Micromorphology of Root Canal Walls After Laser Activated Irrigation.

This study aims to investigate the effects of laser-activated irrigation on root canal dentin using different laser wavelengths. Sixty-six roots were prepared and split longitudinally. First, lasers with different power settings were tested on 34 samples, pre-etched with phosphoric acid, or remaining with a smear-layer to determine the test parameters. Selected parameters were then applied on thirty roots (9 groups) covered with smear layer: 1. Smear-layer removed; 2. Smear-layer untouched; 3. Conventional needle irrigation with NaOCl and EDTA; 4. ER:YAG laser; 5. 9.3 µm CO2 laser; 6-9. Diode lasers. All lasers were applied in ultra-pure water as an irrigant. Root halves were examined by scanning electron microscope to analyze the intracanal dentin micromorphology on 9 consequent photos per specimen @ a magnification of 1000X. The results showed that conventional needle irrigation was effective in removing the smear-layer from coronal and middle root parts, while laser-activated irrigation had two main mechanisms: cleaning and opening of the dentinal tubules by removing the smear layer (Er:YAG laser) and melting of dentin (CO2 and diode lasers) in all root parts. The study concluded that laseractivated irrigation with different wavelengths impacted the smear layer and root canal dentin differently through pure physical/mechanical effects.

The adoption of the HPV vaccine school-entry requirement in Puerto Rico: How practical lessons can inform future vaccine policies.

Vaccine requirements are policy-level strategies used to improve population health outcomes; however, discourse politicization of vaccines may hinder adoption and implementation. An example of the complexities related to adoption of vaccine policies in the United States (US) is the human papillomavirus (HPV) vaccine school-entry requirement. In 2018, Puerto Rico's (PR) Department of Health adopted this policy. This study assessed stakeholders' recommendations for adoption of the HPV vaccine school-entry requirement that could inform future vaccine policies. Stakeholders (e.g., researchers, members of medical and non-profit organizations) were interviewed from May to August 2018. Participants (n = 20) discussed recommendations for public health professionals interested in adopting such policy. Data were analyzed using applied thematic techniques. Participants emphasized the importance of raising HPV vaccine awareness and providing education prior to the requirement. They recommended using real stories and making the problem relevant by using local data. Participants recommended considering the local culture and government bureaucracies, and promoting multisectoral collaborations to combine limited resources. The combination of education efforts, local data, and multisectoral collaborations facilitated the adoption of the HPV vaccine school-entry requirement in PR. Findings highlight the need to understand the contextual distinctions of the communities where vaccination requirements may be adopted and implemented to anticipate barriers and leverage existing resources. Consideration of the politico-cultural context may be important as political beliefs have become entrenched with vaccine policy. These practical lessons can inform public health professionals and policymakers who are seeking to adopt and implement vaccine policies in other settings to ensure equitable vaccine access.

Change Management in Healthcare Organizations: Soft Skills Training Strategies Through Blended Learning Environments.

Teaching soft skills for change management in healthcare organizations is becoming increasingly necessary, even more, when implementing health information systems (HIS). There is little evidence that these skills can be learned through online teaching environments. This paper describes the experience of having taught soft skills to health informatics master's degree students, through blended learning environments.

Cultural Problems Associated with the Implementation of eHealth.

A major hurdle in eHealth implementation is that it is difficult to put into practice. In this study, the primary aim was to identify the main barrier associated with implementing eHealth. This study surveyed IMIA members from May to November 2015. From the results, it is clear that medical professionals were recording most of their data by hand. This paper culture is a paradigm that is difficult to break. Cultural factors are the primary barrier in eHealth implementation.

Peripheral blood monocyte and T cell subsets in children with specific polysaccharide antibody deficiency (SPAD).

Specific polysaccharide antibody deficiency (SPAD) is a well reported immunodeficiency characterized by a failure to produce antibodies against polyvalent polysaccharide antigens, expressed by encapsulated microorganisms. The clinical presentation of these patients involves recurrent bacterial infections, being the most frequent agent Streptococcus (S.) pneumoniae. In SPAD patients few reports refer to cells other than B cells. Since the immune response to S. pneumoniae and other encapsulated bacteria was historically considered restricted to B cells, the antibody deficiency seemed enough to justify the repetitive infections in SPAD patients. Our purpose is to determine if the B cell defects reported in SPAD patients are accompanied by defects in other leukocyte subpopulations necessary for the development of a proper adaptive immune response against S. pneumoniae. We here report that age related changes observed in healthy children involving increased percentages of classical monocytes (CD14++ CD16- cells) and decreased intermediate monocytes (CD14++ CD16+ cells), are absent in SPAD patients. Alterations can also be observed in T cells, supporting that the immune deficiency in SPAD patients is more complex than what has been described up to now.

Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries.

INTRODUCTION: Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS: From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS: The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.

Characterization of yeasts isolated from artisanal short-ripened cows' cheeses produced in Galicia (NW Spain).

A total of 143 presumptive yeast isolates were obtained from the predominant microflora of 21 short-ripened starter-free raw cow's milk cheeses made in Galicia (NW Spain), and the following 68 isolates were identified by both genotyping and sequencing methods: Yarrowia lipolytica (21 isolates), Kluyveromyces lactis (18), Debaryomyces hansenii (11), Pichia guilliermondii (11), Pichia fermentans (4) and Saccharomyces cerevisiae (3). Of these, Y. lipolytica and K. lactis displayed the strongest extracellular proteolytic activity on skim milk agar, and none of the D. hansenii isolates showed any activity on this medium. Y. lipolytica also displayed the highest lipolytic activity on Tween 80 and on tributyrin. This species, which was characterized by production of butanoic acid, free fatty acid esters and sulfur compounds in pasteurized whole milk, was responsible for rancid and cheesy flavors. K. lactis mainly produced acetaldehyde, ethanol, branched chain aldehydes and alcohols, and acetic acid esters, which were responsible for alcoholic, fruity and acetic notes. The volatile profiles of D. hansenii were rather limited and characterized by high levels of methyl ketones. Most of the yeast isolates were described as tryptamine producers, although low concentrations of histamine were produced by five Y. lipolytica and two P. fermentans isolates. We conclude that selected Y. lipolytica strains could be used as adjunct cultures in the manufacture of Arzúa-Ulloa and Tetilla cheeses, and selected K. lactis strains could be used as co-starters in the manufacture of acid curd Cebreiro cheese, thus contributing to the sensory quality and typicality of the cheeses.

Challenges and Hurdles of eHealth Implementation in Developing Countries.

UNLABELLED: Health informatics has the potential to improve the security and quality of patient care, but its impact has varied between developed and developing countries. Related to this, the objective of this study is to identify the challenges and hurdles to improve eHealth in developing countries. We surveyed experts to discover their opinions about five general questions: economic support by Government for eHealth, Government education or training projects in the field, issues related to cultural or educational problems for the implementation of eHealth, policies in terminology or messaging standards and eHealth status policies for long periods. The respondents answered affirmatively in these proportions: 1. Economic support policies 58%, 2. Training policies 25%, 3. Cultural and educational problems 95%, 4. Standards policies, 38%, 5. Policies for long periods, 50% CONCLUSION: Our survey has shown that the important problems that need to be addressed in order to implement e-Health in developing countries are firstly, cultural and educational, secondly, economic resources and thirdly policies for long periods.

Why Patient Centered Care Coordination Is Important in Developing Countries? Contribution of the IMIA Health Informatics for Development Working Group.

UNLABELLED: Patient Centered Care Coordination (PCCC) focuses on the patient health care needs. PCCC involves the organization, the patients and their families, that must coordinate resources in order to accomplish the goals of PCCC. In developing countries, where disparities are frequent, PCCC could improve clinical outcomes, costs and patients satisfaction. OBJECTIVE: the IMIA working group Health Informatics for Development analyzes the benefits, identifies the barriers and proposes strategies to reach PCCC. METHODS: Discussions about PCCC emerged from a brief guide that posed questions about what is PCCC, why consider PCCC important, barriers to grow in this direction and ask about resources considered relevant in the topic. RESULTS: PCCC encompasses a broad definition, includes physical, mental, socio-environmental and self care. Even benefits are proved, in developing countries the lack of a comprehensive and integrated healthcare network is one of the main barriers to reach this objective. Working hard to reach strong health policies, focus on patients, and optimizing the use of resources could improve the performance in the devolvement of PCCC programs. International collaboration could bring benefits. We believe information IT, and education in this field will play an important role in PCCC. CONCLUSION: PCCC in developing countries has the potential to improve quality of care. Education, IT, policies and cultural issues must be addressed in an international collaborative context in order to reach this goal.

Health Informatics in Developing Countries: Systematic Review of Reviews. Contribution of the IMIA Working Group Health Informatics for Development.

OBJECTIVES: An evidence-base is important for medicine and health informatics. Despite numerous publications showing the benefits of health informatics, the emergence of health information systems in developing countries has been slower than expected. The aim of this paper is to identify systematic reviews on the domain of health informatics in developing countries, and classify the different types of applications covered. METHODS: A systematic review of reviews was conducted. The literature search spanned the time period between 2000 and 2012 and included PubMed, EMBASE, CINAHL, Scopus, Cochrane Systematic Reviews, LILACS, and Google Scholar. The search term was 'systematic reviews of health informatics in developing countries', and transparent and systematic procedures were applied to limit bias at all stages. RESULTS: Of the 982 identified articles, only 10 met the inclusion criteria and one more article was added in a second manual search, resulting in a total of 11 systematic reviews for the analysis. CONCLUSIONS: Although it was difficult to find high quality resources on the selected domain, the best evidence available allowed us to generate this report and create an incipient review of the state of the art in health informatics in the developing countries. More studies will be needed to optimize the results.

Immune response to Streptococcus pneumoniae in asthma patients: comparison between stable situation and exacerbation.

In Argentina, more than 3 million people suffer from asthma, with numbers rising. When asthma patients acquire viral infections which, in turn, trigger the asthmatic response, they may develop subsequent bacterial infections, mainly by Streptococcus (S.) pneumoniae. This encapsulated Gram(+) bacterium has been considered historically a T cell-independent antigen. Nevertheless, several papers describe the role of T cells in the immune response to S. pneumoniae. We evaluated the response to S. pneumoniae and compared it to the response to Mycobacterium (M.) tuberculosis, a different type of bacterium that requires a T helper type 1 (Th1) response, in cells from atopic asthmatic children, to compare parameters for the same individual under exacerbation and in a stable situation whenever possible. We studied asthma patients and a control group of age-matched children, evaluating cell populations, activation markers and cytokine production by flow cytometry, and cytokine concentration in serum and cell culture supernatants by enzyme-linked immunosorbent assay (ELISA). No differences were observed in γδ T cells for the same patient in either situation, and a tendency to lower percentages of CD4(+) CD25(hi) T cells was observed under stability. A significantly lower production of tumour necrosis factor (TNF)-α and a significantly higher production of interleukin (IL)-5 was observed in asthma patients compared to healthy individuals, but no differences could be observed for IL-4, IL-13 or IL-10. A greater early activation response against M. tuberculosis, compared to S. pneumoniae, was observed in the asthmatic patients' cells. This may contribute to explaining why these patients frequently acquire infections caused by the latter bacterium and not the former.

The role of cytokines in atopic asthma.

Atopic asthma results from airway inflammation triggered by an environmental allergen. Symptoms include wheezing, dyspnea and cough, airway narrowing and/or hyperresponsiveness to several inhaled stimuli. Inflammation develops in a two-phase fashion. The first phase after exposure to the allergen consists of degranulation and release of both histamine and other stored preformed inflammatory mediators as well as newly synthesized ones, including cytokines, all of which increase mucus secretion and smooth muscle contraction. The second phase occurs later and lasts longer; it is due to different molecules: several cytokines and chemokines, arachidonic acid derivatives, enzymes such as metalloproteinases and cell adhesion molecules. Cytokines are key players in the chronic inflammation in asthma patients, but details on their role and interactions still remain undetermined. Recent evidence suggests that allergic asthma is a multifaceted condition actively controlled by effector as well as regulatory T cells (Tregs). T helper (Th) 2 cells and Th17 cells increase airway inflammation, while Tregs are anti- inflammatory. Cytokines are involved in the development and activation of all T cell subpopulations. They are also involved directly or indirectly in most approaches to asthma treatment. Several cytokines have been tested as therapeutic targets and some of the currently used therapies like corticosteroids, beta agonists and allergen immunotherapy affect cytokine production. The increased knowledge on cytokine interplay and lymphocyte subsets should generate new therapeutic strategies in the near future.

Healthcare Information Systems to Assess Influenza Outbreaks: An analysis of the 2009 H1N1 Epidemic in Buenos Aires.

OBJECTIVE: To determine whether a private HIS could have detected the influenza epidemic outbreaks earlier through changes in morbidity and mortality patterns. METHODS: Data Source included a health information system (HIS) from an academic tertiary health care center integrating administrative and clinical applications. It used a local interface terminology server which provides support through data autocoding of clinical documentation. Specific data subsets were created to compare the burden of influenza during the epidemiological week (EW) 21 to 26 for years 2007 to 2009 among 150,000 Health Maintenance Organization members in Argentina. The threshold for identifying an epidemic was considered met when the weekly influenza-like illness (ILI) rate exceeded 200 per 100,000 visits. Case fatality rates and mortality rates of severe acute respiratory infection (SARI) from 2007 to 2009 were retrospectively compared. Case fatality rates and mortality rates for A/H1N1 influenza 2009 also were estimated. RESULTS: The HIS detected the outbreak in EW 23 while the government Ministry of Health (MoH) gave a national epidemic alert during EW 25. The number of visits for ILI increased more than fourfold when comparing 2009 to the period 2007-2008. The SARI mortality rate in 2009 was higher than in 2008 (RR 2.8; 95%CI 1.18-6.63) and similar to that of 2007 (RR 1.05; 95%CI 0.56-1.49). 2009 was the first year with mortalities younger than 65 years attributable to SARI. The estimated A/H1N1 case fatality rate for SARI was 6.2% (95%CI 2.5 to 15.5) and A/H1N1 mortality rate was 6 per 100,000 (95%CI 0 to 11.6). CONCLUSION: Our HIS detected the outbreak two weeks before than the MoH gave a national alert. The information system was useful in assessing morbidity and mortality during the 2009 influenza epidemic H1N1 outbreak suggesting that with a private-public integration a more real-time outbreak and disease surveillance system could be implemented.

[Atypical Werner syndrome: Atypical progeroid syndrome: A case report]. / Síndrome de Werner atípico: síndrome progeroide atípico.

Progeria is a premature ageing syndrome. Werner Syndrome (WS) is a type of progeria in the adult which includes bilateral juvenile cataracts and cutaneous sclerodermiform changes; it is caused by a mutation if the WRN gene which codes a helicase, a DNA repair enzyme. A case is presented of a patient, a 12 year old girl, with characteristics of WS but with no identifiable mutation in the WRN gene, therefore it was classified as atypical Werner Syndrome (AWS).

Antibiotic resistance in lactic acid bacteria and Micrococcaceae/Staphylococcaceae isolates from artisanal raw milk cheeses, and potential implications on cheese making.

Antibiotic susceptibility against 19 antimicrobial agents was evaluated in isolates of the genera Lactococcus (46 isolates), Leuconostoc (22), Lactobacillus (19), Staphylococcus (8), Enterococcus (7), and Microccoccus/Kocuria (5) obtained from the predominant microflora of nonrecent and recent types of artisanal raw cow's milk cheeses. Beta-lactams showed broad activity against all genera, although leuconostocs and lactobacilli were highly resistant to oxacillin (80% to 95.5%). Resistance to aminoglycosides was frequent for lactococci and enterococci (particularly for streptomycin), whereas lower rates of resistance were detected for lactobacilli and leuconostocs. Technologically interesting traits for the food industry were distributed among isolates that showed different degrees of resistance to common antibiotics. However, isolates showing resistance to less than 2 antibiotics were mainly those with properties of greatest technological interest (acidifying activity, proteolytic/lipolytic activities, or diacetyl production).

Differential effect of appendectomy and tonsillectomy on anti-Kudoa sp. antibodies in patients with MALTectomy.

We found an association between tonsillectomized patients and subsequent appendicitis. We also observed that MALTectomy significantly decreased secretory IgA levels in serum of patients, being this decrease more pronounced when both operations (tonsillectomy and appendectomy) had been performed. The elevated humoral responses detected previously by us in BALB/c mice immunized with Kudoa sp. pseudocyst extracts and the high IgG1 and IgE levels induced by the oral administration of Kudoa sp. pseudocysts to BALB/c mice showed the possible immunopathological effects in man from the ingestion of Kudoa sp. infected fish. We use the ELISA method to investigate the possible relationship between MALTectomy (tonsillectomy and appendectomy) and specific antibody levels to Kudoa sp. Both anti-Kudoa sp. specific antibody levels and the number of patients that recognized Kudoa sp. antigens were greater in tonsillectomy patients when compared to the control and the other studied groups (appendectomized and appendectomized+tonsillectomies patients). Tonsillectomy was associated to a switch in the class of immunoglobulins involved in these responses and these responses may be abrogated by appendectomy. Tonsils and appendix may respond in different ways to Kudoa sp. antigens and these different reactions may be involved in some immunopathological reactions.

[Self-care behavior and patients' knowledge about self-care predict rehospitalization among older adults with heart failure]. / El autocuidado y el conocimiento del manejo de la enfermedad predicen la rehospitalización en ancianos con insuficiencia cardíaca.

INTRODUCTION: This study examined the association of self-care behavior and patients' knowledge about self-care with rehospitalization among older adults with heart failure (HF). METHODS: Case-control comparison (116 cases and 209 controls) nested in a prospective cohort of patients aged 65 years and older admitted for HF at 4 Spanish hospitals. Cases were patients experiencing a first emergency rehospitalization in the 6 months following the index hospital admission. Controls were patients who did not undergo a rehospitalization during such time-period. RESULTS: The number of self-care behaviors was inversely associated with the frequency of readmission (p for linear trend: 0.006). Compared with patients showing the appropriate self-care behavior, hospital readmission was more frequent among those who did no go for a walk daily or did not engage in any daily physical activity (hazard ratio [HR] 1.55; 95% confidence limits [CL] 1.04-2.29), and among those who did not keep their medical appointments (HR 1.82; 95% CL 1.10-3.02). Hospital readmission was also more frequent among patients who: failed to take their medication at the scheduled time (HR 2.07; 95% CL 1.15-3.72); stopped taking their medication when it disagreed with them (HR 1.76; 95% CL 1.08-2.85); and failed to adhere to their drug treatment (HR 1.96; 95% CL 1.29-2.98). Furthermore, the fewer the number of behaviors which patients knew to be required for self-care, the greater the frequency of rehospitalization (p for linear trend:0.029). CONCLUSIONS: A lower degree of self-care and of patients' knowledge about self-care predicted a higher risk of hospital readmission.