Biological relevance of Granzymes A and K during E. coli sepsis.

Aims: Recent in vitro findings suggest that the serine protease Granzyme K (GzmK) may act as a proinflammatory mediator. However, its role in sepsis is unknown. Here we aim to understand the role of GzmK in a mouse model of bacterial sepsis and compare it to the biological relevance of Granzyme A (GzmA). Methods: Sepsis was induced in WT, GzmA-/- and GzmK-/- mice by an intraperitoneal injection of 2x108 CFU from E. coli. Mouse survival was monitored during 5 days. Levels of IL-1α, IL-1ß, TNFα and IL-6 in plasma were measured and bacterial load in blood, liver and spleen was analyzed. Finally, profile of cellular expression of GzmA and GzmK was analyzed by FACS. Results: GzmA and GzmK are not involved in the control of bacterial infection. However, GzmA and GzmK deficient mice showed a lower sepsis score in comparison with WT mice, although only GzmA deficient mice exhibited increased survival. GzmA deficient mice also showed reduced expression of some proinflammatory cytokines like IL1-α, IL-ß and IL-6. A similar result was found when extracellular GzmA was therapeutically inhibited in WT mice using serpinb6b, which improved survival and reduced IL-6 expression. Mechanistically, active extracellular GzmA induces the production of IL-6 in macrophages by a mechanism dependent on TLR4 and MyD88. Conclusions: These results suggest that although both proteases contribute to the clinical signs of E. coli-induced sepsis, inhibition of GzmA is sufficient to reduce inflammation and improve survival irrespectively of the presence of other inflammatory granzymes, like GzmK.

Granzyme A inhibition reduces inflammation and increases survival during abdominal sepsis.

Aims: Peritonitis is one of the most common causes of sepsis, a serious syndrome characterized by a dysregulated systemic inflammatory response. Recent evidence suggests that Granzyme A (GzmA), a serine protease mainly expressed by NK and T cells, could act as a proinflammatory mediator and could play an important role in the pathogenesis of sepsis. This work aims to analyze the role and the therapeutic potential of GzmA in the pathogenesis of peritoneal sepsis. Methods: The level of extracellular GzmA as well as GzmA activity were analyzed in serum from healthy volunteers and patients with confirmed peritonitis and were correlated with the Sequential Organ Failure Assessment (SOFA) score. Peritonitis was induced in C57Bl/6 (WT) and GzmA-/- mice by cecal ligation and puncture (CLP). Mice were treated intraperitoneally with antibiotics alone or in combination serpinb6b, a specific GzmA inhibitor, for 5 days. Mouse survival was monitored during 14 days, levels of some proinflammatory cytokines were measured in serum and bacterial load and diversity was analyzed in blood and spleen at different times. Results: Clinically, elevated GzmA was observed in serum from patients with abdominal sepsis suggesting that GzmA plays an important role in this pathology. In the CLP model GzmA deficient mice, or WT mice treated with an extracellular GzmA inhibitor, showed increased survival, which correlated with a reduction in proinflammatory markers in both serum and peritoneal lavage fluid. GzmA deficiency did not influence bacterial load in blood and spleen and GzmA did not affect bacterial replication in macrophages in vitro, indicating that GzmA has no role in bacterial control. Analysis of GzmA in lymphoid cells following CLP showed that it was mainly expressed by NK cells. Mechanistically, we found that extracellular active GzmA acts as a proinflammatory mediator in macrophages by inducing the TLR4-dependent expression of IL-6 and TNFα. Conclusions: Our findings implicate GzmA as a key regulator of the inflammatory response during abdominal sepsis and provide solid evidences about its therapeutic potential for the treatment of this severe pathology.

Extracellular Granzyme A Promotes Colorectal Cancer Development by Enhancing Gut Inflammation.

If not properly regulated, the inflammatory immune response can promote carcinogenesis, as evident in colorectal cancer (CRC). Aiming to gain mechanistic insight into the link between inflammation and CRC, we perform transcriptomics analysis of human CRC, identifying a strong correlation between expression of the serine protease granzyme A (GzmA) and inflammation. In a dextran sodium sulfate and azoxymethane (DSS/AOM) mouse model, deficiency and pharmacological inhibition of extracellular GzmA both attenuate gut inflammation and prevent CRC development, including the initial steps of cell transformation and epithelial-to-mesenchymal transition. Mechanistically, extracellular GzmA induces NF-κB-dependent IL-6 production in macrophages, which in turn promotes STAT3 activation in cultured CRC cells. Accordingly, colon tissues from DSS/AOM-treated, GzmA-deficient animals present reduced levels of pSTAT3. By identifying GzmA as a proinflammatory protease that promotes CRC development, these findings provide information on mechanisms that link immune cell infiltration to cancer progression and present GzmA as a therapeutic target for CRC.

[Occupational health and safety: educational intervention for cleaning workers in research sectors]. / Salud y seguridad laboral: intervención educativa en trabajadores de limpieza en áreas de investigación.

OBJECTIVE: To evaluate the results of educational interven- tion on health and safety regarding principles of biosafety in cleaning workers of a health institution. MATERIALS AND METHODS: Using concurrent mixed methods, we evaluated a total of 31 workers on their knowledge, attitudes, and practices of biosafety and risk perception. We conducted baseline measurements and two follow-ups. Fractional logistic regression models were fitted with study stage as covariate. Additional models included interactions of study stage with key workers characteristics. Thematic qualitative analysis and triangulation was developed. RESULTS: The knowledge (+33.3 points, scale 0-100), attitudes (+10.6), and practices (+23.5) increased significantly in the first follow-up; knowledge de- creased in the second follow-up (p<0.001). The qualitative findings revealed an improvement in risk prevention attitudes and practices, framed by experiences of vulnerability, stigma, and discrimination. CONCLUSIONS: The study provides key elements for biosafety research related to vulnerable groups and it is effective in promoting the health of a disadvantaged and invisible sector.

OBJETIVO: Evaluar los resultados de una intervención educativa sobre salud y seguridad laboral bajo principios de bioseguridad en trabajadores y trabajadoras de limpieza de una institución de salud. MATERIAL Y MÉTODOS: Evaluación con métodos mixtos concurrentes sobre conocimientos, actitudes y prácticas en bioseguridad y percepción de riesgos, con medición basal y dos seguimientos, en 31 trabajadores y trabajadoras. Se realizaron modelos fraccionales separados para estimar interacciones de las mediciones. Se hizo análisis cualitativo temático y triangulación metodológica. RESULTADOS: Los conocimientos (+33.3 puntos, escala 0 - 100), actitudes (+10.6) y prácticas (+23.5) incrementaron signifi- cativamente en el primer seguimiento; los conocimientos disminuyeron en el segundo seguimiento (p<0.001). Los ha- llazgos cualitativos revelaron mejora en actitudes y prácticas de prevención frente al riesgo, enmarcados por experiencias de vulnerabilidad, estigma y discriminación. CONCLUSIONES: El estudio aporta elementos clave para la investigación en bioseguridad relacionada con grupos vulnerables y es efectivo para la promoción de la salud de un sector desfavorecido e invisibilizado.

Salud y seguridad laboral: intervención educativa en trabajadores de limpieza en áreas de investigación / Occupational health and safety: educational intervention for cleaning workers in research sectors

Resumen: Objetivo: Evaluar los resultados de una intervención educativa sobre salud y seguridad laboral bajo principios de bioseguridad en trabajadores y trabajadoras de limpieza de una institución de salud. Material y métodos: Evaluación con métodos mixtos concurrentes sobre conocimientos, actitudes y prácticas en bioseguridad y percepción de riesgos, con medición basal y dos seguimientos, en 31 trabajadores y trabajadoras. Se realizaron modelos fraccionales separados para estimar interacciones de las mediciones. Se hizo análisis cualitativo temático y triangulación metodológica. Resultados: Los conocimientos (+33.3 puntos, escala 0-100), actitudes (+10.6) y prácticas (+23.5) incrementaron significativamente en el primer seguimiento; los conocimientos disminuyeron en el segundo seguimiento (p<0.001). Los hallazgos cualitativos revelaron mejora en actitudes y prácticas de prevención frente al riesgo, enmarcados por experiencias de vulnerabilidad, estigma y discriminación. Conclusiones: El estudio aporta elementos clave para la investigación en bioseguridad relacionada con grupos vulnerables y es efectivo para la promoción de la salud de un sector desfavorecido e invisibilizado.

Abstract: Objective: To evaluate the results of educational intervention on health and safety regarding principles of biosafety in cleaning workers of a health institution. Materials and methods: Using concurrent mixed methods, we evaluated a total of 31 workers on their knowledge, attitudes, and practices of biosafety and risk perception. We conducted baseline measurements and two follow-ups. Fractional logistic regression models were fitted with study stage as covariate. Additional models included interactions of study stage with key workers characteristics. Thematic qualitative analysis and triangulation was developed. Results: The knowledge (+33.3 points, scale 0-100), attitudes (+10.6), and practices (+23.5) increased significantly in the first follow-up; knowledge decreased in the second follow-up (p<0.001). The qualitative findings revealed an improvement in risk prevention attitudes and practices, framed by experiences of vulnerability, stigma, and discrimination. Conclusions: The study provides key elements for biosafety research related to vulnerable groups and it is effective in promoting the health of a disadvantaged and invisible sector.

Eficacia y seguridad del implante coclear en la hipoacusia neurosensorial severa / Efficacy and safety of the cochlear implant in severe sensorineural hearing loss

INTRODUCCIÓN: Este documento técnico se realiza a solicitud del Hospital Nacional Arzobispo Loayza, a través de la Gerencia Macro Regional Centro Medio del Seguro Integral de Salud, y del Instituto Nacional de Salud del Niño-San Borja. a) Cuadro clínico: La hipoacusia es un problema con detección clínica en recién nacidos y lactantes que puede llegar a consecuencias como pérdida total o parcial. En pacientes con hipoacusia neurosensorial el tratamiento se realiza con una etapa de estimulación acústica con audífonos y posterior inserción del implante coclear (IC). b) Tecnología: Los IC son dispositivos que estimulan eléctricamente el nervio auditivo y permiten que las personas con pérdidas auditivas profunda reconozcan el sonido. Ha sido aprobado en 1984 por la Food and Drug Administration (FDA) de Estados Unidos de América, para pacientes adultos (mayores de 18 años), cinco años después (1989) se aprobó en pacientes de dos años o mayores; y en el año 2000, en pacientes de 12 a más meses. No cuenta con registro en Perú. OBJETIVO: Evaluar la eficacia y seguridad, así como documentos relacionados a la decisión de cobertura del implante coclear en la hipoacusia severa neurosensorial. METODOLOGÍA: Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE (PubMed), LILACS, y COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Scholar y TRIPDATABASE para identificar revisiones sistemáticas (RS) con o sin meta-análisis (MA) y ensayos clínicos aleatorizados (ECAs). Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales instituciones internacionales de otorrinolaringología y agencias de tecnologías sanitarias que realizan evaluación de tecnologías sanitarias (ETS), guías de práctica clínica (GPC) y valuaciones económicas (EE) de la región. RESULTADOS: Se seleccionaron cuatro RS, un ECA, dos GPC y una ETS. No se encontraron EE en la región. CONCLUSIONES: La evidencia disponible respecto a IC en hipoacusia neurosensorial severa a profunda es moderada. Estudios observacionales en niños, sugieren beneficios del IC, pero los resultados deben tomarse con precaución debido a su calidad. Respecto al uso de IC en menores de 12 meses (indicación no aprobada por la FDA), los estudios también observacionales y con alto riesgo de sesgo sugieren una posible ventaja en aquellos pacientes tras 24 meses de uso. En adultos, de la misma forma se sugiere un posible beneficio del IC pero basado en estudios de limitada calidad metodológica. Con respecto al uso de ICB versus ICU, evidencia de moderada calidad procedente de un ECA, refiere que tras dos años de uso no se vio diferencia entre ambas tecnologías; sin embargo, al evaluar la localización del sonido se observó que fue significativamente mejor en el grupo de IC bilateral. Las GPC y la ETS identificadas recomiendan el uso del IC bajo ciertas indicaciones.

Multi-Robot Interfaces and Operator Situational Awareness: Study of the Impact of Immersion and Prediction.

Multi-robot missions are a challenge for operators in terms of workload and situational awareness. These operators have to receive data from the robots, extract information, understand the situation properly, make decisions, generate the adequate commands, and send them to the robots. The consequences of excessive workload and lack of awareness can vary from inefficiencies to accidents. This work focuses on the study of future operator interfaces of multi-robot systems, taking into account relevant issues such as multimodal interactions, immersive devices, predictive capabilities and adaptive displays. Specifically, four interfaces have been designed and developed: a conventional, a predictive conventional, a virtual reality and a predictive virtual reality interface. The four interfaces have been validated by the performance of twenty-four operators that supervised eight multi-robot missions of fire surveillance and extinguishing. The results of the workload and situational awareness tests show that virtual reality improves the situational awareness without increasing the workload of operators, whereas the effects of predictive components are not significant and depend on their implementation.

Factors associated with the latency to diagnosis of childhood cancer in Peru.

BACKGROUND: The latency to diagnosis is the time between the detection of a patient's first symptoms and the cancer diagnosis. The aim of this study was to identify the latency to the diagnosis of cancer in children in Peru and the clinical and sociodemographic factors associated with this latency. METHODS: All patients diagnosed with lymphoma and solid tumors between 2012 and 2014 at a social security referral hospital in Peru were retrospectively evaluated. Clinical and demographic variables were analyzed to assess their association with the latency to diagnosis. RESULTS: A total of 284 patients younger than 18 years of age were included in the study. The median time to diagnosis was 8.8 weeks, with a median patient interval of 2 weeks and diagnostic interval of 4.4 weeks. We found significant differences in the latency to diagnosis for different types of cancer (longer for Hodgkin lymphoma and shorter for Wilms tumor). Older children had significantly longer latencies to diagnosis (P = 0.048; OR: 1.05, 95% CI [1.0-1.1]), as did children who were first diagnosed by a general physician rather than by a pediatrician or surgeon (P = 0.028; OR: 2.1, 95% CI [1.1-4.2]). Parental age, level of education, marital status, metastatic disease, clinical stage, and gender did not significantly affect latency to diagnosis as analyzed by a multivariate analysis. CONCLUSION: In Peru, median latency to diagnosis was comparable to that described in developing countries, where the index of suspicion for childhood cancer remains low. It is crucial to establish strategies to optimize early diagnoses using associated factors.

Staphylococcus aureus resistente a meticilina adquirido en la comunidad aislados en tres hospitales de Lima-Perú / Methicillin resistant Staphylococcus aureus isolates acquired in the community in three hospitals in Lima, Peru

Staphylococcus aureus es un importante patógeno involucrado en una serie de infecciones e intoxicaciones, presenta múltiples factores de virulencia y su impacto se incrementa por su notable resistencia a los antimicrobianos. Objetivo: Determinar la frecuencia de Staphylococcus aureus meticilino resistente adquiridos en la comunidad, en hospitales de Lima- Perú. Material y métodos: Se realizó un estudio descriptivo multicéntrico. La resistencia a meticilina se determinó por el método Oxacillin Agar Screen. El origen de la cepa fue determinado mediante los criterios de los CDC; la Leucocidina de Panton Valentine fue identificada por métodos moleculares. Resultados: Se aislaron 276 cepas de Staphylococcus aureus, 160 fueron resistentes a meticilina (58 por ciento), 9 de ellas fueron identificadas como adquiridas en la comunidad (5,6 por ciento). La PVL fue identificada en 25 cepas (9,1 por ciento), 14 fueron MSSA y 11 MRSA, de éstas últimas solo 4 fueron MRSAcom, 7 fueron MRSAhosp (p menor que 0,001). Conclusiones: El estudio revela niveles elevados de resistencia a meticilina, pero niveles bajos de MRSAcom. En nuestro medio la presencia de PVL no constituiría un marcador para la identificación de los MRSAcom.

Background: Staphylococcus aureus is an important pathogen involved in a series of infections and toxin mediated syndromes, has many virulence factors and its impact increases its resistance to antimicrobial agents. Objectives: To determine the frequency of community acquired methicillin resistant Staphylococcus aureus among hospitals in Lima -Peru. Material and Methods: We performed a prospective multicenter study. The resistance to methicillin was determined by the Oxacillin Agar Screen method. The origin of the strain was determined using CDC criteria, the Panton Valentine Leucocidin was identified by molecular methods. Results: We isolated 276 strains of Staphylococcus aureus, 160 were resistant to methicillin (58 per cent). 9 strains were identified as community acquired MRSA (5.6 per cent). The Panton Valentine Leucocidin was identified in 25 strains (9.1 per cent), 14 were MSSA and 11 MRSA, only 4 of the latter were CA MRSA, 7 were HA MRSA (p less than 0.001). Conclusions: The study showed frequencys of methicillin resistance, but low CA MRSA. In our environment the presence of PVL would not be a marker for the identification of CA MRSA.

Enfermedad de Kikuchi-Fujimoto, tuberculosis ganglionar y tuberculide, comunicación de casos y revisión de literatura / Disease of Kikuchi-Fujimoto, tuberculosis, lymph node and tuberculide, communication of cases and review of literature

Se comunican dos casos de tuberculosis ganglionar que simulan histológicamente la enfermedad de Kikuchi, es decir, un patrón de linfadenitis histiocítica necrotizante. Uno de ellos presentó, además, cambios clínicos e histológicos de la tuberculide rosaceiforme de Lewandowsky, lo que demuestra que esta última entidad puede excepcionalmente ser una verdadera tuberculide.