Sepsis during pregnancy: case report

BACKGROUND AND OBJECTIVES: Sepsis during pregnancy is a rare complication. This potentially fatal disease often occurs due to maternal infectious and can lead to fetal loss. Therefore, any attempted treatment must be aimed at the mother s well being. As a matter of fact, there are few recent medical publications about sepsis in pregnancy. In spite of this, the treatment based on Surviving Sepsis Campaign seems suitable and practical. The aim of this article is making a case report highlighting a very well succeeded treatment of a pregnant woman with urinary sepsis. CASE REPORT: A 22 year old in her 27th week of pregnancy is hospitalized with pyelonefhritis. One day later, she begins presenting signs of sepsis and unresponsive hypoxemia, resulting in intubation. Afterwards, she evolved with persistent low blood pressure that was unresponsive to volume expansion and had to be put on vasopressor medication. She received intensive care support based on Surviving Sepsis Campaign. The patient evolved with an important improvement of her ventilatory stats and was extubated. After completing antibiotic treatment, she was discharged and delivered a healthy baby after 42 weeks pregnancy. CONCLUSIONS: Sepsis in pregnancy is a rare and potentially fatal complication. The main treatment is based on Surviving Sepsis Campaign. The patient had an outstanding improvement and overcame her condition after intensive care support.JUSTIFICATIVA E OBJETIVOS: A sepse durante a gestação é uma complicação rara. O comprometimento fetal resulta principalmente da descompensação materna, por conseguinte, o tratamento deve ser direcionado ao bem-estar da mãe. Poucas evidências permitem extrapolar o tratamento de pacientes não gestantes para as gestantes, porém, o tratamento baseado no Surviving Sepsis Campaing parece adequado e prático. O objetivo deste estudo foi rever o tratamento da sepse na gestação e relatar um caso de gestante com sepse grave que evoluiu favoravelmente. RELATO DO CASO: Paciente com 22 anos, primigesta, na 27ª semana de gestação foi internada com diagnóstico de pielonefrite aguda. Um dia após a internação apresentou quadro de sepse, com hipoxemia refratária às medidas não-invasivas necessitando de intubação traqueal. Após a intubação evoluiu com hipotensão refratária à expansão volêmica necessitando de fármaco vasoativo. Foi interrompido o uso de noradrenalina no mesmo dia e prescrito cefepima. Evoluiu com importante melhora dos padrões ventilatórios, sendo extubada e recebeu alta hospitalar logo após completar o tratamento com antibiótico. Ao completar a 42ª semana de gestação foi internada para indução do trabalho de parto, sendo realizado parto vaginal, sem intercorrências. CONCLUSÕES: A sepse na gestação, mesmo sendo rara é potencialmente fatal. O tratamento foi baseado no Surviving Sepsis Campaign e a paciente apresentou melhora significativa dos parâmetros de perfusão nas primeiras horas com ótima evolução, apesar da gravidade da doença.UNIFESP Clínica Médica da EPMUNIFESP Pronto Socorro da EPM Unidade de Terapia IntensivaUNIFESP, Clínica Médica da EPMUNIFESP, Pronto Socorro da EPM Unidade de Terapia IntensivaSciEL

Neutrophil gelatinase-associated lipocalin in kidney transplantation is an early marker of graft dysfunction and is associated with one-year renal function

Urinary neutrophil gelatinase-associated lipocalin (uNGAL) has been suggested as potential early marker of delayed graft function (DGF) following kidney transplantation (KTx). We conducted a prospective study in 40 consecutive KTx recipients to evaluate serial changes of uNGAL within the first week after KTx and assess its performance in predicting DGF (dialysis requirement during initial posttransplant week) and graft function throughout first year. Urine samples were collected on post-KTx days 0, 1, 2, 4, and 7. Linear mixed and multivariable regression models, receiver-operating characteristic (ROC), and areas under ROC curves were used. At all-time points, mean uNGAL levels were significantly higher in patients developing DGF (n = 18). Shortly after KTx (3-6 h), uNGAL values were higher in DGF recipients (on average +242 ng/mL, considering mean dialysis time of 4.1 years) and rose further in following days, contrasting with prompt function recipients. Day-1 uNGAL levels accurately predicted DGF (AUC-ROC = 0.93), with a performance higher than serum creatinine (AUC-ROC = 0.76), and similar to cystatin C (AUC-ROC = 0.95). Multivariable analyses revealed that uNGAL levels at days 4 and 7 were strongly associated with one-year serum creatinine. Urinary NGAL is an early marker of graft injury and is independently associated with dialysis requirement within one week after KTx and one-year graft function.The authors recognize and thank Abbott Laboratories for their valuable contribution for donating kits used for testing almost 200 samples. The remaining kits were financed by funds of Unit for Multidisciplinary Investigation in Biomedicine, Porto, Portuga

Moisture Control, Inoculant and Particle Size in Tropical Grass Silages

Decreased fermentation and spoilage losses with improved aerobic stability during feed out can be accomplished by several strategies, such as wilting, addition of microbial additives and moisture absorbents. Particle size reduction may increase bulk density and improve the fermentation. The objective of this trial was to evaluate the effects of particle size, moisture content and a microbial additive on chemical-physical parameters and losses in silages made from Tanzania grass

Influência da velocidade de concretagem sobre a pressão lateral do concreto fresco no dimensionamento de fôrmas

A pressão lateral do concreto fresco gera uma carga que possui grande influência no dimensionamento das fôrmas de pilares, paredes e faces laterais das vigas. Sua previsão deve ser realizada de modo que se aproxime bem dos valores suportados pelas fôrmas, evitando-se, assim, o superdimensionamento ou subdimensionamento dessas estruturas provisórias que representam até 12% do custo total da obra. O cálculo da pressão lateral que o concreto fresco exerce sobre as fôrmas envolve diversas variáveis, sendo uma delas a velocidade de concretagem. O principal objetivo deste trabalho foi estudar a influência da velocidade de concretagem sobre a pressão lateral do concreto fresco calculada a partir de modelos teóricos apresentados por normas e referências internacionais. Para isso, foram realizadas medições da velocidade de concretagem em pilares de cinco obras de Goiânia e calculadas as pressões máximas suportadas por suas respectivas fôrmas, a partir das dimensões e dos vãos entre os apoios dos elementos que as constituíam. Os resultados obtidos apontam que as velocidades de concretagem em campo chegam a 248,57 m/h, superando os valores limitados pelos métodos teóricos de cálculo, e que as estimativas da pressão realizadas a partir das velocidades medidas in loco ultrapassam os valores máximos suportados pelas fôrmas em até 603,75 vezes. Assim, concluiu-se que é necessária a formulação de equações para estimar a pressão lateral do concreto fresco a altas velocidades de concretagem, conforme as atuais práticas no mercado da construção civil.The fresh concrete lateral pressure generates a load that has great influence in the design of the formworks of columns, walls and lateral faces of the beams.Its prediction must be performed in such a way in order to approach precisely well over the rate values supported by the formworks, avoiding, therefore, the oversizing or undersizing of these temporary structures which represent up to 12% of the total cost of the construction. The calculation of the lateral pressure that fresh concrete exerts on the formworks involves several variables; one of them is the placement rate. The main objective of this work was to study the influence of the placement rate, in situ, on the lateral pressure of fresh concrete calculated from theoretical models presented by norms and international references. For this purpose, measurements of the placement rate were conducted on columns of five building work places at Goiânia city, Goiás, Brazil and it was calculated the maximum pressure supported by their respective formworks from the dimensions and spans between the supports of the components that constituted them. The obtained results indicate that the placement rate in the field observations reach 249 m/h, exceeding the values limited by the theoretical methods of calculation, and that the lateral pressure estimation produced from the placement rate measured in situ exceed the maximum values supported by the formworks up to 604 times. Thus, it was concluded that it is necessary to adjust equations to estimate the lateral pressure of fresh concrete at high rate of concrete placement, according to the current practices in the construction market

KIAA1840 mutations cause ARCMT2

Charcot–Marie–Tooth disease is a group of hereditary peripheral neuropathies that share clinical characteristics of progressive distal muscle weakness and atrophy, foot deformities, distal sensory loss, as well as diminished tendon reflexes. Hundreds of causative DNA changes have been found, but much of the genetic basis of the disease is still unexplained. Mutations in the ALS5/SPG11/ KIAA1840 gene are a frequent cause of autosomal recessive hereditary spastic paraplegia with thin corpus callosum and peripheral axonal neuropathy, and account for ∼40% of autosomal recessive juvenile amyotrophic lateral sclerosis. The overlap of axonal Charcot–Marie–Tooth disease with both diseases, as well as the common autosomal recessive inheritance pattern of thin corpus callosum and axonal Charcot–Marie–Tooth disease in three related patients, prompted us to analyse the ALS5/SPG11/ KIAA1840 gene in affected individuals with autosomal recessive axonal Charcot–Marie–Tooth disease. We investigated 28 unrelated families with autosomal recessive axonal Charcot–Marie–Tooth disease defined by clinical, electrophysiological, as well as pathological evaluation. Besides, we screened for all the known genes related to axonal autosomal recessive Charcot–Marie-Tooth disease (CMT2A2/HMSN2A2/ MFN2 , CMT2B1/ LMNA , CMT2B2/ MED25 , CMT2B5/ NEFL , ARCMT2F/dHMN2B/ HSPB1 , CMT2K/ GDAP1 , CMT2P/ LRSAM1 , CMT2R/ TRIM2 , CMT2S/ IGHMBP2 , CMT2T/ HSJ1 , CMTRID/ COX6A1 , ARAN-NM/ HINT and GAN/ GAN ), for the genes related to autosomal recessive hereditary spastic paraplegia with thin corpus callosum and axonal peripheral neuropathy (SPG7/ PGN , SPG15/ ZFYVE26, SPG21/ ACP33 , SPG35/ FA2H , SPG46/ GBA2 , SPG55/ C12orf65 and SPG56/ CYP2U1 ), as well as for the causative gene of peripheral neuropathy with or without agenesis of the corpus callosum ( SLC12A6 ) . Mitochondrial disorders related to Charcot–Marie–Tooth disease type 2 were also excluded by sequencing POLG and TYMP genes. An additional locus for autosomal recessive Charcot–Marie–Tooth disease type 2H on chromosome 8q13-21.1 was excluded by linkage analysis. Pedigrees originated in Italy, Brazil, Canada, England, Iran, and Japan. Interestingly, we identified 15 ALS5/SPG11/ KIAA1840 mutations in 12 families (two sequence variants were never reported before, p.Gln198* and p.Pro2212fs*5). No large deletions/duplications were detected in these patients. The novel mutations seemed to be pathogenic since they co-segregated with the disease in all pedigrees and were absent in 300 unrelated controls. Furthermore, in silico analysis predicted their pathogenic effect. Our results indicate that ALS5/SPG11/ KIAA1840 is the causative gene of a wide spectrum of clinical features, including autosomal recessive axonal Charcot–Marie–Tooth disease

Evidência da transmissão do vírus da diarreia viral bovina através da lâmina d’água em leitões experimentalmente infectados

Os suínos podem ser infectados pelo vírus da diarreia viral bovina (BVDV). No entanto, as vias de transmissão entre os suínos são ainda desconhecidas. O objetivo do presente estudo foi induzir a infecção experimental de BVDV-1 em leitões desmamados e avaliar a potencial transmissão pela lâmina d’água, que ajuda na troca de calor dos suínos alojados em baias. Duas repetições do experimento (BP1 e BP2) foram realizadas com 12 animais comprovadamente livres de BVDV (n=6 por repetição) alocados em três grupos: controle, sentinelas e infectados, com dois animais cada. Os animais foram mantidos em isoladores de aço inoxidável. O grupo infectado recebeu um inóculo contendo BVDV-1, estirpe Singer. Os animais permaneceram nos isoladores durante 25 dias e, durante esse período, amostras de suabe nasal foram coletadas diariamente e sangue coletado semanalmente. No final, os animais foram eutanasiados, necropsiados e fragmentos de órgãos foram coletados para histopatologia, imuno-histoquímica e RT-PCR. No primeiro experimento (BP1), os animais infectados excretaram partículas virais entre os dias 6 e 21 pós-infecção. Quanto ao grupo sentinela, a excreção ocorreu apenas em um animal, no 20º dia pós-infecção, e a soroconversão foi observada no 25º dia pós-infecção. Na BP2, os animais infectados I3 e I4 excretaram partículas virais nos dias 4 e 21 pós-infecção, respectivamente. Apenas um animal sentinela (S3) apresentou excreção no dia 13 pós-infecção. Concluiu-se que os suínos podem se infectar com BVDV-1 e excretar partículas virais potencialmente infecciosas, sendo capazes de transmitir o vírus a outros suínos através da lâmina d’água.Swine can be infected by bovine viral diarrhea virus (BVDV). However, transmission routes among pigs are still unknown. The objective of the present study was to induce experimental infection of BVDV-1 in weaned piglets and to assess the potential transmission through pen back pond water, used to facilitate heat exchange of the pigs housed in barns. Two repetitions (BP1 and BP 2) were performed using 12 piglets proven to be free BVDV (n=6 per repetition) allocated into three groups: control, sentinels and infected with two piglets each. The piglets were placed in stainless steel isolators. The infected group received an inoculum containing BVDV-1, Singer strain. The piglets remained in the cabinets for 25 days, during which samples of nasal swab were collected daily and blood sampled weekly. At the end, the piglets were euthanized, necropsied and organ fragments were collected for histopathology, immunohistochemistry and RT-PCR. In the first experiment (BP1) the infected animals shed the virus between days 6 and 21 post-infection. Regarding the sentinel group, shedding occurred in only one piglet, on the 20th day after infection, and seroconversion was observed on the 25th day post-infection. In BP2, infected piglets I3 and I4 shed the virus on days 4 and 21 post-infection, respectively. Only one sentinel piglet (S3) she the virus on day 13 post-infection. Therefore, it was concluded that pigs can become infected with BVDV-1 and shed potentially infectious viral particles consequently, being able to transmit the virus to other pigs through back pond water

Modeling Respiratory Depression Induced by Remifentanil and Propofol during Sedation and Analgesia Using a Continuous Noninvasive Measurement of pCO 2 s

ABSTRACT Respiratory depression is a common adverse effect of propofol and remifentanil. We aimed to develop a model for respiratory depressant effects of propofol with remifentanil in patients undergoing endoscopy with sedation. Data were available for 136 patients undergoing endoscopy with sedation. Participants randomly received infusions of propofol and remifentanil. Predicted plasma concentrations, outputted by infusion pumps, were available. Transcutaneous arterial pressure of carbon dioxide (pCO 2 ) was measured. Data were analyzed using nonlinear mixed-effects modeling methods. Covariate relationships were investigated for age, noxious stimuli (endoscopy tube insertion), and A118G genotype for the m-opioid receptor (OPRM1). Participants had a median 21 . Propofol affected the modulator compartment with an IC 50 of 4.97 mg/ml (no effect-site compartment). Propofol IC 50 and remifentanil k e0 were reduced with increasing age. Noxious stimuli and genotype were not significant covariates. An indirect-effect model with a rebound mechanism can describe remifentanil-and propofolinduced changes in pCO 2 in patients undergoing noxious procedures. The model may be useful for identifying optimal dosing schedules for these drugs in a combination that provides adequate sedation but avoids respiratory depression