Adipositas cordis: um difícil diagnóstico diferencial

A infiltração gordurosa do miocárdio representa desafio diagnóstico para o clínico e para o patologista, pois pode ser um achado compatível com a normalidade como ser responsável por doenças que apresentem desfechos fataiscomo, por exemplo, morte súbita, arritmias, disfunção do miocárdio e insuficiência cardíaca congestiva.O diagnóstico diferencial entre as doenças relacionadas à infiltração gordurosa do miocárdio de evolução desfavorável como a Adipositas Cordis e a Displasia/CardiomiopatiaArritmogênica do Ventrículo Direito também é difícil, sendo necessário avaliá-las com bases em achados clínico-laboratoriais e histopatológicos.Os autores apresentam o caso de um paciente sem qualquer comorbidade prévia, não obeso, que inesperadamente apresentou hipotensão refratária após estresse fisiológico, caracterizado pelo pós-operatório imediato de hemicolectomia,evoluindo a óbito. O achado da necropsia foi de infiltração gordurosa do ventrículo direito que caracteriza Adipositas Cordis, explicando a insuficiência de ventrículo direito e conseqüente hipotensão refratária.Myocardial fatty infiltration is a diagnostic challenge for clinicians and pathologists once it may be found as part of normal myocardial tissue or may be a manifestation of diseases responsible for fatal outcomes like sudden death, arrhythmias and heart failure.Differential diagnosis between the diseases related to myocardial fatty infiltration as, Adipositas Cordis and Arrhythmogenic Dysplasia of the Right Ventricle requiresclinical, laboratory and histopathological correlation.The authors present a case of a previously healthy patient, non obese, who unexpectedly presented a refractory hypotension after a physiologic stress characterized by immediate post operatory.The necropsy findings showed fatty infiltration of the heart characterizing the histological features of Adipostas Cordis. This finding explained the right ventricle failure and consequent refractory hypotension

Clinical and microbiological characteristics of patients colonized or infected by Stenotrophomonas maltophilia: is resistance to sulfamethoxazole/trimethoprim a problem?

Stenotrophomonas maltophilia has emerged as an important opportunistic pathogen in the last decade. Increased resistance to sulfamethoxazole/trimethoprim (SMX/TMP) has been reported in S. maltophilia strains in the past few years, leading to few therapeutic options. We conducted a prospective multicenter study at two Brazilian teaching hospitals that identified S. maltophilia isolates and evaluated their antimicrobial susceptibility profile, SMX/TMP resistance genes and their clonality profile. A total of 106 non-repeated clinical samples of S. maltophilia were evaluated. Resistance to SMX/TMP was identified in 21.6% of the samples, and previous use of SMX/TMP occurred in 19 (82.6%). PCR detected the sul1 gene in 14 of 106 strains (13.2%). Of these isolates, nine displayed resistance to SMX/TMP. The resistant strains presented a polyclonal profile. This opportunistic pathogen has emerged in immunocompromised hosts, with few therapeutic options, which is aggravated by the description of emerging resistance mechanisms, although with a polyclonal distribution profile

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Factors associated with mortality in Nosocomial infections with Stenotrophomonas maltophilia

Paez JIG. Fatores associados à mortalidade em infecções nosocomiais por Stenotrophomonas maltophilia [dissertação]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2007. 154p. Infecção de corrente sanguínea (ICS) e pneumonia por S. maltophilia são associadas á alta mortalidade. A identificação de fatores relacionados à mortalidade em pacientes com infecções por esse agente pode permitir intervenções no sentido de diminuir a sua mortalidade. Realizamos um estudo retrospectivo com 60 pacientes com ICS ou pneumonia de origem hospitalar no Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-FMUSP) durante o período de 30 de julho de 1999 a 30 de julho de 2005. Analisamos os fatores de risco relacionados à mortalidade global e a mortalidade nos primeiros 14 dias da infecção por meio de um estudo de coorte retrospectivo comparando os pacientes que apresentaram óbito com os que não apresentaram óbito.As seguintes características foram encontradas na população estudada no momento da infecção, 57 (85%) dos pacientes receberam antibióticos prévios, 88% tinham cateter venoso central, 57% estavam em uso de ventilação mecânica, 35% em uso de quimioterapia e 75% estavam internados em unidade de cuidado intensivo. Neoplasia foi a principal doença de base presente em 45%. Choque séptico foi descrito em 30% dos casos, a média de pontuação na escala de APACHE II foi de 17 pontos e a média de pontuação da escala SOFA foi de 7 pontos. Foram diagnosticadas 8 pneumonias e 52 ICS, 47% foram ICS primárias, entre estas 13% foram ICS relacionadas ao cateter. Foram diagnosticadas também 40% ICS secundárias, sendo o principal foco pulmonar (18%). 27% das infecções foram polimicrobianas. Os fatores de risco independentes associados à mortalidade nos primeiros 14 dias identificados na análise multivariada foram, pontuação maior que 6 no índice SOFA (RR=18,9. IC95%=2,4-146,2) e presença de choque séptico (RR=11,6. IC95%=1,3-105,9). O fator de risco associado à mortalidade global na análise multivariada foi, pontuação maior que 6 no índice SOFA (RR=37,1. IC95%=2,8-494,3). A instituição de terapia antimicrobiana inadequada para o tratamento das infecções por S. maltophilia foi freqüente, sendo observada em 40 (85%) pacientes, principalmente por atraso no inicio e por tempo curto de tratamento. Não houve diferença estatística quando comparado o tratamento adequado do tratamento inadequado. A curva de sobrevida de Kaplan-Meier mostrou que pacientes com APACHE II >20 e SOFA > 10 tinham respectivamente uma chance de sobrevida menor que 8% e menor que 10% (P= 6 points (RR=18.9. 95%CI=2.4-146.2) and septic shock (RR=11.6. 95%IC=1.3-105.9). Risk factor associated with overall mortality was SOFA index > 6 points, (RR=37.1. 95%IC=2.8-494.3). Used of inappropriate antimicrobial therapy was observed in 40 (85%) patients, of whom received therapy with more 72 hours and received therapy for an insufficient length of time and there was no difference when compared appropriated and non-appropriated therapy. Kaplan-Meier estimations curves showed that patients with APACHE II >20 and SOFA > 10 had respectively a survival chance less than 8% and less than 10% (P=<0.001) at 21 days after the first positive S. maltophilia culture. The overall mortality and 14-day mortality after the onset of infections rates were 75% and 38% respectively. Our results showed that infections caused by S. maltophilia occur in critically ill patients with multiple risk factors and that the most important risk factors associated with mortality are the initial clinical condition and severity of diseases

Risk of COVID-19 after natural infection or vaccinationResearch in context

Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health

Risk of COVID-19 after natural infection or vaccinationResearch in context

Summary: Background: While vaccines have established utility against COVID-19, phase 3 efficacy studies have generally not comprehensively evaluated protection provided by previous infection or hybrid immunity (previous infection plus vaccination). Individual patient data from US government-supported harmonized vaccine trials provide an unprecedented sample population to address this issue. We characterized the protective efficacy of previous SARS-CoV-2 infection and hybrid immunity against COVID-19 early in the pandemic over three-to six-month follow-up and compared with vaccine-associated protection. Methods: In this post-hoc cross-protocol analysis of the Moderna, AstraZeneca, Janssen, and Novavax COVID-19 vaccine clinical trials, we allocated participants into four groups based on previous-infection status at enrolment and treatment: no previous infection/placebo; previous infection/placebo; no previous infection/vaccine; and previous infection/vaccine. The main outcome was RT-PCR-confirmed COVID-19 >7–15 days (per original protocols) after final study injection. We calculated crude and adjusted efficacy measures. Findings: Previous infection/placebo participants had a 92% decreased risk of future COVID-19 compared to no previous infection/placebo participants (overall hazard ratio [HR] ratio: 0.08; 95% CI: 0.05–0.13). Among single-dose Janssen participants, hybrid immunity conferred greater protection than vaccine alone (HR: 0.03; 95% CI: 0.01–0.10). Too few infections were observed to draw statistical inferences comparing hybrid immunity to vaccine alone for other trials. Vaccination, previous infection, and hybrid immunity all provided near-complete protection against severe disease. Interpretation: Previous infection, any hybrid immunity, and two-dose vaccination all provided substantial protection against symptomatic and severe COVID-19 through the early Delta period. Thus, as a surrogate for natural infection, vaccination remains the safest approach to protection. Funding: National Institutes of Health