Training the Next Generation of Infectious Disease Researchers: A Biorisk Management Module Embedded in a European Master Program.

Introduction: The current global situation with increasing zoonotic transmissions of pathogens, rapidly changing ecosystems due to the climate change and with it the distribution of potential vectors, demands new ways of teaching and educating students in the field of infectious disease research. Methods: The international master program "Infectious Diseases and One Health-IDOH" started its second application period in 2019. Biosafety is an integral part of IDOH, exemplified by a biosafety level 3 hands-on training at the Animal Health Research Center IRTA-Centre de Recerca en Sanitat Animal (CReSA), Barcelona. At Hanover Medical School, biosafety is expanded to a comprehensive biorisk management approach with focus on risk assessment, bioethics, and training in a mobile containment laboratory. This article illustrates in depth the intention and the individual teaching units of the biorisk management module within the third semester of the IDOH master. Risk assessment is taught based on the new WHO Laboratory Biosafety Manual 4th edition, which represents a paradigm shift toward a risk-based approach instead of a prescriptive definition of biosafety levels. This methodology will enable the international IDOH students to cope with different national legislations and to provide guidance on biosafety in their home countries. In the final unit, the students operate a mobile containment laboratory and simulated a viral hemorrhagic fever outbreak in Africa. Conclusion: In sum, this module combines theoretical risk assessment and its practical implementation in the mobile laboratory as a future direction for training infectiologists. In addition, our report may serve as a blue print for others to amend their education with the herewith mentioned pillars of biosafety teaching.

Vaccine-derived yellow fever in an immunocompromised patient on anti-CD20-antibody therapy and its treatment with sofosbuvir.

Yellow fever (YF) is a potentially lethal viral hemorrhagic fever that can be prevented with the 17D live attenuated YF vaccine. However, this vaccination can cause severe adverse reactions including vaccine-associated YF. Here, we describe the case of a 32-year-old female who was permanently immunosuppressed with an anti-CD20 antibody due to multiple sclerosis. Following YF vaccination, the patient developed a variety of symptoms such as febrile temperatures, muscle and joint pain, headaches, and dysuria. A vaccine-associated YF with viremia was diagnosed. To avoid a potentially severe course of the disease, sofosbuvir was used as antiviral treatment followed by the resolution of symptoms and serological response. As travelers with chronic diseases and immunosuppression will increasingly engage in long distance travel, this case demonstrates the importance of assessing patient history prior to the administration of live vaccines and points towards a possible therapeutic approach in those suffering from vaccine-associated YF.

Brazilian clinical engineering regulations: health equipment management and conditions for professional exercise

Abstract Introduction In Brazil, professionals, scientific community, and members of regulatory bodies have not yet achieved a consensus regarding who can legally perform the professional duties of a clinical engineer. We aim at clarifying this aspect, based on a detailed analysis of the pertinent regulations. Methods We acted on three fronts: (i) reviewing the current legislation regarding the clinical engineering exercise; (ii) visiting hospitals and working as trainee to understand how this exercise is implemented on Brazil's Federal District; (iii) one of the authors participated in virtual discussion groups of clinical engineering professionals, monitoring collective understanding of regulations, checking consistency of proper knowledge, and acting as an active opinion leader in the subject among peers. Results We try to make a formal definition of clinical engineer and indicate their characteristic activities. We propose a synthesis of the regulation regarding healthcare products' integrity protection and health technology management, identifying the engineering activities necessary to achieve those legal requirements. We analyze the legal constraints and conditions to exert engineering, indicating the necessary professionals' attributions and the way to obtain them. Finally, we provide a brief analysis of the technical requirements presented by the Brazilian Consumer Protection Code and of the 15.943 Brazilian Standard (NBR). Discussion We conclude that, despite the lack of consensus about the Clinical Engineering activity, there exists in Brazil a Clinical Engineering regulation, but it is spread in complex laws and normative resolutions, defining compulsory responsibilities and attributions, as well as conditions and prerequisites for role performance.

Epidemiologicalaaspects of hepatocellular carcioma in a referral center of minnas gerais, Brazil / Aspectos epidemiologicos do carcinoma hepatocelular em centro de referencia de Minas Gerais

Context Studies on epidemiology of hepatocellular carcinoma and modalities of therapy used to treat this condition are scarce in Brazil. Our aim was to characterize hepatocellular carcinoma according to etiology of the underlying chronic liver disease, and treatment modalities, in a referral center in Brazil. Methods All cases of hepatocellular carcinoma registered in the Department of Pathology during a 12-year period (1998-2010) were included. Demographic data, etiology of the underlying liver disease and treatment performed were collected. Results This case series included 215 patients, mean age 57.3 (± 14.1) years, 164 (76.2 %) male. Virus C and virus B infection were detected in 88 (43%) and 47 (23%) patients, respectively. Ethanol abuse alone or combined with other etiologies was identified in 64 (32%) individuals. Schistosomiasis was found in 18 (9%) patients. Liver transplantation was the treatment of choice in 112 (51%) patients. This procedure was more frequently performed in hepatitis C virus-related hepatocellular carcinoma (70%) than B virus-related hepatocellular carcinoma (17%). Tumor resection was performed in 40 (18%) individuals, ethanol injection or thermo ablation in 18 (14%), and chemoembolization in 14 (7%). In 40 (19.4%) patients no treatment was performed and this percentage remained constant over the years. Conclusions Chronic hepatitis C, followed by ethanol abuse and chronic hepatitis B were the leading causes of underlying chronic liver disease associated with hepatocellular carcinoma. The results show a trend of increasing incidence of hepatocellular carcinoma; however, the proportion of untreated patients remained constant over the analyzed period. .

Contexto Estudos sobre epidemiologia do carcinoma hepatocelular e terapias utilizadas em seu tratamento são escassos no Brasil. O objetivo foi caracterizar o carcinoma hepatocelular quanto à etiologia da hepatopatia crônica subjacente e modalidades terapêuticas empregadas, em um centro de referência no Brasil. Método Todos os casos de carcinoma hepatocelular registrados no Departamento de Patologia em período de 12 anos (1998-2010) foram incluídos. Dados demográficos, etiologia da hepatopatia crônica e tipo de tratamento realizado foram coletados dos prontuários. Resultado Esta série de casos incluiu 215 pacientes, com média de idade 57,3 (± 14,1) anos, 164 (76,2%) do sexo masculino. Infecções virais C e B foram detectadas em 88 (43%) e 47 (23%), respectivamente. Abuso de etanol isoladamente ou associado a outras causas foi identificado em 64 (32%) indivíduos. Esquistossomose foi encontrada em 18 (9%) indivíduos. Transplante hepático foi o tratamento de escolha em 112 (51%) pacientes. Esse procedimento foi mais frequentemente realizado em carcinoma hepatocelular relacionado com hepatite C (70%) do que hepatite B (17%). Ressecção cirúrgica foi realizada em 40 (18%) indivíduos, alcoolização ou termo-ablação em 18 (14%) e quimioembolização em 14 (7%). Em 40 (19,4%) pacientes nenhum tratamento foi empregado e esta porcentagem permaneceu constante ao longo dos anos do estudo. Conclusões Hepatite viral C seguida de abuso de etanol e hepatite viral B foram as causas de hepatopatia crônica mais frequentemente associadas ao carcinoma hepatocelular. Os resultados mostram tendência a aumento da incidência do carcinoma hepatocelular; no entanto, a proporção de pacientes não-tratados permaneceu constante ...

Evaluación de las competencias clínicas en una residencia de pediatría con el Mini-CEX (Mini-Clinical Evaluation Exercise) / Assessment of clinical competence in a pediatric residency with the Mini-Clinical Evaluation Exercise (Mini-CEX)

Objetivo. Evaluar las competencias clínicas de los residentes de pediatría con la implementación del Mini-CEX, determinando su validez, confabilidad, factibilidad y la satisfacción de docentes y de residentes. Métodos. Participaron 14 docentes y 8 residentes. Se utilizó el Mini-CEX, método basado en la observación directa del desempeño del residente durante su práctica diaria, por parte de un docente. Resultados. Se realizaron 181 observaciones, media de 12,92 observaciones por cada docente. Cada docente evaluó a 5,78 residentes. Hubo una media de 22,6 evaluaciones por residente. Las observaciones se realizaron en consultorios externos 38,7%, internación pediátrica 19,3%, neonatología 17,1%, sala de recepción del recién nacido 14,4% y en internación conjunta 10,5%. Los puntajes promedios fueron: profesionalismo 7,15; entrevista 6,64; examen clínico 6,67; criterio clínico 6,70; asesoramiento 6,79 y organización 6,73. Los puntajes de competencia global variaron de acuerdo a los años de experiencia. Primer año 6,57; segundo 6,87 y tercero 7,3; p= 0,004. El puntaje de satisfacción de los docentes fue 7,89 y de los residentes 7,74. El tiempo de duración de las observaciones fue de 28,35 minutos. El coeficiente alfa de Cronbach fue de 0,97 lo que indica elevada confabilidad del método de evaluación. El ANOVA de puntajes de competencia global de todos los docentes mostró diferencias estadísticamente signifcativas, p <0,0001. Conclusiones. La implementación del Mini-CEX fue factible, bien aceptada por residentes y docentes, permitió valorar los diferentes niveles de desempeño de los residentes.

Purpose. Assess the clinical competence of pediatric residents with the implementation of Mini-Clinical Evaluation Exercise (Mini-CEX), determining its validity, reliability, feasibility and satisfaction of examiners and residents. Methods. 14 examiners and 8 residents of pediatrics took part. The Mini-CEX, a method based on direct observation of residents during their daily training, was used. A nine-point rating scale was used in order to evaluate their skills regarding medical interviewing, physical examination, professionalism, clinical judgment, counselling, organization, overall competence and satisfaction with the method. Results. 181 observations were made, an average of 12.92 observations per examiner (range-2-39). Each examiner assessed 5.78 residents, (range 2-8). There was an average of 22.6 assessments per resident, range (18-30). The observations took place in outpatient clinic 38.7%, pediatric inpatient unit 19.3%, neonatal intensive care unit 17.1%, neonatal reception unit 14.4% and rooming-in 10.5%. The mean scores were: professionalism 7.15; interviewing 6.64; physical examination 6.67; clinical judgment 6.70; counselling 6.79 and organization 6.73. The overall competence score varied according to experience levels. Mean scores were: frst-year residents 6.57; second-year residents 6.87 and third-year residents 7.3; p= 0.004. The score related to ex-aminers's satisfaction was 7.89 and that of the residents was 7.74. The duration of the observation period was 28.35 minutes. Cronbach alfa coeffcient was 0.97 showing the high reliability of the assessment method. The ANOVA score for overall competence of all examiners showed statistically signifcant differences, p <0.0001 in relation to stricter or more lenient judgment to evaluate skills. Conclusions. The implementation of the Mini-CEX in the Pediatrics Residency was feasible and positively accepted by residents and examiners. It allowed the assessment of different levels of performance among residents according to their experience, in every clinical setting of a pediatrician's practice. The variability criteria among examiners and the lack of constructive criticism are matters to be dealt with in future investigations.

Diagnóstico de síndrome de Cowden a partir de papilomatosis oral / Diagnosis of Cowden's syndrome based on the identification of oral papillomatosis

El síndrome de Cowden o síndrome de hamartomas múltiples, es una rara genodermatosis de tipo autosómico dominante con expresividad variable. Los pacientes muestran una mezcla compleja de lesiones hamartomatosas de origen ectodérmico, mesodérmico y endodérmico, entre las que destacan pápulas en piel y mucosa oral, alteraciones en la tiroides, glándulas mamarias y tracto gastrointestinal. El diagnóstico temprano es de gran importancia, ya que los hombres afectados muestran alta susceptibilidad para desarrollar carcinoma de tiroides y las mujeres carcinoma de mamas. Este artículo describe las características de una paciente de 28 años de edad, cuyo diagnóstico de enfermedad de Cowden se estableció a partir del estudio clínico e histológico de pequeñas pápulas que representaba en encías y dorso de la lengua. Asimismo, a la lista de alteraciones que componen el síndrome se agrega la presencia de siringomas faciales.

Histoplasmosis oral en pacientes VIH seropositivos y seronegativos / Oral Histoplasmosis in seropositive and seronegative patients VIH

La histoplasmosis es una infección granulomatosa producida por el hongo Histoplasma capsulatum que afecta principalmente a los pulmones. En los últimos años se ha reconocido que lesiones de histoplasmosis oral pueden ser la primera manifestación de la infección VIH/SIDA. En este trabajo se presentan los hallazgos clínicos e histopatológicos de histoplasmosis oral detectados en tres pacientes con SIDA y tres pacientes VIH seronegativos. En los seis casos las lesiones orales se presentaron como úlceras dolorosas de varios meses de evolución que afectaban generalmente más de una zona de la cavidad oral. En los casos el diagnóstico de SIDA se estableció a partir del diagnóstico de las lesiones orales de histopalsmosis. Histológicamente, en los pacientes VIH seronegativos, los granulomas presentaban abundante cantidad de células gigantes tipo Langhans, en contraste, las biopsias de los pacientes con SIDA no presentaron este tipo de células. También se discute la detección del Mycobacterium tuberculosis en dos de los seis casos estudiados.

Exposición percutánea y de membranas mucosas en alumnos de odontología / Percutaneous injuries and mucous menbrane exposures among dental students

El propósito de este estudio fue determinar la frecuencia de lesiones percutáneas y salpicaduras y sus factores asociados en 205 estudiantes del 3er, 4to y 5to de estudios de odontología de la Universidad Peruana Cayetano Heredia. La información se obtuvo a través de fichas de auto-reporte de lesiones percutáneas y salpicaduras (eventos de riesgo de contaminación paciente-operador) ocurridos en la Clínica Estomatológica Central entre los meses de julio y octubre de 1995. Se reportaron 39 eventos (20 lesiones percutáneas y 19 salpicaduras), sobre un total de 4,516 procedimientos clínicos lo que arrojó un 1.2 por ciento de probabilidad que ocurra un evento durante un procedimiento clínico. El 14 por ciento de los alumnos reportaron por los menos un evento en los últimos cuatro meses. El número de eventos fue mayor en los alumnos de tercero y cuarto año que en aquellos del quinto año. La operatoria dental y la exodoncia fueron las actividades clínicas más relacionadas con lesiones percutáneas, la operatoria dental y la profilaxis fueron las actividades clínicas más relacionadas con exposición a salpicaduras. Se recomienda intensificar las medidas de control de infecciones para minimizar el riesgo de trasmisión ocupacional.