in studies conducted in Oeiras and Lisbon. This study is a platform for future surveillance activities.

Temporal trends and molecular epidemiology of recently described serotype 6C of Streptococcus pneumoniae.

We studied the epidemiology of the recently described serotype 6C of Streptococcus pneumoniae among a collection of carriage isolates recovered between 1996 and 2007 in Portugal. Of 4,064 isolates, 106 (2.6%) were of serotype 6C, 17.9% of which were multidrug resistant. The strains were genetically diverse.

High rates of transmission of and colonization by Streptococcus pneumoniae and Haemophilus influenzae within a day care center revealed in a longitudinal study.

Day care centers (DCCs) are unique settings where young children are at increased risk for colonization by pneumococci and Haemophilus influenzae. Although point prevalence studies in DCCs are frequent, only a few longitudinal studies on the dynamics of colonization have been published. We conducted a 1-year longitudinal study with 11 sampling periods on nasopharyngeal carriage of pneumococci and H. influenzae among 47 children who attended a single DCC. All isolates were antibiotyped and genotyped by pulsed-field gel electrophoresis. Pneumococci were also serotyped. Of the 414 samples obtained, 61.4% contained pneumococci, and 87% contained H. influenzae. Only 8.3% of the samples were negative for both species. Twenty-one pneumococcal clones and 47 H. influenzae clones were identified. Introduction of clones occurred during all year. Ninety-eight percent and 96% of all pneumococcal and H. influenzae isolates, respectively, belonged to clones shared by more than one child. Children were sequentially colonized with up to six pneumococcal clones (mean, 3.6) and five serotypes and nine H. influenzae clones (mean, 7.1). Clones with increased capacity for transmission and/or prolonged colonization were identified in both species. These two fitness properties appeared to be independent. In conclusion, among DCC attendees, a high rate of acquisition and turnover of strains was observed, and all children were overwhelmingly colonized by clones shared with others. DCCs are units where permanent introduction of new clones occurs, and attendees, as a whole, provide a pool of hosts where the fittest clones find privileged opportunities to persist and expand.

Optochin resistance among Streptococcus pneumoniae strains colonizing healthy children in Portugal.

Two percent of 1,973 pneumococcus strains isolated from carriers since 2001 in Portugal were found to be optochin resistant. These strains belonged to eight serotypes (and some were nontypeable), and they had diverse genetic backgrounds. Novel optochin-resistant lineages were detected over time, suggesting that there was a continuous, although sporadic, emergence of optochin resistance.

A crioterapia como estratégia para alívio da dor no trabalho de parto: um estudo exploratório / Criotherapy as a strategy for pain relief in chidbirth: an exploratory study

Estudo exploratório cujo objeto foi a crioterapia como prática aplicada de enfermagem obstétrica e estratégia de alívio da dor no parto. Foi desenvolvido com 21 parturientes acompanhadas por enfermeira obstétrica no Hospital Maternidade Carmela Dutra, no Rio de Janeiro, em 2004. Teve como objetivos identificar os sintomas referidos durante o uso de gelo como recurso para alívio da dor e verificar possíveis efeitos sobre a evolução do trabalho de parto e perfil biofísico do feto. Os resultados mostraram que o uso da crioterapia proporcionou o relaxamento geral das parturientes, permitindo a algumas dormirem profundamente em plena fase ativa do trabalho de parto. Não foram evidenciados efeitos indesejados sobre o perfil biofísico do feto, pois todos os recém-nascidos alcançaram APGAR superior a sete no primeiro e quinto minutos de vida. Concluiu-se que a crioterapia pode ser aplicada para alívio da dor no parto, sendo necessário, no entanto, estudos que aprofundem e ampliem o conhecimento sobre seu emprego nessa situação.

Exploratory study on the procedure of criotherapy in obstetric nursing as a strategy for pain relief in childbirth. It was performed on 21 women during labor, accompanied by the obstetric nurse in the Hospital Maternidade Carmela Dutra, Rio de Janeiro - Brazil, in 2004. The study aimed both at identifying the symptoms described upon the use of ice as resource for pain relief and at verifying the effects of the criotherapy on labor and on the biophysical profile of the fetus. The results showed that the use of the criotherapy provided overall relaxation for women in labor, allowing some of them to sleep deeply during the active phase of childbirth. Unexpected effects were not evidenced on the fetus’s biophysical profile. All the newborn reached APGAR scores higher than seven at the first and the fifth minutes of life. It was concluded that criotherapy can be used by obstetric nurses for pain relief in childbirth. However, studies that deepen and enlarge the findings on its employment in this specific situation are required.

Estudio exploratorio cuyo objeto fue la crioterapia como práctica aplicada de enfermería obstétrica y estrategia de alivio del dolor en el parto. Desarrollado con 21 parturientes acompañadas por enfermera obstétrica en el Hospital Maternidad Carmela Dutra, en Río de Janeiro – Brasil, en 2004. Tuvo como objetivos identificar los síntomas referidos durante el uso de hielo como recurso para el alivio del dolor y verificar los efectos de la crioterapia en la evolución del parto y del perfil biofísico del feto. Los resultados mostraron que el uso de la crioterapia proporcionó un relajamiento general de las parturientes, lo que permitió a algunas de ellas duermir profundamente durante la fase activa del parto. No se evidenciaron efectos indesejados en el perfil biofísico del feto. Los escores de APGAR alcanzados por todos los recién nacidos fueron superiores a siete en el primero y quinto minutos de vida. Se concluyó que la crioterapia puede ser aplicada para el alivio del dolor en el parto. Sin embargo, son necesarios estudios que ahonden y agranden el conocimiento sobre su empleo en esa situación.

Identification, prevalence and population structure of non-typable Streptococcus pneumoniae in carriage samples isolated from preschoolers attending day-care centres.

The authors aimed to get insights into the population structure of non-(sero)typable pneumococci (NTPn), a specific group of natural atypical pneumococci whose identification is often difficult, and which has remained insufficiently studied. A total of 265 presumptive NTPn, isolated between 1997 and 2003 from the nasopharynx of children, were characterized. Strains were confirmed to be pneumococci on the basis of bile solubility, and PCR detection or Southern blotting hybridization of lytA and psaA, genes ubiquitous in this species. Multilocus sequence typing (MLST) was used to exclude two isolates that gave ambiguous results. Non-typability was confirmed by the Quellung reaction using Omniserum. A total of 213 isolates were considered to be true NTPn. The molecular analysis of the true NTPn by PFGE and MLST showed that this population was genetically diverse, although a dominant cluster, accounting for 66 % of the isolates, was identified. Antimicrobial resistance was observed in most genetic backgrounds, and multidrug resistance to penicillin, erythromycin, clindamycin, tetracycline and sulfamethoxazole-trimethoprim was associated with strains belonging to the dominant cluster. Comparison with PFGE fingerprints and sequence types of large collections of serotypable strains showed that the genetic backgrounds of all but two NTPn were different from those found in serotypable strains. In addition, we found that NTPn strains with similar genetic backgrounds to those identified in our study had been isolated from disease sources in other countries. These observations seem to indicate that NTPn have diverse genetic backgrounds and may have evolved as a distinct group of pneumococcal isolates.