Prevalence and subtype distribution of Blastocystis sp. infecting children from a rural community in Panama.

Blastocystis sp. is a commonly reported intestinal parasite with a worldwide distribution. Phylogenetic analyses describe at least 17 subtypes for this parasite, and nine of them have been found in humans. However, the prevalence and some epidemiological characteristics of this parasitic infection in rural communities are not well known. The objective of this cross-sectional study was to evaluate the prevalence, subtypes, and epidemiological factors related to Blastocystis sp. Infection in children from of a small rural community in the central area of Panama. For this, 66 fecal samples from children (1 to 12 years old), were initially analyzed for the presence of parasites by a formalin-ethyl acetate/concentration method. Molecular detection and identification of Blastocystis sp. subtypes were carried out by amplification and sequencing of a partial fragment of the small-subunit ribosomal RNA gene. Using data from a questionnaire, analyses of epidemiological conditions potentially associated with Blastocystis sp. transmission were also conducted. Microscopic diagnostics showed that 33.3% (22/66) of the analyzed samples presented entero-parasites. Among them, Blastocystis sp. was the most prevalent, with 21.2% (14/66), followed by the E. histolytica/dispar/moshkovskii complex 4.5% (3/66), Giardia lamblia 1.5% (1/66) and Strongyloides stercoralis 1.5% (1/66). PCR-based analyses detected a prevalence of Blastocystis sp. infection of 74.2% (49/66) in apparently healthy children. Phylogenetic analysis revealed two different subtypes of this parasite: ST1 with 42.2% (28/66) infected, and ST3 with 31.8% (21/66) infected. In addition, recent diarrhea was significantly associated with Blastocystis sp. infection. None of the other risk factors evaluated was statistically associated with infection. These results highlight the need to further investigate clinical, epidemiological, and genetic characteristics of Blastocystis sp. infections in this community.

[Utilisation of first-line antibiotics six years after a multifaceted intervention]. / Uso de antibióticos de primera línea 6 años después de una intervención multifacética.

OBJECTIVE: No study has evaluated the impact of a multifaceted intervention on the quality of the antibiotics prescribed more than 5 years later. METHODS: A total of 210 general practitioners (GP) from eight different regions of Spain were asked to participate in two registrations of respiratory tract infections (RTI) in 2008, before, and in 2009, just after a multifaceted intervention including prescriber feedback, clinical guidelines, training sessions focused on appropriate antibiotic prescribing, workshop on rapid tests and provision of these tests in the GP consultation. They were all again invited to participate in a similar registration in 2015. A new group of clinicians from the same areas who had never participated in antimicrobial stewardship courses were also invited to participate and acted as controls. RESULTS: The 121 GPs who continued the study (57.6%) and the 117 control GPs registered 22,407 RTIs. The antibiotic most commonly prescribed was amoxicillin and clavulanic acid, prescribed in 1,801 cases (8.1% of the total), followed by amoxicillin (1,372 prescriptions, 6.2%), being lower among GPs just after the intervention. The third leading antibiotic among GPs just after the intervention was penicillin V (127 cases, 3.3%) whereas macrolides ranked third in the other three groups of GPs. CONCLUSIONS: The use of first-line antibiotic for RTIs wanes over time after an intervention, but their utilisation is still significantly greater among intervened clinicians six years later compared to GPs who have never been exposed to any antimicrobial stewardship programmes.

Domestic dog health worsens with socio-economic deprivation of their home communities.

Dogs play an important role in infectious disease transmission as reservoir hosts of many zoonotic and wildlife pathogens. Nevertheless, unlike wildlife species involved in the life cycle of pathogens, whose health status might be a direct reflection of their fitness and competitive abilities, dog health condition could be sensitive to socio-economic factors impacting the well-being of their owners. Here, we compare several dog health indicators in three rural communities of Panama with different degrees of socio-economic deprivation. From a total of 78 individuals, we collected blood and fecal samples, and assessed their body condition. With the blood samples, we performed routine hematologic evaluation (complete blood counts) and measured cytokine levels (Interferon-γ and Interleukin-10) through enzyme-linked immunosorbent assays. With the fecal samples we diagnosed helminthiases. Dogs were also serologically tested for exposure to Trypanosoma cruzi and canine distemper virus, and molecular tests were done to assess T. cruzi infection status. We found significant differences between dog health measurements, pathogen prevalence, parasite richness, and economic status of the human communities where the dogs lived. We found dogs that were less healthy, more likely to be infected with zoonotic pathogens, and more likely to be seropositive to canine distemper virus in the communities with lower economic status. This study concludes that isolated communities of lower economic status in Panama may have less healthy dogs that could become major reservoirs in the transmission of diseases to humans and sympatric wildlife.

Cardiac computed tomography for valve disease.

Heart valve disease and coronary heart disease are very prevalent in the general population and often coincide in the same patient. Cardiac computed tomography (CT) makes it possible to noninvasively rule out coronary disease before valve surgery and to potentially avoid invasive heart catheterization in 66% to 75% of patients. The same imaging test provides abundant anatomic and functional information that complements the information from echocardiography, making it possible to characterize the etiology of the valve disease and its repercussions on the heart and aorta, as well as to quantify the severity of disease affecting the valves of the left side of the heart. In this article, we describe the anatomy of the heart valves and the technical requisites of cardiac CT for the study of the valves. We go on to explore the usefulness of CT in the preoperative study of the coronary arteries and in the morphological and functional characterization of valve disease, with special emphasis on the valves of the left side of the heart.

Consideraciones y algunas recomendaciones para escribir un artículo científico en una revista biomédica

"Un manuscrito que se envía a publicación en una revista biomédica, al igual que una ponencia en un congreso o el informe final de un proyecto, corresponde a una forma de informar los resultados de un proceso de investigación científica. ¿Para qué sirve un artículo científico? Cuando se redacta en forma apropiada, un artículo nosotorga valiosa información referente a lo que se hizo, por qué se hizo, cómo se hizo, qué resultó de lo que se hizo y qué significa lo que se hizo (...)" (AU)

Prevalence of trypanosome infections in dogs from Chagas disease endemic regions in Panama, Central America.

The prevalence of canine trypanosomosis was investigated in two Chagas disease endemic rural communities located in the central region of Panama. Serologic tests for Trypanosoma cruzi infection revealed a prevalence of 11.1%. Hemocultures coupled with PCR analysis demonstrated a Trypanosoma rangeli infection rate of 5.1%. An overall trypanosome infection index of 16.2% (16/99) was detected in this canine population. One dog had a mixed infection of T. cruzi and T. rangeli. Six of the trypanosome-infected dogs belong to people who were diagnosed of Chagas disease. We conclude that dogs from this rural area of Panama are frequently infected with trypanosomes transmitted by the sylvatic vector, Rhodnius pallescens, and suggest that dogs are important in the peridomestic transmission cycle of trypanosomes as reservoirs and hosts. The epidemiological implications of these findings are discussed.

Principios físicos básicos del ultrasonido / Basic physics of ultrasound

El ultrasonido es una técnica de imagen sencilla, no invasiva y accesible que permite la evaluación del sistema musculoesquelético en tiempo real, con la ventaja de examinar las articulaciones en forma dinámica; adicionalmente, con la ayuda del Doppler de poder y de color, se pueden evaluar los fenómenos inflamatorios locales, sin someter al paciente a radiación ionizante. Tiene como desventaja ser dependiente del operador, el cual debe tener un amplio conocimiento de los principios físicos del ultrasonido, estar familiarizado con la ecotextura de los tejidos y de la anatomía musculoesquelética. Además es importante que sepa reconocer los fenómenos sonográficos que pueden presentarse como confusores, denominados artefactos. Este cúmulo de conocimientos es deseable para el especialista en padecimientos musculoesqueléticos, para que pueda interpretar adecuadamente los estudios ecográficos, reconocer los artefactos y así evitar diagnósticos erróneos y procedimientos innecesarios. En una serie de tres artículos se analizan los principios físicos básicos de la ecografía, la sonoanatomía del sistema musculoesquelético y los artefactos más comunes encontrados en ecografía. En esta primera entrega analizaremos los principios físicos básicos involucrados en la producción de imágenes ecográficas.

Ultrasonography is a simple, non invasive and accessible imaging technique that allows the evaluation of a variety of musculoskeletal structures in real time. It has the advantage of dynamic assessment of joints, tendons and muscles; furthermore, the presence of an underlying inflammatory phenomenon can be evaluated with power or color Doppler techniques in the same session without radiation exposure. However, it is an operator dependant technique that needs a in-depth knowledge of basic principles of ultrasound, musculoskeletal anatomy and ecostructure. Additionally, it is important to identify and recognize the presence of ultrasound artifacts that can be image confusors. A basic knowledge of ultrasound physics, as well as, sonoanatomy and ultrasound artifacts recognition is essential to understand ultrasound images. This knowledge diminishes the possibilities of misdiagnoses and unnecessary procedures. In a series of three papers, we will analyze the basic principles of ultrasound, musculoskeletal sonoanatomy and finally ultrasonographic artifacts. In the present paper we review the basic physical and technical principles behind ultrasound images.

Sonoanatomía del sistema musculoesquelético / Musculoskeletal sonoanatomy

El ultrasonido musculoesquelético se ha convertido en una herramienta útil y eficaz en el diagnóstico de diferentes patologías que afectan el sistema musculoesquelético. Al ser un medio que permite visualizar estructuras tales como tendones, ligamentos, músculos, entre otras, el médico dedicado a este estudio debe tener un conocimiento profundo de la anatomía del sistema musculosquelético. La correcta visualización de estas estructuras y el diagnóstico acertado dependen también de que el operador conozca las imágenes sonográficas propias de cada estructura. En este artículo describimos las características sonográficas normales de las estructuras anatómicas que pueden ser evaluadas por ultrasonido.

Musculoskeletal ultrasound has become a useful and effective tool in the diagnosis of different pathologies that affect the musculoskeletal system. This method allows the visualization of soft tissue structures such as tendons, ligaments, muscles, among others. The healthcare professional dedicated to this area must have a deep knowledge of the anatomy of the musculoskeletal system. The correct visualization of these structures and the correct diagnosis also depend on the operator’s knowledge of the normal sonographic images of each structure. In this paper we describe the normal sonographic characteristics of the locomotor system that can be evaluated by ultrasound.

Artefactos en ecografía musculoesquelética / Artifacts in muskuloeskeletal ultrasound

El ultrasonido musculoesquelético es susceptible de presentar defectos en su técnica operativa. Estos defectos son llamados artefactos. En este artículo revisaremos los artefactos que comúnmente ocurren en la práctica de este método diagnóstico. El conocimiento de los artefactos y su detección oportuna ayudan al operador a optimizar la práctica diaria del ultrasonido.

The musculoskeletal ultrasound is susceptible to present defects in its operative technique. These defects are called artifacts. In this article we will review the artifacts more susceptible to be found in daily practice. The knowledge of artifacts and their timely detection will help the operator to perform this technique accurately.

Analgesia in patients with acute abdominal pain.

BACKGROUND: For decades, analgesia for patients with acute abdominal pain was withheld until a definitive diagnosis was established for fear of masking the symptoms, changing physical findings or ultimately delaying diagnosis and treatment of a surgical condition. This non-evidence-based approach has been challenged by recent studies demonstrating that the use of analgesia in the initial evaluation of patients with acute abdominal pain leads to significant pain reduction without affecting diagnostic accuracy. However, early administration of analgesia to such patients can greatly reduce their pain and does not interfere with a diagnosis, which may even be facilitated due to the severity of physical symptoms being reduced. OBJECTIVES: To determine if the currently available evidence supports the use of opioid analgesia in patient management with acute abdominal pain; and to assess changes in a patient comfort while awaiting definitive diagnosis and final treatment decisions. SEARCH STRATEGY: Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 4, 2006), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). Randomized controlled trial filter for MEDLINE and EMBASE search. Trials will also be identified by "related articles". The searches were not limited by language or publication status. SELECTION CRITERIA: Randomized controlled trials (RCTs) that include adult patients with acute abdominal pain, without gender restriction, comparing any opioid analgesia regime to no analgesia administered prior to any intervention regardless of outcomes. DATA COLLECTION AND ANALYSIS: Two authors looked independently at the titles and abstracts of reports. Potentially relevant studies selected by at least one reviewer were retrieved in full text versions for potential inclusion. Allocation concealment was important to avoid bias and was graded using the Cochrane approach. The data from studies included was reviewed qualitatively and quantitatively using the Cochrane Collaborations methodology and statistical software RevMan Analysis 1.0.5. In the case of homogeneity or non- worrying heterogeneity, a random effects model was used. Sensitivity analysis was performed based on quality assessment. MAIN RESULTS: Six studies fulfilled the inclusion criteria. Improvement with use of opioid analgesia was verified in variables patient comfort, reduction of pain, changes in physical examination. AUTHORS' CONCLUSIONS: The review provide some evidence to support the notion that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not retard decisions to treat.

Pancreatic pseudocyst located in the liver.

Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. Extrapancreatic locations of pancreatic pseudocyst in the liver, pleura, mediastinum, or pelvis have been described. However, a pancreatic pseudocyst located in the liver is an infrequent condition. We present the case of a 46-year-old man with pancreatic pseudocyst located in the liver secondary to chronic alcoholic pancreatitis. During admission, the patient underwent an abdominal CT scan that showed a mass located in the head and body of the pancreas, as well as a thrombosis of the splenic vein. A percutaneous needle aspiration biopsy of the pancreas was obtained under CT guidance, which showed no tumoral involvement. Fourty-eight hours after the procedure the patient developed abdominal pain and elevated serum amylase levels. A pancreatic MRI exam showed two pancreatic pseudocysts, one of them located in the left hepatic lobe, the other in the pancreatic tail. Chronic pancreatitis signs also were found. Enteral nutrition via a nasojejunal tube was administered for two weeks. The disappearance of the pancreatic pseudocyst located in the pancreatic tail, and a subtotal resolution of the pancreatic pseudocyst located in the liver were observed. To date twenty-seven cases of pancreatic pseudocyst located in the liver have been published, most of them managed with percutaneous or surgical drainage.

Nutritional control of gene expression: how mammalian cells respond to amino acid limitation.

The amino acid response (AAR) pathway in mammalian cells is designed to detect and respond to amino acid deficiency. Limiting any essential amino acid initiates this signaling cascade, which leads to increased translation of a "master regulator," activating transcription factor (ATF) 4, and ultimately, to regulation of many steps along the pathway of DNA to RNA to protein. These regulated events include chromatin remodeling, RNA splicing, nuclear RNA export, mRNA stabilization, and translational control. Proteins that are increased in their expression as targets of the AAR pathway include membrane transporters, transcription factors from the basic region/leucine zipper (bZIP) superfamily, growth factors, and metabolic enzymes. Significant progress has been achieved in understanding the molecular mechanisms by which amino acids control the synthesis and turnover of mRNA and protein. Beyond gaining additional knowledge of these important regulatory pathways, further characterization of how these processes contribute to the pathology of various disease states represents an interesting aspect of future research in molecular nutrition.

Bilateral breast cancer associated with diffuse scleroderma.

There is a strong evidence to suggest the association between breast cancer and diffuse scleroderma, though it is an infrequent occurrence. We describe the clinical and radiological findings in a patient who, over a period of 2 years, was diagnosed initially of diffuse scleroderma, next with right breast cancer and finally with left breast cancer. A review of the literature evidencing the relation between these two pathologies is provided. We suggest that special vigilance for tumoral pathology of the breast should be performed in patients with systemic scleroderma.

Epidemiology of invasive Streptococcus pneumoniae infections in children in an area of Barcelona, Spain.

AIM: Streptococcus pneumoniae is the most common cause of bacteraemia, pneumonia, sinusitis and acute otitis media. With the advent of conjugate vaccines, there is now the possibility of preventing disease caused by this organism. However, little is known about the epidemiology of invasive pneumococcal disease in children in Spain. The aim of this study was to determine the incidence and the clinical and microbiologic characteristics of invasive pneumococcal disease in Sabadell, an industrial area in the province of Barcelona, Spain. METHODS: From January 1990 to December 2000, the case records of children with pneumococcal invasive disease at Sabadell Hospital were retrospectively (1990-1996) reviewed and prospectively (1997-2000) collected. The hospital serves a population of 61,143 children under 15 y of age, 18,073 children under 4 y of age and 7300 children under 2 y of age. RESULTS: A total of 112 children (54% under 24 mo of age and 93% under 6 y of age) with invasive pneumococcal disease were diagnosed during a period of 11 y. The incidence of invasive pneumococcal disease was 76 per 100,000 for children aged 0 to 24 mo, 45 for children aged 0-48 mo and 16.6 for children aged 0-14 y. Occult bacteraemia was the most common manifestation of invasive pneumococcal disease (66 cases), pneumonia was the second form (34 cases) and meningitis (10 cases) and arthritis (2 cases) were the other clinical manifestations. Of the 105 strains tested, 8.6% were highly penicillin resistant, 37.1% were intermediately penicillin resistant. 16.2% were intermediately cefotaxime resistant and 32.4% were erythromycin resistant. Pneumococci of serogroups 6, 14, 18, 19, 1, 5, 4, 9, 23 and 33 were the most frequently isolated groups (92%) but only 6, 9, 14, 19 and 23 were resistant to penicillin, cefotaxime, or erythromycin. CONCLUSIONS: In this study the incidence of invasive pneumococcal disease was found to be greater than that reported elsewhere in Spain and Europe. Penicillin resistance levels are high but the trend towards increasing penicillin resistance may have ended over the past few years. The currently licensed seven-valent (7-V) pneumococcal conjugate vaccine would cover 78% of cases of invasive pneumococcal in children aged 0-14 y, 80% in children aged 0-24 mo and 100% of cases of penicillin- or cefotaxime-resistant invasive pneumococcal disease.

Eleven-year study of recurrent pneumococcal bacteremia.

In order to describe the epidemiology and the clinical and microbiological manifestations of recurrent pneumococcal bacteremia, a long-term study was conducted. Between January 1988 and December 1998, a total of 344 episodes of bacteremia caused by pneumococci was detected in 331 patients. Thirteen (3.9%) of these patients experienced recurrent episodes of pneumococcal bacteremia, and all of them had underlying diseases. In 12 of these patients the recurrence was considered to be a reinfection, and in one patient it was considered to be a relapse. Three patients were found to harbor identical strains in both bacteremic episodes, as determined by pulsed-field techniques. Only hematological neoplasia appeared to be a predisposing factor for recurrent pneumococcal bacteremia.

Prevalence of Haemophilus influenzae pharyngeal carriers in the school population of Catalonia. Working Group on invasive disease caused by Haemophilus influenzae.

The objective of this study was to determine the prevalence of healthy Haemophilus influenzae (Hi) pharyngeal carriers in a representative sample of the Catalonian school population, as well as the factors associated. A two-stage cluster sampling was carried out. Parents were given a questionnaire to collect information on sociodemographic and epidemiological variables. A pharyngeal swab was performed on children when informed consent was given by parents, and was cultured on chocolate agar with 260 microg/ml bacitracin. Of the 1212 children studied, 316 (26%) H. influenzae carriers were detected: 5 (0.4%) serotype b, 1 (0.08%) serotype c, 6 (0.5%) serotype e, 5 (0.4%) serotype f, and 299 (24.7%) non-typable. Age, gender and geographical location were the only variables associated with H. influenzae carrier status. The prevalence of non-typable H. influenzae carriers was similar to that of studies carried out in other countries, while that of serotype b carriers was similar to the remainder of H. influenzae capsulates, and lower than that described in previous studies. These data are in accordance with the low incidence of the disease observed in our context, although the possibility that the vaccine coverage may have affected the results of this study cannot be dismissed.