Group B Streptococcus rectovaginal colonization screening on term pregnancies: culture or polymerase chain reaction?

OBJECTIVES: The aim of this study was to evaluate if screening Group B Streptococcus colonization by intrapartum polymerase chain reaction could improve intrapartum administration of antibiotic prophylaxis, compared with antepartum culture screening and analyze the sensitivity and specificity of polymerase chain reaction test. METHODS: 198 pregnant women with Group B Streptococcus colonization antepartum culture screening were included. When they arrived at hospital for delivery, two rectovaginal swabs were collected: for culture and polymerase chain reaction method. RESULTS: The rate of Group B Streptococcus colonization antepartum detected by culture was 16.7%; at delivery was 17.2% when detected by culture and 19.7% using polymerase chain reaction method. The rate of inconclusive polymerase chain reaction tests was 0.5%. Considering intrapartum culture screening as gold standard, sensitivity and specificity of polymerase chain reaction test for intrapartum Group B Streptococcus colonization was 97.1% and 95.7%, respectively. The global rate of discordance between antepartum and intrapartum Group B Streptococcus colonization was 6.6%. The rate of women not treated with intrapartum antibiotic prophylaxis in the setting of positive intrapartum culture was significantly lower using intrapartum polymerase chain reaction test (0.5%) than with antepartum culture method (3.5%, p = 0.035). CONCLUSION: The use of intrapartum antibiotic prophylaxis can be more efficient when screening Group B Streptococcus colonization intrapartum by polymerase chain reaction test. Polymerase chain reaction method had a good performance in our study, with high sensitivity and specificity.

Emergence of NDM-1 and KPC-3 carbapenemases in Kluyvera cryocrescens: Investigating genetic heterogeneity and acquisition routes of blaNDM-1 in Enterobacterales species in Portugal.

OBJECTIVES: A higher diversity of species, clones and genes have been increasingly implicated in carbapenemases spread, though the mobile genetic elements responsible for their acquisition and dispersion at local and global levels are less explored, particularly in species other than Klebsiella pneumoniae or Escherichia coli. We aim to explain the emergence of NDM-1 and KPC-3 carbapenemases in a Kluyvera cryocrescens isolate, and to shed light on the heterogeneity of genetic platforms and acquisition routes of blaNDM-1 in diverse Enterobacterales species in Portugal. METHODS: A KPC-3 and NDM-1-producing K. cryocrescens colonizing a hospitalized patient in 2019 was characterized by whole-genome sequencing and antibiotic resistance profiling following standard methods. Conjugative transfer of carbapenemases genes was assessed by filter mating. Plasmids were reconstructed with in silico and in vitro approaches. blaNDM-1 genetic context was compared with that of diverse NDM-1-producing Enterobacterales species, previously described in Portugal. RESULTS: K. cryocrescens K629 showed a multidrug resistance profile. Resistance gene blaKPC-3 was harboured by a Tn4401d transposon within a worldwide-spread IncN-ST15 plasmid (pKLU-KPC3), whereas blaNDM-1 was located in a Tn3000 within a non-typeable mosaic plasmid (pKLU-NDM1). The heterogeneous blaNDM-1 genetic platforms and variable plasmid backbones identified in various Enterobacterales species suggested multiple introductions of blaNDM-1 in Portugal, mediated by variable insertion sequences. CONCLUSIONS: We report the convergence of KPC-3 and NDM-1 in K. cryocrescens and the variable dissemination modes of these carbapenemases in different Enterobacterales species, underlining the need to track down genetic platforms responsible for carbapenemases diffusion.

Nocardia spp. isolation in chronic lung diseases: Are there differences between patients with pulmonary nocardiosis and Nocardia colonization?

AIMS: Chronic lung diseases are a recognized risk factor for Nocardia spp. INFECTION: Nocardia spp. isolation does not inevitably imply disease, and thus colonization must be considered. Here, we aimed to analyse the differences between pulmonary nocardiosis (PN) and Nocardia spp. colonization in patients with chronic lung diseases. METHODS AND RESULTS: A retrospective study of patients with laboratory confirmation of isolation of Nocardia spp. in at least one respiratory sample was performed. Patients with PN and Nocardia spp. colonization were compared. There were 71 patients with Nocardia spp. identification, 64.8% were male, with a mean age of 67.7 ± 11.2 years. All patients had ≥1 pre-existing chronic lung disease, and 19.7% of patients were immunocompromised. PN and Nocardia spp. colonization were considered in 26.8% and 73.2% of patients, respectively. Symptoms and chest CT findings were significantly more frequent in patients with PN (p < 0.001). During follow-up time, 12 (16.9%) patients died, 6 in PN group. Immunosuppression, constitutional symptoms, haematological malignancy and PN diagnosis were associated with significantly shorter survival times, despite only immunosuppression (HR 3.399; 95% CI 1.052-10.989) and PN diagnosis (HR 3.568; 95% CI 1.078-11.910) remained associated with a higher death risk in multivariate analysis. CONCLUSIONS: PN was associated with clinical worsening, more chest CT findings and worse clinical outcomes. SIGNIFICANCE AND IMPACT OF STUDY: Nocardia spp. isolation in chronic lung disease patients is more common than expected and the differentiation between colonization and disease is crucial.

Outbreak of KPC-producing Klebsiella pneumoniae at a Portuguese university hospital: Epidemiological characterization and containment measures.

Background: KPC-producing K pneumoniae (KPC-Kp) is a public health problem with important clinical and epidemiological implications. We describe an outbreak of KPC-Kp at vascular surgery and neurosurgery wards in a central hospital in Porto, Portugal. Methods: A case of KPC-Kp was considered to be a patient positive for KPC-Kp with strong epidemiological plausibility of having acquired this microorganism in the affected wards and/or with genetic relationship ≥92% between KPC-Kp isolates. Active surveillance cultures (ASCs) and real-time polymerase chain reaction were used for the detection of carbapenemase genes through rectal swab in a selected population. Molecular analysis was performed using pulsed-field gel electrophoresis at the National Reference Laboratory. Patient risk factors were collected from the electronic medical record system. Information regarding outbreak containment strategy was collected from the Infection Control Unit records. Results: Of the 16 cases, 11 (69%) were identified through active screening, representing 1.4% of the total 766 ASCs collected. The most frequent risk factors identified were previous admission (63%), antibiotic exposure in the past 6 months (50%), and immunodepression (44%). The length of stay until KPC-Kp detection was high (0-121 days, mean 35.6), as was the total length of stay (5-173 days, mean 56.6). Three patients (19%) were infected by KPC-Kp, 2 of whom died. One previously colonized patient died later because of KPC-Kp infection. Conclusions: Multifactorial strategy based on contact precautions (with patient and healthcare professional cohorts) and ASC, as well as Antibiotic Stewardship Program reinforcement, allowed to contain this KPC-Kp outbreak.

Bacterial growth and recovery on hospital biometric devices: effect of two types of disinfectants.

OBJECTIVES: The aim of the study was to evaluate the presence of bacterial contamination on biometric identification devices in a public hospital; identify the species of bacteria implicated in the contamination and assess bacterial recovery after the use of 2 types of disinfectants: alcohol 70% and isopropyl alcohol chlorhexidine. DESIGN: Before and after trial. SETTING: Public hospital, tertiary referral center. PARTICIPANTS: All existing biometric identification devices in the hospital (n = 20). METHODS: Collection of 2 microbiological samples from the fingerprint reading surface of biometric devices immediately before and after applying the solution with alcohol 70% and in separate time periods with isopropyl alcohol chlorhexidine. RESULTS: It have been identified 21 different bacterial species in a total of 78 samples, mostly Staphylococcus epidermidis (32 samples) and S aureus (7 samples). S epidermidis was eliminated in 61.5% of the samples after disinfecting with alcohol 70% and in 92.3% of the samples disinfected with isopropyl alcohol chlorhexidine. S aureus was eliminated in 33.3% and 100% of the samples, respectively. We found no bacterial growth in 10% of the devices after disinfection with 70% alcohol and in 78.9% of devices after disinfection with isopropyl alcohol chlorhexidine. We also found that there was a decrease in the frequency of species isolated after using both disinfection solutions, although isopropyl alcohol chlorhexidine appeared to be more effective. CONCLUSIONS: The biometric identification devices used in this hospital seem to be safe regardless of the products used for its cleaning. The majority of the bacteria found are commensal skin microorganisms. We did not find pathogenic bacteria for immunocompetent individuals, in particular methicillin-resistant S aureus.

Effects of Electronic Cigarettes on Oral Cavity: A Systematic Review.

INTRODUCTION: The increase in the use of electronic cigarettes (e-cigs) in young people and the lack of knowledge of the health effects of smoking in the short and long term are worrying. Although the oral cavity is the first to interact directly with the e-cig aerosol, studies on potential oral cavity lesions are still limited and there is some controversy about safety. OBJECTIVE: To perform a systematic review to evaluate the adverse effects of e-cigs on oral health. MATERIALS AND METHODS: The research was conducted using Cochrane Library, Embase, PubMed, and Web of Science. The research was limited to articles in English, Portuguese, and Spanish, published between January 2003 and November 2018. The research question was formulated according to the population, intervention, comparison, outcome (PICO) strategy. The quality of the methodology of each study was evaluated following the guidelines described in the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool. RESULTS: The initial search resulted in 432 articles, of which only eight were included for analysis. Periodontal and peri-implant clinical and radiographic parameters (plaque index, clinical attachment loss, probing depth, peri-implant bone loss, and radiographic bone level) are worse, and proinflammatory cytokine levels are higher among electronic and conventional cigarette smokers than among nonsmokers. Bleeding on probing was higher in nonsmokers than in conventional cigarette smokers and e-cig users. Nine different lesions of the oral mucosa were detected, with nicotinic stomatitis, hairy tongue, and angular cheilitis being more prevalent in e-cig consumers. CONCLUSION: The results suggest that e-cigs are less harmful than conventional cigarettes. However, there is also a greater susceptibility of e-cig consumers to developing alterations in oral biological tissues than ex-smokers or nonsmokers. There is still a clear need for the development of new studies.

Chronic Bacterial Infection Prevalence, Risk Factors, and Characteristics: A Bronchiectasis Population-Based Prospective Study.

BACKGROUND: Few data are available on chronic bacterial infections (CBI) in bronchiectasis patients. Given that CBI seems to trigger longer hospital stays, worse outcomes, and morbimortality, this study was undertaken to assess CBI prevalence, characteristics, and risk factors in outpatients with bronchiectasis. METHODS: A total of 186 patients followed in a bronchiectasis tertiary referral centre in Portugal were included. Demographic data and information on aetiology, smoking history, mMRC score, Bronchiectasis Severity Index (BSI) score, sputum characteristics, lung function, exacerbations, and radiological involvement degree were collected. RESULTS: Patients included (mean age 54.7 ± 16.2 years; 60.8% females) were followed up for a period of 3.8 ± 1.7 years. The most common cause of bronchiectasis was infection (31.7%) followed by immune deficiencies (11.8%), whereas in 29% of cases, no cause was identified. Haemophilus influenzae (32.3%) and Pseudomonas aeruginosa (30.1%) were the most common CBI-associated possible pathogenic microorganisms. CBI patients presented a higher follow-up time than no-CBI patients (p = 0.003), worse lung function, BSI (p < 0.001), and radiological (p < 0.001) scores, and more prominent daily sputum production (p = 0.002), estimated mean volume (p < 0.001), and purulent sputum (p < 0.001). The number of exacerbations/year (p = 0.001), including those requiring hospital admission (p = 0.009), were also higher in the CBI group. Independent CBI predictors were BSI score (OR 3.577, 95% CI 1.233⁻10.378), sputum characteristics (OR 3.306, 95% CI 1.107⁻9.874), and radiological score (OR 1.052, 95% CI 1.004⁻1.102). CONCLUSION: According to the CBI status, two different sub-groups of patients were found on the basis of several clinical outcomes, emphasizing the importance of routine sputum microbiological monitoring. Further studies are needed to better characterize CBI profiles and to define the individual clinical impact of the most prevalent pathogenic microorganisms.

Construção e validação de conteúdo do plano multiprofissional de alta em terapia intensiva / Construction and validation of multi-professional discharge plan in intensive therapy

O presente estudo objetiva construir e validar o conteúdo do instrumento de sistematização da continuidade do cuidado, mediante plano multiprofissional de alta. Foram realizadas as seguintes etapas: levantamento bibliográfico nas bases de dados Pubmed e BVS; construção do instrumento; validação do conteúdo por 20 especialistas, segundo técnica Delphi, e análise e consolidação dos itens do instrumento, sendo calculado o índice de concordância para os itens linguagem, pertinência, relevância, organização, clareza e aplicabilidade. A concordância entre os avaliadores variou de 85,0 a 100,0%, com uma concordância global de 94,2% para o modelo inicial. Foram incluídas dez (23,2%) variáveis e 31 itens (72,0%) sofreram modificações. Após a validação do plano, o instrumento permaneceu com 11 domínios e 55 itens. Este estudo favoreceu o planejamento para uma alta eficaz, por meio do uso de instrumento validado, para a obtenção de uma assistência multiprofissional de qualidade.

Construct and validate the contents of a tool for the systematization of care continuity by means of a multi-professional discharge plan. The following stages were taken: bibliographic survey of PubMed and BVS databases; construction of the tool; validation of contents by 20 specialized professionals, following Delphi´s technique, analysis and consolidation of the tool´s items by calculating the agreement index for language, pertinence, relevance, organization, clarity and applicability. Agreement among evaluators varied between 85.0 and 100.0%, with an overall 94.2% for the first model. Ten variables (23.2%) were included and 31 items (72.0%) were modified. After the plan´s validation, the tool remained with 11 domains and 55 items. Current study enhanced planning with great efficiency to obtain quality multi-professional assistance.

Nontuberculous mycobacteria in a tertiary Hospital in Portugal: A clinical review.

BACKGROUND: Nontuberculous mycobacteria (NTM) form a heterogeneous group regarding their ability to cause disease. To further understand their clinical relevance, the characteristics of patients who had positive cultures for NTM at a tertiary hospital in Portugal were reviewed. METHODS: Retrospective analysis of patients assessed at the Infectious Diseases (ID) Department of the São João Hospital Center, from January 2007 to December 2014, from whom at least one biological sample was tested culture positive for NTM. RESULTS: A total of 74 patients with at least one positive culture for NTM were identified. Forty-nine (66.2%) were infected by the human immunodeficiency virus, 4 (5.4%) had cancer, and 7 (9.5%) were under immunosuppressive medication. A total of 13 patients (17.6%) fulfilled the American Thoracic Society/ID Society of America criteria for pulmonary NTM disease and treatment was initiated in 12 other patients (16.2%), all of which were immunocompromised. Mycobacterium avium complex was more frequently associated with disease, responsible for 56% of the patients treated. Patients were treated with antituberculosis drugs adjusted for the species isolated, and cure was achieved in 13 patients (52%). CONCLUSION: The present study highlights the importance of understanding the epidemiology of NTM to better comprehend their clinical impact.

Comparação entre os índices de sífilis na gestação e sífilis congênita na região de Catanduva-SP / Comparison between syphilis indexes in gestation and congenital syphilis in Catanduva-SP area

Introdução: A meta proposta pela OMS para casos de Sífi lis congênita é de 0,5 casos para mil nascidos vivos. O índice brasileiro nãose enquadra em tal meta apesar de ser uma moléstia infectocontagiosa passível de prevenção e tratamento. A Sífi lis materna temaumentado nas últimas décadas, o que levou à ascensão do índice de Sífi lis congênita, considerada uma das principais causas de morteneonatal. Objetivos: Avaliar o aumento da incidência de Sífi lis em gestantes e comparar a incidência de Sífi lis materna e congênita entreos primeiros semestres de 2014, 2015 e 2016, além de realizar levantamento epidemiológico das gestantes no referido período estudado.Métodos: Estudo descritivo, transversal, analítico retrospectivo realizado a partir da coleta de dados referentes a prontuários de gestantesatendidas no setor da maternidade de um hospital universitário no interior de São Paulo. Considerou-se os testes não-treponêmicos(VDRL) materno e do recém-nascido como parâmetros classifi catórios de Sífi lis materna e provável Sífi lis congênita, respectivamente.Ademais, foram avaliadas variáveis como idade materna, via de parto, óbito fetal, e se a gestante pertencia ao Sistema Único de Saúdeou a um plano particular. Resultados: Foram avaliadas 3000 gestantes, com um total de 2985 nascidos vivos (NV) e 15 natimortos (0,5%).A média de idade foi de 25 anos de idade (com variação de 12 anos até 49 anos). Observou-se parto cesáreo em 72% dos nascimentos,e parto vaginal em 28%. Do total de gestantes, 70% eram provenientes da rede pública de saúde e 30% da rede particular. Observou-seaumento progressivo do índice de Sífi lis materna, obtendo-se os valores de 19,5, 22 e 26 casos de Sífi lis materna/1000 NV nos períodosavaliados de 2014, 2015 e 2016...

Introduction: The target proposed by World Health Organization (W.H.O.) for congenital Syphilis cases is 0.5 cases per 1000 live births.Despite of Syphilis being an infectious-contagious disease that is preventable and treatable, the Brazilian index doesn't meet this goal.Maternal Syphilis has been increasing in recent decades, leading to the increase of congenital Syphilis rate, considered one of the mostimportant causes of neonatal death. Objectives: To assess the increase of Syphilis incidence in pregnant women and to compare thematernal and congenital syphilis rates in the fi rst half of 2014, 2015 and 2016, besides of conducting an epidemiological survey of thepregnant women during the related periods. Material and methods: It is a descriptive, cross-sectional, analytical and retrospective studyperformed through the data collected from medical records of the pregnant women which were attended at the maternity Departmentof a University Hospital in São Paulo state countryside. Maternal and newborn non-treponemal (VDRL) tests were both considered asclassifi catory parameters of maternal syphilis and probable congenital Syphilis, respectively. Furthermore, variables such as maternalage, delivery path, fetal death and whether pregnant woman belonged to Unifi ed Health System or to a private healthcare plan wereassessed. Results: Three thousand pregnant women were assessed, with a total of 2985 live births and 15 stillborn (0,5%). The mean agewas 25...

Introducción: La meta propuesta por la OMS para casos de sífi lis congénita es de 0,5 casos para mil nacidos vivos. El índice brasileñono se encuadra en tal objetivo apesar de ser una molestia infectocontagiosa susceptible de prevención y tratamiento. La Sífi lis maternaha aumentado en las últimas décadas, lo que llevó al ascenso del índice de Sífi lis congénita, considerada una de las principales causasde muerte neonatal. Objetivos: Evaluar el aumento de la incidencia de Sífi lis en gestantes y comparar la incidencia de sífi lis materna ycongénita entre los primeros semestres de 2014, 2015 y 2016, además de realizar levantamiento epidemiológico de las gestantes en elreferido período estudiado. Métodos: Estudio descriptivo, transversal, analítico retrospectivo realizado a partir de la recolección de datosreferentes a prontuarios de gestantes atendidas em el sector de la maternidad de un hospital universitário en el interior de São Paulo.Se consideraron lãs pruebas no treponémicas (VDRL) materno y del recién nacido como parâmetros clasifi catorios de Sífi lis maternay probable Sífi lis congénita, respectivamente. Además, se evaluaron variables como edad materna, vía de parto, muerte fetal, y si lagestante pertenecía al Sistema Único de Salud o a un plano particular. Resultados: Se evaluaron 3000 gestantes, com un total de 2985nacidos vivos (NV) y 15 nacimientos (0,5%). El promedio de edad fue de 25 años de edad (convariación de 12 años hasta 49 años). Seobservó un parto cesáreo en el 72% de los nacimientos, y el parto vaginal en un 28%. Del total de gestantes, el 70% provenía de la redpública de salud y el 30% de la red privada. Se observó un aumento progresivo del índice de Sífi lis materna, obteniéndos elos valoresde 19,5, 22 y 26 casos...

Cosegregation of a novel mutation in the sixth transmembrane segment of the luteinizing/choriogonadotropin hormone receptor with two Brazilian siblings with severe testotoxicosis.

PURPOSE: Testotoxicosis is an autosomal dominant form of gonadotropin-independent precocious puberty caused by heterozygous constitutively activating mutations of the luteinizing hormone/choriogonadotropin receptor (LHCGR) gene. The aim of this study was to describe two Brazilian siblings with testotoxicosis, to confirm the molecular diagnosis, and to perform an in silico analysis of a novel mutation in the hot spot of the LHCGR gene. MATERIALS AND METHODS: Molecular analysis of the mutation on the LHCGR gene was performed by direct Sanger sequencing, followed by an in silico analysis using HOPE bioinformatics tool to predict a functional defect of the mutant. RESULTS: Both patients presented with gonadotropin-independent precocious puberty before the age of four years. Genetic analysis revealed a novel non-maternally inherited p.Asp578Val mutation of the LHCGR gene. An in silico analysis showed that the p.Asp578Val mutation disturbed amino acid physicochemical features regarding its size, charge, and hydrophobicity value. CONCLUSIONS: Clinical and hormonal profile of the siblings here evaluated was not different while compared to those patients previously described. An in silico mutation analysis reinforced the causative role of recurrent activating mutations in the intracellular loop and transmembrane helices of the LHCGR. The segregation of this mutation with the offsprings' phenotype indicated that it is causative.

Elizabethkingia meningoseptica and Contact Lens Use.

A 47-year-old man presented to our emergency department complaining of acute ocular pain and redness of his left eye. Ophthalmological antecedents included use of semi-rigid contact lens and primary open-angle glaucoma. Slit-lamp examination revealed a small central corneal ulcer associated with stromal inflammatory infiltrate. Scraping from the corneal ulcer was positive for Elizabethkingia meningoseptica. He was empirically treated with topical 0.5% levofloxacin and 0.3% gentamicin, and five weeks later the infection had resolved. In this case report we describe the uncommon association between contact lens and Elizabethkingia meningoseptica. Despite possible serious complications associated with this atypical agent, prompt diagnosis and adequate treatment lead to good visual prognosis.

Doente de 47 anos, sexo masculino, recorreu ao serviço de urgência por início súbito de dor ocular e hiperemia conjuntival no olho esquerdo. Os antecedentes oftalmológicos incluíam o uso de lente de contacto semi-rígida e glaucoma primário de ângulo aberto. O exame na lâmpada de fenda revelou uma pequena úlcera de córnea central associada a infiltrado inflamatório estromal. A zaragatoa da base da úlcera de córnea permitiu a identificação de colónias de Elizabethkingia meningoseptica. O doente foi empiricamente tratado com levofloxacina colírio 0,5% e pomada de gentamicina 0,3%, tendo a infecção resolvido após cinco semanas. Neste caso clínico, descrevemos a associação incomum entre lentes de contacto e Elizabethkingia meningoseptica. Apesar das possíveis complicações graves relacionadas com este agente etiopatogénico, o diagnóstico rápido e tratamento adequado permitiram um bom prognóstico visual.

Prozone-like phenomenon in travellers with fatal malaria: report of two cases.

Malaria diagnosis remains a concern in non-endemic countries, with rapid diagnosis being crucial to improve patients' outcome. Rapid diagnostic tests have high sensitivity but they also have flaws and false-negative results that might jeopardize malaria diagnosis. Some false-negative results might relate to a prozone-like effect. The authors describe two patients with false-negative rapid diagnostic tests in which a prozone-like effect might have been involved. The authors highlight that these tests should not be used without accompanying light microscopy observation of blood films and discuss potential benefits of using rapid diagnostic tests with more than one specific antigen for Plasmodium falciparum.

Does company compliance with RS-17 influence the characterization of a casual nexus in expert testimony?

OBJECTIVE: To examine whether company compliance with RS-17 influences the characterization of the casual nexus in physical therapists' expert reports of cumulative trauma disorders in the labor court of Pernambuco, Brazil. METHOD: The sample was composed of seven physical therapists who provided expert testimony regarding cumulative trauma disorder cases in the labor court of Pernambuco, Brazil. Data collection was performed across two stages. In the first stage, the experts answered a sociodemographic survey and requested the identification numbers of recent cases where expert testimony was provided to characterize the causal nexus. In the second stage, the researchers went to the labor court to collect expert testimony data. These experts indicated that of 75 total cases, 31% (N=23) of the companies fulfilled RS-17, whereas 69% (N=52) did not comply with the law. RESULTS: Among the organizations that complied with legislation, 30% of the analyzed expert testimonies showed a positive causal nexus. However, of the companies that did not comply with RS-17, 71% of the expert testimonies revealed a causal nexus. These results indicate that the breach of the law increases the probability that a causal nexus will be determined by 54.8%. CONCLUSION: The results showed that failure to comply with RS-17 significantly increases the probability that a causal nexus will be determined in physical therapists' expert testimony of cumulative trauma disorders.

Does company compliance with RS-17 influence the characterization of a casual nexus in expert testimony?

Objective: To examine whether company compliance with RS-17 influences the characterization of the casual nexus in physical therapists' expert reports of cumulative trauma disorders in the labor court of Pernambuco, Brazil. Method: The sample was composed of seven physical therapists who provided expert testimony regarding cumulative trauma disorder cases in the labor court of Pernambuco, Brazil. Data collection was performed across two stages. In the first stage, the experts answered a sociodemographic survey and requested the identification numbers of recent cases where expert testimony was provided to characterize the causal nexus. In the second stage, the researchers went to the labor court to collect expert testimony data. These experts indicated that of 75 total cases, 31% (N=23) of the companies fulfilled RS-17, whereas 69% (N=52) did not comply with the law. Results: Among the organizations that complied with legislation, 30% of the analyzed expert testimonies showed a positive causal nexus. However, of the companies that did not comply with RS-17, 71% of the expert testimonies revealed a causal nexus. These results indicate that the breach of the law increases the probability that a causal nexus will be determined by 54.8%. Conclusion: The results showed that failure to comply with RS-17 significantly increases the probability that a causal nexus will be determined in physical therapists' expert testimony of cumulative trauma disorders. .

The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk.

AIMS: To estimate 3-year risk for diabetic foot ulcer (DFU), lower extremity amputation (LEA) and death; determine predictive variables and assess derived models accuracy. MATERIAL AND METHODS: Retrospective cohort study including all subjects with diabetes enrolled in our diabetic foot outpatient clinic from beginning 2002 until middle 2010. Data were collected from clinical records. RESULTS: 644 subjects with mean age of 65.1 (±11.2) and diabetes duration of 16.1 (±10.8) years. Cumulative incidence was 26.6% for DFU, 5.8% for LEA and 14.0% for death. In multivariate analysis, physical impairment, peripheral arterial disease complication history, complication count and previous DFU were associated with DFU; complication count, foot pulses and previous DFU with LEA and age, complication count and previous DFU with death. Predictive models' areas under the ROC curves ranged from 0.80 to 0.83. A simplified model including previous DFU and complication count presented high accuracy. Previous DFU was associated with all outcomes, even when adjusted for complication count, in addition to more complex models. CONCLUSIONS: DFU seems more than a marker of complication status, having independent impact on LEA and mortality risk. Proposed models may be applicable in healthcare settings to identify patients at higher risk of DFU, LEA and death.

Extended-spectrum ß-lactamases of Escherichia coli and Klebsiella pneumoniae screened by the VITEK 2 system.

The VITEK 2 automated system (bioMérieux) is one of the most widely used instruments in clinical microbiology laboratories for the identification and evaluation of the susceptibility profiles of bacteria including the detection of extended-spectrum ß-lactamases (ESBLs) produced by Escherichia coli, Klebsiella pneumoniae and Klebsiella oxytoca. Currently, the Clinical and Laboratory Standards Institute recommends the use of ESBL confirmatory tests in addition to standard susceptibility testing. In order to evaluate the accuracy of VITEK 2-positive results regarding clinical isolates of E. coli (n = 110) and K. pneumoniae (n = 72), four additional ESBL detection systems were compared: the Phoenix Automated Microbiology System (BD Diagnostic Systems) and the MicroScan WalkAway-96 System (Dade Behring), and two manual systems as confirmatory tests, the Etest (AB Biodisk) and double disc diffusion (DDS) test. Epidemiological data regarding the tested strains were also collected and their susceptibility phenotypes were determined. The four methods resulted in concordant results for 126 of the 182 strains. However, the different tests displayed distinct results: the VITEK 2 system was in disagreement in 23.9 % of cases with DDS, in 15.3 % with Etest, in 23 % with the MicroScan WalkAway-96 System and in 23.6 % with the Phoenix Automated Microbiology System. Epidemiological data indicated that the majority of ESBL-positive E. coli strains were isolated from patients admitted to internal medicine wards (72.7 %), whilst K. pneumoniae ESBL-positive isolates were equally distributed between internal medicine wards (45.8 %) and intensive care units (45.8 %). Most of these strains were isolated from urine. In contrast to ESBL-negative isolates, the ESBL-positive strains displayed multiple drug resistance, namely to quinolones, aminoglycosides and trimethoprim-sulfamethoxazole. No significant resistance to carbapenems was detected. Overall, this study demonstrates the need for a confirmatory test following positive ESBL detection with the VITEK 2 system (panel AST-037), which appears to yield a large number of false-positive results.