Figura Central
: Fatores de Risco para Infecção da Ferida Operatória em Pacientes Submetidos à Cirurgia Cardíaca Pediátrica
Fatores de risco para infecção da ferida operatória em pacientes submetidos ...à cirurgia cardíaca pediátrica.
This study developed a photo and video database of 4-to-6-year-olds expressing the seven induced and posed universal emotions and a neutral expression. Children participated in photo and video ...sessions designed to elicit the emotions, and the resulting images were further assessed by independent judges in two rounds.
In the first round, two independent judges (1 and 2), experts in the Facial Action Coding System, firstly analysed 3,668 emotions facial expressions stimuli from 132 children. Both judges reached 100% agreement regarding 1,985 stimuli (124 children), which were then selected for a second round of analysis between judges 3 and 4.
The result was 1,985 stimuli (51% of the photographs) were produced from 124 participants (55% girls). A Kappa index of 0.70 and an accuracy of 73% between experts were observed. Lower accuracy was found for emotional expression by 4-year-olds than 6-year-olds. Happiness, disgust and contempt had the highest agreement. After a sub-analysis evaluation of all four judges, 100% agreement was reached for 1,381 stimuli which compound the ChildEFES database with 124 participants (59% girls) and 51% induced photographs. The number of stimuli of each emotion were: 87 for neutrality, 363 for happiness, 170 for disgust, 104 for surprise, 152 for fear, 144 for sadness, 157 for anger 157, and 183 for contempt.
The findings show that this photo and video database can facilitate research on the mechanisms involved in early childhood recognition of facial emotions in children, contributing to the understanding of facial emotion recognition deficits which characterise several neurodevelopmental and psychiatric disorders.
A endocardite infecciosa (EI) é uma doença grave com cerca de 20% de mortalidade intra-hospitalar. Streptococcus pneumoniae, que na era pré-antibiótica foi responsável por 15% de todos os casos de ...EI, afeta menos de <1% na atualidade. Cursa com destruição valvar extensa, insuficiência cardíaca e alta letalidade. Série de casos: Descrevemos sete pacientes adultos com endocardite pneumocócica de 2007 até 2019, oriundos de 4 instituições brasileiras, em um total de 1154 casos (frequência de 0,6%) de EI definitiva pelos critérios modificados de Duke coletados prospectivamente. Eram do sexo masculino 5/7 (71%), com média de idade de 51 anos (amplitude 22-77), 1 deles era esplenectomizado, todos tiveram EI em valva nativa, nenhum tinha valvopatia prévia, 3 pacientes tiveram comprometimento mitro-aórtico, 2 de válvula mitral e 2 de válvula aórtica. Abscesso perivalvar esteve presente em 4/7. Cinco pacientes foram submetidos a cirurgia, e tiveram tempo médio de internação de 31,28 dias (55-6), e 3 de 7 evoluiram a óbito.
Apresentamos uma série brasileira de casos contemporâneos de EI por pneumococo, agente relativamente raro nos dias atuais. É importante notar que os pacientes eram em sua maioria jovens e sem fatores de risco para doença pneumocócica, exceto pela idosa de 61 anos que era esplenectomizada. Todos tiveram acometimento de EI esquerda com importante complicação que foi o abscesso perivalvar, indicação absoluta de cirurgia. De fato, todos foram submetidos a cirurgia, exceto pela idosa, que morreu antes, aos 6 dias do início do tratamento. Em conclusão, o pneumococo, embora um estreptococos do grupo viridans, deve ser diferenciado por sua virulência quando agente de EI.
•Patients with isolated right-sided fungal endocarditis had better survival.•Heart failure/medical treatment only were related to death in Candida endocarditis.•Isolated right-sided endocarditis a ...less harmful illness in Candida endocarditis.
To compare the clinical and epidemiological features, treatments, and outcomes of patients with isolated right-sided and left-sided fungal endocarditis and to determine the risk factors for in-hospital mortality in patients with Candida sp endocarditis.
A retrospective review of all consecutive cases of fungal endocarditis from five hospitals was performed. Clinical features were compared between patients with isolated right-sided and left-sided endocarditis. In the subgroup of fungal endocarditis due to Candida species, binary logistic regression analysis was performed to determine variables related to in-hospital mortality.
Seventy-eight patients with fungal endocarditis were studied. Their median age was 50 years; 55% were male and 19 patients (24%) had isolated right-sided endocarditis. Overall, cardiac surgery was performed in 46 patients (59%), and in-hospital mortality was 54%. Compared to patients with left-side fungal endocarditis, patients with isolated right-sided endocarditis had lower mortality (32% vs. 61%; p=0.025) and were less often submitted to cardiac surgery (37% vs. 66%; p=0.024). The most frequent etiology was Candida spp (85%). In this subgroup, acute heart failure (odds ratio 5.0; p=0.027) and exclusive medical treatment (odds ratio 11.1; p=0.004) were independent predictors of in-hospital death, whereas isolated right-sided endocarditis was related to a lower risk of mortality (odds ratio 0.13; p=0.023).
Patients with isolated right-sided fungal endocarditis have particular clinical and epidemiological features. They were submitted to cardiac surgery less often and had better survival than patients with left-sided fungal endocarditis. Isolated right-sided endocarditis was also a marker of a less harmful illness in the subgroup of Candida sp endocarditis.
Infective endocarditis continues to be a significant concern and may be undergoing an epidemiological transition.
Were studied 1804 consecutive episodes of infective endocarditis between 1978 and ...2022. The mean age was 48 ( ± 19), and 1162 (64%) patients were male. Temporal trends in demographic data, comorbidities, predisposing conditions, microorganisms, complications and in-hospital death have been studied over the decades (1978–1988, 1989–1999, 2000–2010 and 2011–2022). The outcomes and clinical characteristics were modeled using nonlinear cubic spline functions.
Valve surgery was performed in 50% of the patients and overall in-hospital mortality was 30%. From the first to the fourth decade studied, the average age of patients increased from 29 to 57 years (p < 0.001), with significant declines in the occurrence of rheumatic valvular heart disease (15% to 6%; p < 0.001) and streptococcal infections (46% to 33%; p < 0.001). Healthcare-associated infections have increased (9% to 21%; p < 0.001), as have prosthetic valve endocarditis (26% to 53%; p < 0.001), coagulase-negative staphylococcal infections (4% to 11%; p < 0.001), and related-complications (heart failure, embolic events, and perivalvular abscess; p < 0.001). These changes were associated with a decline in adjusted in-hospital mortality from 34% to 25% (p = 0.019).
In the 44 years studied, there was an increase in the mean age of patients, healthcare-related, prosthetic valve, coagulase-negative staphylococci/MRSA infections, and related complications. Notably, these epidemiological changes were associated with a decline in the adjusted in-hospital mortality.
Endocardite infecciosa (EI) permanece como doença com alta morbimortalidade. EI causadas por bactérias não usuais, como bactérias Gram-negativas não-HACEK (BGNNH), têm aumentado, podendo estar ...associados a formas mais graves da doença. Estudos sugerem que infecções relacionadas aos cuidados de saúde parecem estar associadas à EI causada por BGNNH, incluindo a realização de procedimentos cirúrgicos, como troca valvar cardíaca, a inserção de marca-passo e outros. O objetivo deste estudo é descrever as características clínicas e fatores de risco associados à aquisição de EI por BGNNH. Este estudo prospectivo observacional incluiu pacientes com diagnóstico definitivo de EI através dos critérios modificados de Duke com cultura positiva para BGNNH em 4 hospitais no Brasil entre os anos de 2006 e 2019. Dos 1154 pacientes incluídos, 38 (3,3%) apresentaram EI por BGNNH. A mediana de idade foi de 57 (IIQ 43-69) anos, eram do sexo masculino 25/38 (65,8%) e 32/38 (84,2%) apresentou EI aguda. Os agentes etiológicos mais comuns foram Pseudomonas aeruginosa e Klebsiella spp. (8 episódios, 21% cada), Serratia marcescens (6 episódios, 16%), Enterobacter spp. (6 episódios, 16%), Acinetobacter spp. e Burkholderia cepacia (3 episódios, 10% cada). Piora da função cardíaca foi encontrada em 18/38 (47,4%) dos pacientes. Eventos embólicos ocorreram em 18/38 (47,4%), a maioria para o sistema nervoso central 7/38 (18,4%). Comorbidades foram frequentes, como insuficiência cardíaca prévia 19/38 (50%) e doença renal crônica 17/38 (44,7%). Regurgitação valvar nova foi encontrada em 5/38 (13,2%), vegetações aórticas em 17/38 (44,7%) e mitrais em 16/48 (42,1%). Valvas protéticas foram afetadas em 19/38 (50%) e dispositivos cardíacos em 6/8 (15,8%). Exposição a cuidados de saúde recentes foi identificado em 52,6% dos pacientes. Mortalidade foi de 19/38 (50%). A maioria das infecções foi causada por agentes susceptíveis a maioria das classes de antimicrobianos 30/38 (79%). Fatores relacionados a óbito foram presença de cateter venoso central (OR = 5,93, IC = 1,29-27,3, p = 0,017), ter disfunção renal crônica (p = 0,049, IC = 1,20-19,1 e OR = 4,8) e hemodiálise (OR = 16,2 IC = 1,78-147, p = 0,008). A incidência de EI por BGNNH encontrada foi similar a encontrada em estudos prévios. Infecções nosocomiais envolvendo enterobactérias e Pseudomonas aeruginosa, patógenos oportunistas e formadores de biofilme predominaram. Valvas protéticas e demais dispositivos intracardíacos foram mais afetados com alta taxa de mortalidade.
Appropriate use of antimicrobials is essential to improve outcomes in sepsis. The aim of this study was to determine whether the use of a rapid molecular blood test-Septi
(SF) reduces the antibiotic ...consumption through early de-escalation in patients with nosocomial sepsis compared with conventional blood cultures (BCs).
This was a prospective, randomized, superiority, controlled trial conducted at Sao Paulo Heart Institute in the period October 2012-May 2016. Adult patients admitted to the hospital for at least 48 h with a diagnosis of nosocomial sepsis underwent microorganism identification by both SF test and BCs. Patients randomized into the intervention group received antibiotic therapy adjustment according to the results of SF. Patients randomized into the control group received standard antibiotic adjustment according to the results of BCs. The primary endpoint was antimicrobial consumption during the first 14 days after randomization.
A total of 200 patients were included (100 in each group). The intention to treat analysis found no significant differences in median antibiotic consumption. In the subgroup of patients with positive SF and blood cultures (19 and 25 respectively), we found a statistically significant reduction in the median antimicrobial consumption which was 1429 (1071-2000) days of therapy (DOT)/1000 patients-day in the intervention group and 1889 (1357-2563) DOT/1000 patients-day in the control group (
= 0.017), in the median time of antimicrobial de-escalation (8 versus 54 h-
< 0.001), in the duration of antimicrobial therapy (
= 0.039) and in anti-gram-positive antimicrobial costs (
= 0.002). Microorganism identification was possible in 24.5% of patients (45/184) by SF and 21.2% (39/184) by BC (
= 0.45).
This randomized clinical trial showed that the use of a rapid molecular-based pathogen identification test does not reduce the median antibiotic consumption in nosocomial sepsis. However, in patients with positive microbiological tests, the use of Septi
reduced antimicrobial consumption through early de-escalation compared to conventional blood cultures. These results were driven by a reduction in the consumption of antimicrobials used for Gram-positive bacteria.
The trial was registered at ClinicalTrials.gov (NCT01450358) on 12th October 2011.
Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae ...strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis.
A 21-year-old male cocaine drug abuser presented to the emergency department with a 1-week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of antimicrobial treatment.
Despite the effectiveness of toxoid-based vaccines, recent global outbreaks of invasive C. diphtheriae infectious related to non-toxigenic strains have been described. These infectious could be highly invasive as demonstrated in this case. Interdisciplinary work with an institutional "endocarditis team" is essential to achieve favorable clinical outcomes in such defiant scenarios.
•Studies reporting the etiology of prosthetic valve endocarditis (PVE) are an unmet clinical need.•A prospective cohort study was performed along with a literature review to describe the distribution ...of the etiology of PVE.•At >120days after valve surgery, there is a decrease in the incidence of resistant microorganisms.•PVE occurring at >120days after surgery may be treated with the same empirical treatment as for late PVE.•This approach could lead to higher antibiotic efficacy and less damage to the patient’s natural flora.
To determine the annual incidence of prosthetic valve endocarditis (PVE) and to evaluate its current classification based on the epidemiological distribution of agents identified and their sensitivity profiles.
Consecutive cases of PVE occurring within the first year of valve surgery during the period 1997–2014 were included in this prospective cohort study. Incidence, demographic, clinical, microbiological, and in-hospital mortality data of these PVE patients were recorded.
One hundred and seventy-two cases of PVE were included, and the global annual incidence of PVE was 1.7%. Most PVE cases occurred within 120days after surgery (76.7%). After this period, there was a reduction in resistant microorganisms (64.4% vs. 32.3%, respectively; p=0.007) and an increase in the incidence of Streptococcus spp (1.9% vs. 23.5%; p=0.007). A literature review revealed 646 cases of PVE with an identified etiology, of which 264 (41%) were caused by coagulase-negative staphylococci and 43 (7%) by Streptococcus spp. This is in agreement with the current study findings.
Most PVE cases occurred within 120days after valve surgery, and the same etiological agents were identified in this period. The current cut-off level of 365days for the classification of early-onset PVE should be revisited.
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