Made available in DSpace on 2019-03-30T00:12:07Z (GMT). No. of bitstreams: 0 Previous issue date: 2016-10-28 / Although Ventilator-Associated Pneumonia (VAP) is associated with high prevalence and mortality. Risk factors added to the clinical situation help to suggest it, but not confirmed. The microbiological study improves the diagnostic accuracy and helps in the treatment, but there is not always bacterial or fungal growth. A plasm protein profile would help the diagnosis of patients with ventilator-associated pneumonia (VAP). Fifty patients were enrolled resulting in 14 with the diagnosis of VAP and 36 with Complication Ventilator-Associated Complication, VAC. Three risk factors were associated with VAP, length permanence in ICU, Parenteral Nutrition Total (PNT) and the presence of multidrug-resistant bacteria to carbapenens. Totality, eleven proteins were identified by Mass Espectrometry,ESI-TOF, five only in patients and six expressed in different ways in both groups, patients and controls. Immunoglobulin free light chain Kappa, Serum Amyloid A1 / A2, C-Reactive Protein (CRP) and Cofactor heparin II were expressed in plasms of hospitalized patients with lung infection. The six others proteins, two were down-regulated in patients compared to controls: Apolipoprotein AII and Alpha 2 HS Glycoprotein. Four proteins were up-regulated in patients: Complement C9, Alpha 1 Acid Glycoprotein, Alpha 1 Antichymotrypsin and Leucine Rich in Alpha 2 Glycoprotein. The group where the tracheal aspirate showed fungal growth did not express the protein Alpha 2 HS Glycoprotein and Cofactor heparin 2. Furthermore, Leucine Rich in Alpha 2 Glycoprotein was higher in the group of fungi than the others, with ratio of 5.75. This is the first Brazilian research, as our knowledge, by analyzing proteomic techniques plasm of patients with ventilator-associated infection. Keywords: Proteomics analysis, VAP, ESI-TOF, Leucin Rich Alpha 2 Glycoprotein, Fungal disease. / Pneumonia associada à ventilação mecânica (PAV) tem altas prevalência e mortalidade. Fatores de risco somados aos os dados clínicos ajudam a sugeri-la, porém não a confirmam. O estudo microbiológico aumenta a acurácia diagnóstica e contribui no tratamento, porém nem sempre há crescimento bacteriano ou fúngico. Um perfil proteico plasmático auxiliaria no diagnóstico dos pacientes com infecção associada à ventilação mecânica. Cinquenta pacientes foram seguidos resultando em 14 com o diagnóstico de PAV e 36 com Complicação Associada à Ventilação Mecânica, CAV. Três fatores de risco estavam associados com PAV, tempo de permanência aumentada em UTI, uso de Nutrição Parenteral Total (NPT) e presença de bactéria multirresistente aos Carbapenêmicos. Onze proteínas foram diferencialmente expressas por ESI-TOF, sendo cinco unicamente nos doentes e seis sendo expressas de maneiras diferentes nos dois grupos, doentes e sadios. Imunoglobulina de cadeia leve Kappa, Amiloide sérica A1/A2, Proteína C Reativa (PCR) e Cofator de Heparina 2 estavam expressas nos plasmas dos pacientes internados com infecção pulmonar. Das seis proteínas restantes, duas estavam down-regulated nos pacientes em relação aos controles: Apolipoproteína AII e Alfa 2 HS Glicoprotéina.Quatro proteínas estavam up-regulated nos doentes: Complemento C9,Alfa 1 Glicoproteína Ácida, Alfa 1 Antiquimiotripsina e Leucina Rica em Alfa 2 Glicoproteína. O grupo onde o aspirado traqueal mostrou crescimento fúngico não expressou as proteínas Alfa 2HS Glicoproteína e Cofator de Heparina 2. Glicoproteína alfa 2 rica em Leucina foi superior no grupo com fungos em relação aos demais, com razão de 5,75. Este é o primeiro trabalho brasileiro, até onde se tem conhecimento, que analisa por técnicas de proteômica (ESI-TOF), o plasma de pacientes com infecção pulmonar associada à ventilação mecânica. Palavras-chave: Análise proteômica, PAV, ESI-TOF, Glicoproteína Alfa 2 rica em Leucina, doença fúngica.

No presente trabalho faz-se uma revisão da literatura sobre pneumonia por Legionella pneumophila e se comparam estes dados com a série da autora, que se compõe de 10 casos esporádicos desta pneumonia, adquiridos na comunidade, ocorridos no perÍodo entre outubro de 1983 e maio de 1989. Todos os pacientes desta série eram do sexo masculino e de cor branca, com idade variando entre 36 e 71 anos. Os sintomas mais freqüentes foram febre alta, calafrios, cefaléia, tosse seca e mialgias. A hipótese diagnóstica baseou-se nos dados clínicos, radiológicos e laboratoriais. Em todos os casos o critério de comprovaçao diagnóstica foi a imunofluorescência indireta para Legionella. Salienta-se a importância do reconhecimento desta doença, que ainda apresenta um baixo Índice de suspeição em nosso meio. Procura-se tanto ressaltar os principais achados clínicos e radiológicos como também contribuir com orientações diagnósticas e terapêuticas. ApÓs a análise dos dados obtidos no trabalho, a autora concluiu que: 1. Os achados da série nao diferem daqueles descritos na literatura. 2. A casuística é restrita para o traçado de um perfil da doença no Rio Grande do Sul. 3. Quadros pneumônicos com má resposta clÍnica à penicilina ou derivados, associados a lesões radiolÓgicas com rápida mutabilidade, devem chamar a atenção para este diagnóstico. 4. A infreqüência deste diagnóstico em nosso meio deve-se ao baixo Índice de suspeição. Logo, a divulgação de informações sobre a doença pode resultar em substancial acréscimo ao registro de casos. / In the present work a review is made on the 1iterature about pneumonia by Legione11a pneumophi1a and the data are compared with the series presenteà by the author, composed of 10 sporadic cases of this pneumonia, acquired in the community, October, 1983 and May, 1989. between A11 the patients of this group were ma1e, caucasian, age varying from 36 to 71. The most frequent symptoms were high fever, chills, headache, dry cough and myalgia. The diagnostic hypothesis was baseà on laboratory, radiological and clinicai data. For all the cases, the criterion for diagnostic comprovation was indirect immunofluorescence for Legionella. The importance of the recognition of this disease s emphasized for it still shows a very low 1evel of suspicion in Rio Grande do Sul. The author looks for to ernphazise the main clinicai and radiological findings as well as contributes with diagnostics and therapeutical orientations. After the analysis of the data obtained in the present work the author concludes that: 1. The findings of this series does no differ from those described in the 1iterature. 2. The casuistic is too restricted to draw a profile of the disease in Rio Grande do Sul. 3. Pneumonias with bad clinicai response to penicillin or its derivatives, associated with radiologic lesions with rapid mutability shall call the attention for this diagnosis. 4. The low frequency of this diagnosis in our country is due to the low index of suspicion. Thus, the divulgation of information about the disease could result in substantial increase in the record of new cases.

A bactéria Mycoplasma hyopneumoniae é o agente etiológico da pneumonia enzoótica suína e se adere às células do epitélio ciliar pulmonar do hospedeiro para a colonização. Essa doença é responsável por perdas econômicas em muitos países devido à morbidade dos rebanhos. A bactéria Mycoplasma flocculare é encontrada principalmente na mucosa traqueal de suínos, como M. hyopneumoniae, mas é uma bactéria comensal. Ambas apresentam similaridades genéticas, como o compartilhamento de 90% das proteínas de superfície preditas e o perfil transcritômico dos genes que codificam adesinas, proteínas que proporcionam a aderência do micro-organismo, altamente semelhante. Contudo, análises genômicas e transcritômicas não foram capazes de explicar a diferença fenotípica entre M. hyopneumoniae e M. flocculare no hospedeiro. Considerando estudos realizados previamente, se hipotetiza que parte dessa diferença ocorra devido a discrepâncias na sequência de aminoácidos de proteínas de superfície ortólogas, uma vez que 85% dos pares de proteínas ortólogas destas espécies apresentam, pelo menos, um domínio diferencial. Tais domínios diferenciais podem determinar variação funcional e/ou variação na resposta imune induzida no suíno. Para caracterizar imunologicamente um par de proteínas ortólogas de superfície de M. hyopneumoniae e M. flocculare, MHP556 e MF306, respectivamente, as versões recombinantes dessas foram expressas em Escherichia coli BL21 pLysE. Os produtos recombinantes, MHP556-GST e MF306-GST, foram purificados e utilizados em ensaios de avaliação de imunogenicidade e antigenicidade. Foram demonstradas a antigenicidade das proteínas nativas MHP556 e MF306, além da imunogenicidade da proteína recombinante MF306-GST. A comparação desses resultados contribuirá para a elucidação da função dessas proteínas de superfície na interação patógeno-hospedeiro e da importância da presença de domínios diferenciais entre proteínas ortólogas na resposta imune desencadeada pelo hospedeiro. / The bacteria Mycoplasma hyopneumoniae is the etiological agent of swine enzootic pneumonia and attaches to the cilliary tracheal cells to colonize the host. This disease is responsible for economic losses in many countries due to the morbidity of pig herds. The bacteria Mycoplasma flocculare is also found mainly in the tracheal mucosal, as M. hyopneumoniae, but it is a commensal species. Both species have genetic similarities as they share 90% of their predicted surface proteins and the transcriptomic profiles of the genes encoding adhesins, proteins that enable the attachment in host tissue, very similar. Yet, genomic and transcriptional analysis does not explain the phenotypic difference between M. hyopneumoniae and M. flocculare within its host. Considering these previous studies, it was hypothesized that the difference in pathogenicity may be due, in part, tothe amino acid sequence of the orthologous surface proteins, once that 85% of all orthologous surface proteins of both species show, at least, one differential domain. These differential domains may trigger functional modifications and/or immunological modifications by the host. To immunologically characterize a pair of orthologous surface proteins MHP556 and MF306, from M. hyopneumoniae and M. flocculare, respectively, recombinant versions were expressed in Escherichia coli BL21 pLysE. The recombinant products, MHP556-GST and MF306-GST, were purified and used in immunological and antigenicity assay. The antigenicity of the native proteins MHP556 and MF306 were established, and the immunogenicity of the recombinant protein MF306-GST as well. The comparison of the results of this study may help to elucidate the different functions of both surface proteins in the host-pathogen interaction and shed light about the importance of the presence of differential domains in orthologous proteins in the host immune response.

We are grateful to Centro de Investigacion del Envejecimiento (CIEN) of Universidad San Martin de Porres (USMP) for providing us with the database for the study. To the faculty team of research of the medical school of Universidad de Ciencias Aplicadas (UPC) for their appreciations and comments. Jorge L. Maguiña is a doctoral candidate studying Epidemiological Research at Universidad Peruana Cayetano Heredia under FONDECYT/CIENCIACTIVA scholarship EF033-235-2015 and supported by training grant D43 TW007393 awarded by the Fogarty International Center of the US National Institutes of Health . / El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Introduction: Sarcopenia is a geriatric syndrome characterized by loss of muscle mass and strength. The prevalence in people between 60–70 years is about 5–13% and in adults over 80 years, between 11–50% in the USA. Sarcopenia increases the risk of mortality and nosocomial infections. Community-acquired pneumonia is the first infectious-related cause of death in elderly people. However, there is lack of evidence about the association between sarcopenia and pneumonia. The aim of our study was to determine the incidence and risk factors of community-acquired pneumonia in older adults with sarcopenia in a Peruvian hospital. Methods: A retrospective cohort study was conducted in the geriatrics service of Centro Medico Naval “Cirujano Mayor Santiago Tavara”. Sarcopenia was defined by “European Consensus of Sarcopenia” criteria. MultivariatePoisson regression model was conducted to estimate the effect of the independent association between sarcopenia and pneumonia. Results: A total of 1598 subjects were enrolled, 59.0% were male; with a mean age of 78.3 ± 8.6 years. The prevalence of sarcopenia was 15.1% (95% CI: 13.3–16.8) and the incidence of community-acquired pneumonia was 15.14% (95%CI 13.4–16.9). In the multivariate model, we found a higher incidence of pneumonia in sarcopenic compared to non-sarcopenic, RR(a) 3.88 (95% CI: 2.82–5.33). Discussion: Our study showed a higher incidence of community-acquired pneumonia in sarcopenic subject. Results provide information on the importance of detecting this syndrome because it gives us scientific evidence of the interest of a correct comprehensive geriatric assessment in older patients with a high risk of pneumonia. / We are grateful to Centro de Investigacion del Envejecimiento (CIEN) of Universidad San Martin de Porres (USMP) for providing us with the database for the study. To the faculty team of research of the medical school of Universidad de Ciencias Aplicadas (UPC) for their appreciations and comments. Jorge L. Maguiña is a doctoral candidate studying Epidemiological Research at Universidad Peruana Cayetano Heredia under FONDECYT/CIENCIACTIVA scholarship EF033-235-2015 and supported by training grant D43 TW007393 awarded by the Fogarty International Center of the US National Institutes of Health . / Revisión por pares / Revisión por pares

Orientador: Roberto Calderon Gonçalves / Banca: Simone Biagio Chiacchio / Banca: Raimundo de Souza Lopes / Banca: Fernando José Benesi / Banca: Débora Cristina Damasceno / Resumo: Nas espécies domésticas as pneumonias cursam com intensa resposta inflamatória e acúmulo de células fagocíticas nos pulmões, levando a danos expressivos das estruturas do trato respiratório e à função pulmonar devido ao estresse oxidativo decorrente da liberação de grandes quantidades de Espécies Reativas do Oxigênio (ERO) durante a explosão respiratória. O objetivo deste estudo foi analisar o status oxidativo, a resposta inflamatória e a gasometria arterial, de ovinos sadios (n=20) e com diagnóstico clínico de pneumonia (n=20). Inicialmente os animais foram submetidos ao exame clínico e divididos em dois grupos: I) G1/controle, composto pelos animais clinicamente sadios e II) G2, composto pelos animais portadores de pneumonia. O status oxidativo foi avaliado por determinação indireta da atividade enzimática da Superóxido Dismutase (SOD) e Glutationa Peroxidase (GSH-Px) e das concentrações de Glutationa total (GSH-t) e Substâncias Reativas ao Ácido Tiobarbitúrico (TBARS) no sangue periférico por método colorimétrico. A resposta inflamatória foi avaliada pelo hemograma e proteína total e fibrinogênio plasmáticos e a função pulmonar pela determinação das variáveis hemogasométricas Pressão Arterial de Oxigênio (PaO2), Pressão Arterial de Gás Carbônico (PaCO2), Hidrogeniônico (pH), Saturação de Oxigênio (SO2), Bicarbonato (HCO3¯), Dióxido de Carbono Total (TCO2) e Excesso de Bases (EB), avaliados em sangue arterial. O leucograma revelou leucocitose com neutrofilia, eosinofilia, monocitose e linfopenia nos animais doentes (p<0,05). Com relação aos parâmetros bioquímicos, os ovinos portadores de pneumonia apresentaram aumento significativo (p>0,05) da concentração de fibrinogênio e proteína plasmática total. Os animais portadores de pneumonia apresentaram diminuição estatisticamente... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: In domestic species, pneumonia is accompanied by intense inflammatory response and accumulation of phagocytic cells in the lungs, causing structural damage of the respiratory tract due to oxidative stress resulting from the release of large amounts of Reactive Oxygen Species (ROS) during the respiratory burst. The aim of this study was to analyze the oxidative status, inflammatory response and arterial blood gases values in healthy sheep (n=20) and animals with a clinically diagnosed pneumonia (n = 20). After physical examination the animals were divided into two groups: i) G1/control, composed of clinically healthy animals and ii) G2, composed of animals with pneumonia. The oxidative status was assessed by indirect determinations of enzymatic activity of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and concentrations of total glutathione (GSH-t) and thiobarbituric acid reactive substances (TBARS) in peripheral blood by a colorimetric method. The inflammatory response was evaluated by complete blood count and total protein and plasma fibrinogen. The lung function was evaluated by determinations of blood gas parameters in arterial blood: Oxygen Pressure (PaO2) Pressure of Carbon Dioxide (PaCO2), Pressure Hydrogen (pH), Oxygen Saturation (SO2), Bicarbonate (HCO3¯), Total Carbon Dioxide (TCO2) and Base Excess (EB). The leucogram results showed Leukocytosis with neutrophilia, eosinophilia, monocytosis and lymphopenia in sick animals (p<0,05). With regard to biochemical parameters, sheep with pneumonia showed a significant increase (p<0,05) of fibrinogen and total plasma protein concentrations. The animals from group G2 had a statistically significant reduction (p<0,05) in SOD and GSH-Px enzymatic activity and GSH-t concentration, while TBARS concentration was significantly higher (p<0,05). Arterial blood... (Complete abstract click electronic access below) / Doutor

Introdução: Atualmente a incidência anual de pneumonia adquirida na comunidade nos países em desenvolvimento é de 150,7 milhões de casos entre crianças menores de 5 anos de idade , dos quais 11 a 20 milhões (7-13%) necessitam de internação hospitalar devido à gravidade. O tratamento geralmente é empírico mas o Streptococcus pneumoniae é o principal agente etiológico bacteriano.É necessário manter monitoramento dos sorotipos e padrão de resistência para melhor orientação terapêutica. Metodologia: Estudo de coorte retrospectivo com inclusão de 107 crianças com diagnóstico clínico e radiológico de pneumonia e com isolamento de Streptococcus pneumoniae em sangue e ou líquido pleural no período de janeiro de 2003 a outubro de 2008. Realizado determinação de concentração inibitória mínima (MIC) para penicilina e antibiograma para outros antimicrobianos. A sensibilidade para penicilina utilizada foi conforme Clinical and Laboratory Standards Institute (CLSI ) de 2008. Realizado sorotipagem de 96 cepas de pneumococos (89,7%) e analisados os dados da população em estudo e da evolução clínica. Resultados:Cerca de 47,5% das internações na enfermaria foram por pneumonia ou broncopneumonia e a média de positividade em cultura para pneumococo (sangue e ou líquido pleural) foi de 2,5%. Houve uma sazonalidade bem definida da pneumonia pneumocócica. Cerca de 70% ocorreram nos meses de junho a outubro. A mediana de idade foi de 23 meses (82,2%<5anos); predomínio do sexo masculino (58,9%);utilização de antibioticoterapia nos dois meses prévios à internação de 23,4%; freqüência em creche no menores de 2 anos de 36,4%; apenas um caso com vacinação heptavalente completa; doença associada em 44,9% sendo a mais freqüente a sibilância( 77,1%); tempo de febre e de sintomas respiratórios antes da admissão foi de 4 dias;necessidade de oxigenoterapia não invasiva em 70,1% com tempo médio de utilização de 4 dias;necessidade de ventilação mecânica em 19,6%, mediana do tempo de internação de 9 dias.Em 62% houve complicações sendo as mais freqüentes: empiema (53%) e efusão pleural não complicada (42%). As crianças com empiema tiveram mais pneumonia necrotizante, abscesso pulmonar, sepse, pneumotórax, necessidade de decorticação e ainda maior mortalidade (todas com p<0,05). As crianças com complicações tiveram mais dias de sintomas respiratórios antes da admissão (3x5dias), mais tempo de febre após o início de antibiótico (1x4,5dias), necessitaram de oxigenoterapia não invasiva(58,5x77,3%) e ventilação mecânica (7,3x27,3%) por tempo maior e permaneceram por mais tempo internados (5x12 dias). Das 107 cepas de pneumococo, 100 (93,5%) foram sensíveis à penicilina e 7 (6,5%) de sensibilidade intermediária. Todas as cepas testadas foram sensíveis para rifampicina e vancomicina e ainda mantiveram boa sensibilidade para clindamicina, cloranfenicol, ceftriaxone, eritromicina e levofloxacina. Cinco cepas foram multiresistentes. Notou-se que a média geométrica das concentrações inibitórias mínimas (GMC) para penicilina foram maiores nas crianças com complicações. Os sorotipos mais freqüentes foram: 14(36,5%), 1(16,7%) , 5(14,6%) e 6B(6,3%). O sorotipo 14 apresentou a maior GMC para penicilina e houve um aumento progressivo no decorrer dos anos de estudo. A cobertura dos sorotipos pela vacina heptavalente seria de 53,1% e esta cobertura menor se deve principalmente ao sorotipo 1 e 5, que corresponde a 31,3% dos casos. A cobertura dos sorotipos associados à resistência seria de 94,2%. A cobertura pela vacina 10-valente seria de 86,5% e com a 13-valente seria de 96,9%. Três casos que evoluíram para óbito (2,8%) tinha mediana de idade de 18 meses, todos do sexo masculino, todos com concentração inibitória mínima para penicilina menor ou igual 1g/mL, todos evoluíram com empiema e sepse. Dois foram do sorotipo 5 e um do sorotipo 14. Conclusões: Aproximadamente 2,5% das crianças internadas com diagnóstico de pneumonia foram diagnosticadas como pneumonia pneumocócica.Verificamos uma sazonalidade bem definida.Houve complicações em 62% dos casos. As mais freqüentes foram : empiema e a efusão pleural não complicada. Evidenciou-se uma GMC para penicilina maior nas crianças com complicações comparadas às crianças com ausência de complicações. Os sorotipos mais freqüentes foram 14,1 ,5 e 6B sendo que os sorotipos 1 e 5 totalizam 31,3%. A cobertura pela vacina heptavalente dos sorotipos isolados seria de 53,1%. A sensibilidade para penicilina dos pneumococos isolados de pneumonia foi de 93,5%. Assim, a opção terapêutica continua sendo a penicilina. / Introduction: Currently, the annual incidence of the acquired pneumonia in the developing country communities are around 150.7 million cases, among childrens under 5 years of age, and 11 to 20 million (7-13%) of those require hospitalization due to their gravity. In general, the treatments used to be empirical, however, it is important to be noted that Streptococcus pneumoniae is far the major bacterial etiologic agent. It is necessary to keep monitoring the serotypes and the pattern of resistance in order to improve the therapy guidance. Methodology: Retrospective cohort study with inclusion of the 107 childrens with clinical and radiological diagnosis of the pneumonia, and the isolation of Streptococcus pneumoniae in the blood and/or pleural fluid during the period of January 2003 to October 2008. It was performed determination of the minimum inhibitory concentration (MIC) related to the penicillin and other antibiotics. The sensitivity analysis to the penicillin was based on Clinical and Laboratory Standards Institute (CLSI), 2008, recommendations. They were performed serotyping in 96 pneumococcal strains (89.7%) and they were analyzed datas referred to the considered population and their clinical course. Results: About 47.5% of admissions in the ward were caused by pneumonia or bronchopneumonia, and the average positive occurrences in the pneumococcal (blood and / or pleural) culture were 2.5%. It was noted a clear seasonality phenomena of the pneumococcal pneumonia. About 70% of the cases occurred during months of June to October. The median age was 23 months (82.2%<5 years); with predominance of males (58.9%); in the 23,4% of the cases the antibiotic therapy was used during two months prior to the admission; the daycare frequency of the childs less than 2 years were 36.4%; only one case with complete vaccination heptavalent; associated disease was detected in the 44.9% of the cases and the most frequent was wheezing (77.1%); time of fever and respiratory symptoms before admission were 4 days; the need for noninvasive oxygen therapy occurred in 70.1% being 4 days of the average time of the use; the need for mechanical ventilation occurred in 19.6%; the median period of stay were 9 days. In 62% of the cases there were the most frequent complications: empyema (53%) and non-complicated pleural effusion (42%). The childrens with empyema had more necrotizing pneumonia, lung abscess, sepsis, pneumothorax, need for decortication, and even higher mortality (all with p<0.05). The childrens with complications had more days of respiratory symptoms before admission (3x5days), more time of the fever after initiation with antibiotic (1x4, 5days), they need noninvasive oxygen therapy (58,5 x77, 3%) and mechanical ventilation (7 , 3x27, 3%) for more time and remained hospitalized during longer period(5x12 days). Among 107 pneumococcal strains, 100 (93.5%) were susceptible to penicillin and 7 (6.5%) presented intermediate sensitivity. All strains tested were sensitive to rifampicin and vancomycin, and they maintained good sensitivity to clindamycin, chloramphenicol, ceftriaxone, erythromycin and levofloxacin. Five strains were multi-resistant. It was noted that the geometric mean of minimum inhibitory concentrations (GMC) to penicillin were higher in children with complications. The most frequent serotypes were: 14 (36.5%), 1 (16.7%), 5 (14.6%) and 6B (6.3%). The serotype 14 presented the highest GMC for penicillin and it was verified a progressive increase during the years of the study. The coverage of serotypes by the heptavalent vaccine would be cover 53.1% and this less coverage is represented by serotype 1 and 5, which corresponds to 31.3% of the cases. The coverage of serotypes associated with resistance would be 94.2%. The coverage of the 10-valent vaccine would be 86.5% and for 13-valent would be 96.9%. Three cases that carried to died (2.8%) had median age of 18 months, all they male, all they with minimum inhibitory concentration for penicillin <= 1g/mL, all they progressed to empyema and sepsis. Two of them were serotype 5 and one of them was serotype 14. Conclusions: Approximately 2.5% of children were admitted with diagnosis of pneumonia were diagnosed as pneumococcal pneumonia. It was verified a clear seasonality phenomena. They were observed complications in 62% of the cases. The most frequent were: empyema and non-complicated pleural effusion cases. It was confirmed a higher GMC for penicillin in children with complications compared to the children without complications. The most frequent serotypes were 14, 1, 5 and 6B and the serotypes 1 and 5 accounted 31.3%. The coverage of heptavalent vaccine for the isolated serotypes would be 53.1%. The sensitivity to the penicillin of the isolated pneumococcal was 93.5%. Therefore, the therapy option remains being the penicillin.

Ventilator-associated pneumonia (VAP) is a serious complication in critically ill patients; it can prolong intubation, increase intensive care unit and hospital length of stay, and increase mortality to twice the level of patients who do not develop VAP. The purpose of this project was to determine the effect of an evidence-based educational program to prevent VAP on ICU nurses' actual and documented practices for preventing VAP. The research questions addressed whether an educational program focused on VAP prevention will affect critical care nurses' compliance with a VAP prevention bundle, and whether the education will result in maintenance of a rate of zero cases of VAP per 1000 ventilator days. Data will be collected from all ICU patients intubated more than 24 hours and will include: (a) the frequency of oral care, (b) head-of-bed elevation of 30-45 degrees, (c) daily sedation vacation, (d) assessment of readiness for extubation, and (e) whether prophylaxis for deep vein thrombosis and for peptic ulcer disease was ordered. Observations of care will verify the accuracy of nurses' documentation in the medical record. A survey will assess nurse satisfaction with the educational program. Paired t tests will be used to compare the compliance of the nurses with each element of oral care and hygiene practices before and after the intervention. Analysis of variance will be calculated on the mean duration of ventilation, mean ICU and hospital length of stay, mortality before discharge, patient acuity, and rates of VAP per 1000 ventilator days. The goal of this project is a compliance rate of 90% or greater with the elements of the VAP prevention bundle, leading to decreased ventilator and ICU days, decreased morbidity, decreased mortality, and lower emotional distress. Positive social change will be accomplished through an immediate improvement in the lives of VAP-prone individuals.

Pneumonia is the main killer of under-five children worldwide. The developing nations suffer the most. But within such countries, the spatial and temporal distribution of pneumonia cases is not uniform; yet little is known of the spatial and temporal distribution of pneumonia or the factors that might affect spatial and temporal variability. This dissertation explores the causes of spatial and temporal variation in under-five pneumonia morbidity in Tanzania. This study uses an ecological analysis to explore weather, land cover and politics as potential drivers of the observed differences in the distribution of pneumonia. A study is at an ecological level when it examines the population-level health aspects. That is, ecological analyses in health studies evaluate groups of people rather than individuals. The current study found that weather variables such as temperature and atmospheric pressure partially explained pneumonia variance. The strength of weather-pneumonia association varies over space and time in both seasonal elements (temporal factors) and broadly-defined climate zones (spatial factors). For example, the prevalence rate was higher in the regions with bimodal rainfall compared with the regions with unimodal rainfall, with a statistically difference 117.3 (95% confidence interval: 36.6 to 198.0) cases per 100,000. In addition, within the regions (mikoa) with unimodal rainfall regime, however, the rainy season (msimu) had lower rates of pneumonia compared to the dry season (kiangazi). Land use and land cover also were partial drivers of pneumonia. Some land cover types—particularly urban areas and croplands—were associated with high rates of childhood pneumonia. In addition, districts (wilaya) categorized as urban land cover had high rates of pneumonia compared to those categorized as only rural. To determine the associations between politics and pneumonia, this study compared the pneumonia cases in the administrative locations that received less central government funding with those locations that were financially rewarded for voting for the ruling party. The locations with lower funding generally had higher rates of childhood pneumonia. However, it is unclear whether these locations had higher rates of childhood pneumonia because of, or in addition, to their funding gaps. In sum, this dissertation evaluated population-level factors affecting distribution of childhood pneumonia. Like other similarly population-level studies, this dissertation provides an understanding of the coarse-scale dynamics related to childhood pneumonia. By so doing, it contributes to the pneumonia etiology scientific literature. That is, this dissertation contributes to the understanding of within-nation pneumonia distribution in developing nations. It is the first in Tanzania to evaluate the impact of weather, land cover and politics on childhood pneumonia. By evaluating the impact of weather and land cover, this dissertation also provides an example of non socio-economic factors affecting health inequalities. By analyzing a large landmass of two main climatic types, this dissertation also contributes appreciation of non-stationarity of temporal variations of childhood pneumonia, in addition to the commonly-evaluated spatial variations.

Objectives: This Study wanted to analysis the characteristics of the elder adult who had hospitalized with pneumonia. We also evaluated the factors that will affect the unexpected readmission in elderly pneumonia patients. Methods: This is a retrospective cohort study design. The study data was collected 341 pneumonia patients who have hospitalized in a general teaching hospital in Kaohsiung city from year 2009 to 2010. The study population was divided into two groups, the sample size of the old group (age >= 65yrs), and the young group (age < 65yrs) was 173 and 168, respectively. The methods of stepwise multiple logistic regressions were needed to evaluate the association between aging and different days of unplanned readmission in adult pneumonia patients. Results: All the 341 adult pneumonia patients, we found 613 male and 926 female. The demography characteristic of the study subjects, the means of age was 61.9yrs (s.d. = 19.3yrs), and BMI was 23.4 kg/m2 (s.d. = 4.5 kg/m2). The percentage of ICD-9-CM that code 486 was 95.6%. Most patients were community-acquired pneumonia (98.8%), hospitalized from emergency room (85.3%), and admission in general wards (92.7%). The unplanned readmission within 14/30 days, 60 days, and 90days were 9.1%, 11.7%, and 15.0%, respectively. The significant factors that were associated with readmission within 14 days include age, Hb, hospitalized days, hypertension, and other disease. When we used the multiple logistic regression analysis to adjust the other variables, only age still significant with readmission within 14 days (the crude OR of the old group was 4.561, adjusted OR was 2.714, 95% CI of OR from 1.002 to 7.353). In the stepwise multiple logistic regression models, the variable that was associated with readmission with 14 or 30 days were age (>= 65yrs, OR = 3.025), WBC (>=10750 mm3, OR=2.917), and Hb (>=12.4 g/dL, OR=0.390). We remain the elderly subjects to evaluate the factor that will influence readmission states. In all the stepwise logistic regression models, we found the experience with used endotracheal tube in the hospitalized period were the significant increases the readmission rate within 14 or 30 days, 60 days, and 90 days. Conclusion: In our study shows that the situations of unexpected readmission in pneumonia patients were strong association with aging. We suggest that the indicator of medical quality should be adjusted before we comparison the readmission rate in the different institute. The major factors that will be associated to affect the readmission states were endotracheal tube used (significant with 14 or 30 days readmission rate), CRP level (significant with 60 days and 90 days readmission rate), and Hb level (significant with 60 days and 90 days readmission rate).

The aim of this study was to determine whether there was an association between a failed test of cough reflex sensitivity and history of chest infection in a general population of rest home residents. One hundred rest home residents from four different levels of care (rest home, hospital, dementia and psycho-geriatric) were recruited and their cough reflex assessed using a solution of 0.6 Mol/L citric acid nebulised and presented via a facemask.Participant’s records were then checked to see if there were any documented episodes of chest infection in the 6 month period prior to cough reflex testing.The results showed that out of 100 participants, 4 failed the cough reflex test. Of the 4 that failed the test, 3 had no documented episodes of chest infections recorded in the 6 month period prior to cough reflex testing. Data was not available for one participant who was deceased by the time of collection of the second data set. As such, there was no direct association demonstrated between a failed cough reflex test and development of chest infection or aspiration pneumonia. The results of the study are unexpected in two ways. Firstly, the relatively low number of participants who failed the cough reflex test is surprising as 72% of the participants for whom a full data set was obtained had neurological conditions that are known predisposing factors for reduced cough reflex sensitivity. Secondly, the finding of no association between a failed cough reflex test and history of recorded chest infection is not consistent with other studies. There is however an established body of research that indicates the causes of aspiration pneumonia are multifactorial and not solely dependent upon aspiration. The characteristics of participants and the implications of the findings are described. The potential use of cough reflex testing as a tool to screen against the risks of silent aspiration in relation to assessment of oro-pharyngeal dysphagia in this frail, elderly population is discussed.