Effect of urban vs. rural residence on the association between atopy and wheeze in Latin America: findings from a case-control analysis.

BACKGROUND: The association between atopy and asthma is attenuated in non-affluent populations, an effect that may be explained by childhood infections such as geohelminths. OBJECTIVE: To investigate the association between atopy and wheeze in schoolchildren living in urban and rural areas of Ecuador and examine the effects of geohelminths on this association. METHODS: We performed nested case-control studies among comparable populations of schoolchildren living in rural communities and urban neighbourhoods in the Province of Esmeraldas, Ecuador. We detected geohelminths in stool samples, measured recent wheeze and environmental exposures by parental questionnaire, and atopy by specific IgE (sIgE) and skin prick test (SPT) reactivity to aeroallergens. RESULTS: Atopy, particularly sIgE to house dust mite (HDM), was more strongly associated with recent wheeze in urban than rural schoolchildren: (urban, adj. OR 5.19, 95% CI 3.37-8.00, P < 0.0001; rural, adj. OR 1.81, 95%CI 1.09-2.99, P = 0.02; interaction, P < 0.001). The population fractions of wheeze attributable to atopy were approximately two-fold greater in urban schoolchildren: SPT to any allergen (urban 23.5% vs. rural 10.1%), SPT to HDM (urban 18.5% vs. rural 9.6%), and anti-HDM IgE (urban 26.5% vs. rural 10.5%), while anti-Ascaris IgE was related to wheeze in a high proportion of rural (49.7%) and urban (35.4%) children. The association between atopy and recent wheeze was attenuated by markers of geohelminth infections. CONCLUSIONS: Our data suggest that urban residence modifies the association between HDM atopy and recent wheeze, and this effect is explained partly by geohelminth infections.

Effects of geohelminth infection and age on the associations between allergen-specific IgE, skin test reactivity and wheeze: a case-control study.

BACKGROUND: Most childhood asthma in poor populations in Latin America is not associated with aeroallergen sensitization, an observation that could be explained by the attenuation of atopy by chronic helminth infections or effects of age. OBJECTIVE: To explore the effects of geohelminth infections and age on atopy, wheeze, and the association between atopy and wheeze. METHODS: A case-control study was done in 376 subjects (149 cases and 227 controls) aged 7-19 years living in rural communities in Ecuador. Wheeze cases, identified from a large cross-sectional survey, had recent wheeze and controls were a random sample of those without wheeze. Atopy was measured by the presence of allergen-specific IgE (asIgE) and skin prick test (SPT) responses to house dust mite and cockroach. Geohelminth infections were measured in stools and anti-Ascaris IgE in plasma. RESULTS: The fraction of recent wheeze attributable to anti-Ascaris IgE was 45.9%, while those for SPT and asIgE were 10.0% and 10.5% respectively. The association between atopy and wheeze was greater in adolescents than children. Although Anti-Ascaris IgE was strongly associated with wheeze (adj. OR 2.24 (95% CI 1.33-3.78, P = 0.003) and with asIgE (adj. OR 5.34, 95% CI 2.49-11.45, P < 0.001), the association with wheeze was independent of asIgE. There was some evidence that the association between atopy and wheeze was greater in uninfected subjects compared with those with active geohelminth infections. CONCLUSIONS AND CLINICAL RELEVANCE: Atopy to house dust mite and cockroach explained few wheeze cases in our study population, while the presence of anti-Ascaris IgE was an important risk factor. Our data provided only limited evidence that active geohelminth infections attenuated the association between atopy and wheeze in endemic areas or that age modified this association. The role of allergic sensitization to Ascaris in the development of wheeze, independent of atopy, requires further investigation.

Is breast ultrasound a good alternative to magnetic resonance imaging for evaluating implant integrity?

OBJECTIVE: To compare the diagnostic performance of breast ultrasound and breast magnetic resonance imaging and to correlate the findings on the two techniques that are suggestive of implant rupture. MATERIAL AND METHODS: We reviewed the images and reports of breast ultrasound and magnetic resonance imaging studies done in our diagnostic and interventional breast imaging unit to evaluate breast implants in 205 patients between January 2015 and December 2017. RESULTS: Ultrasound findings were compatible with implant rupture in 87 (42.4%) patients: intracapsular rupture in 44 (21.5%) and intracapsular and extracapsular rupture in 43 (21.0%). Ultrasound yielded 85.2% sensitivity, 89.7% specificity, 86.2% positive predictive value, and 89.0% negative predictive value. Magnetic resonance imaging findings were compatible with implant rupture in 88 (42.9%) patients: intracapsular rupture in 50 (24.4%) and intracapsular and extracapsular rupture in 38 (18.5%). The correlation between positive findings for the location of the rupture on the two imaging techniques was excellent (0.77; p < 0.0001). CONCLUSION: We found high concordance between the two techniques for the detection of intracapsular and extracapsular implant rupture. These results consolidate the use of ultrasound as the first-line imaging technique to evaluate implant integrity in our population; magnetic resonance imaging can be reserved for cases in which the ultrasound diagnosis of implant integrity is uncertain.

Is breast ultrasound a good alternative to magnetic resonance imaging for evaluating implant integrity? / ¿Es la ecografía mamaria una buena alternativa a la resonancia magnética en la evaluación de la integridad protésica?

OBJECTIVE: To compare the diagnostic performance of breast ultrasound and breast magnetic resonance imaging and to correlate the findings on the two techniques that are suggestive of implant rupture. MATERIAL AND METHODS: We reviewed the images and reports of breast ultrasound and magnetic resonance imaging studies done in our diagnostic and interventional breast imaging unit to evaluate breast implants in 205 patients between January 2015 and December 2017. RESULTS: Ultrasound findings were compatible with implant rupture in 87 (42.4%) patients: intracapsular rupture in 44 (21.5%) and intracapsular and extracapsular rupture in 43 (21.0%). Ultrasound yielded 85.2% sensitivity, 89.7% specificity, 86.2% positive predictive value, and 89.0% negative predictive value. Magnetic resonance imaging findings were compatible with implant rupture in 88 (42.9%) patients: intracapsular rupture in 50 (24.4%) and intracapsular and extracapsular rupture in 38 (18.5%). The correlation between positive findings for the location of the rupture on the two imaging techniques was excellent (0.77; p<0.0001). CONCLUSION: We found high concordance between the two techniques for the detection of intracapsular and extracapsular implant rupture. These results consolidate the use of ultrasound as the first-line imaging technique to evaluate implant integrity in our population; magnetic resonance imaging can be reserved for cases in which the ultrasound diagnosis of implant integrity is uncertain.

Long-term periodic anthelmintic treatments are associated with increased allergen skin reactivity.

BACKGROUND: The low prevalence of allergic disease in the rural tropics has been attributed to the protective effects of chronic helminth infections. There is concern that treatment-based control programmes for these parasites may lead to an increase in the prevalence of allergic diseases. OBJECTIVE: We measured the impact of 15-17 years of anthelmintic treatment with ivermectin on the prevalence of allergen skin test reactivity and allergic symptoms in school-age children. METHODS: The prevalence of allergen skin test reactivity, exercise-induced bronchospasm and allergic symptoms was compared between school-age children living in communities that had received community-based treatments with ivermectin (for onchocerciasis control) for a period of 15-17 years with those living in geographically adjacent communities that had received no ivermectin. RESULTS: The prevalence of allergen skin test reactivity was double in children living in treated communities compared with those in untreated communities (16.7% vs. 8.7%, adjusted OR 2.10, 95% CI 1.50-2.94, P<0.0001), and the effect was mediated partly by a reduced prevalence of Trichuris trichiura among treated children. Ivermectin treatments were associated with an increased prevalence of recent eczema symptoms (adjusted OR 2.24, 95% CI 1.05-4.78, P=0.04) but not symptoms of asthma or rhino-conjunctivitis. The effect on eczema symptoms was not associated with reductions in geohelminth infections. CONCLUSION: Long-term periodic treatments with ivermectin were associated with an increased prevalence of allergen skin test reactivity. There was some evidence that treatment was associated with an increased prevalence of recent eczema symptoms but not those of asthma or rhino-conjunctivitis.

High prevalence of bacterial vaginosis in adolescent girls in a tropical area of Ecuador.

Bacterial vaginosis (BV) is a common clinical syndrome, but data are scarce on the BV prevalence in tropical regions among sexually active and virgin adolescents. To estimate the prevalence of BV among adolescent girls in an Ecuadorian coastal town, girls were asked to complete a questionnaire on risk factors for BV and vaginal samples were examined. Bacterial vaginosis was present in 31.5% of 213 girls, and the prevalence was similar in self-reported virgin and sexually active girls (OR 1.06, 95% CI, 0.51-2.21, P = 0.88), although the power of this analysis was limited. The prevalence of BV was high among Ecuadorian adolescent girls, and did not appear to be associated with sexual activity.

Interobserver and intraobserver variability in determining breast density according to the fifth edition of the BI-RADS® Atlas. / Estudio de la variabilidad inter- e intraobservador en la determinación de la densidad mamaria según la 5.a edición del Atlas BI-RADS®.

OBJECTIVE: To determine the level of agreement within and between observers in the categorization of breast density on mammograms in a group of professionals using the fifth edition of the American College of Radiology's BI-RADS® Atlas and to analyze the concordance between experts' categorization and automatic categorization by commercial software on digital mammograms. METHODS: Six radiologists categorized breast density on 451 mammograms on two occasions one month apart. We calculated the linear weighted kappa coefficients for inter- and intra-observer agreement for the group of radiologists and between the commercial software and the majority report. We analyzed the results for the four categories of breast density and for dichotomous classification as dense versus not dense. RESULTS: The interobserver agreement among radiologists and the majority report was between moderate and nearly perfect for the analysis by category (κ=0.64 to 0.84) and for the dichotomous classification (κ=0.63 to 0.84). The intraobserver agreement was between substantial and nearly perfect (κ=0.68 to 0.85 for 4 categories and k=0.70 to 0.87 for the dichotomous classification). The agreement between the majority report and the commercial software was moderate both for the four categories (κ=0.43) and for the dichotomous classification (κ=0.51). CONCLUSION: Agreement on breast density within and between radiologists using the criteria established in the fifth edition of the BI-RADS® Atlas was between moderate and nearly perfect. The level of agreement between the specialists and the commercial software was moderate.

Prevalence of hypertriglyceridemia in adults and related cardiometabolic factors. SIMETAP-HTG study. / Prevalencia de hipertrigliceridemia en adultos y factores cardiometabólicos asociados. Estudio SIMETAP-HTG.

AIM: To determine in the adult population the crude and the sex- and age-adjusted prevalence rates of hypertriglyceridaemia (HTG) and to assess its association with cardiovascular risk factors, chronic kidney disease, cardiovascular and cardiometabolic diseases. METHODS: Cross-sectional observational study conducted in Primary Care, with 6,588 adult study subjects, randomly selected on base-population. Patients had HTG if the triglyceride level was≥150mg/dL (≥1.7mmol/L), or were on lipid-lowering therapy to lower triglyceride. Associations were assessed by univariate and multivariate analysis, and crude and sex- and age-adjusted prevalence rates were determined. RESULTS: The arithmetic and geometric means of triglyceride levels were respectively 120.5 and 104.2mg/dL in global population, 135.7 and 116.0mg/dL in men, and 108.6 and 95.7mg/dL in women. The crude HTG prevalence rates were 29.6% in global population, 36.9% in men and 23.8% in women. The sex- and age-adjusted HTG prevalence rates were 27.0% in global population, 34.6% in men and 21.4% in women. The independent variables that were most associated with HTG were hypercholesterolemia (OR: 4.6), low HDL-C (OR: 4.1), hepatic steatosis (OR: 2.8), diabetes (OR: 2.0), and obesity (OR: 1.9). CONCLUSIONS: The means of triglyceride levels and HTG prevalence rates are intermediate between those of other national and international studies. A fifth of the female adult population and more than a third of the male population had HTG. The independent factors associated with HTG were hypercholesterolemia and low HDL-C, and the cardiometabolic variables diabetes, hepatic steatosis and obesity.

How well do questionnaires perform compared with physical examination in detecting flexural eczema? Findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two.

BACKGROUND: Questionnaires are widely used in epidemiological studies to measure eczema symptom prevalence, but there are concerns regarding their accuracy if used as a diagnostic tool. OBJECTIVES: To compare the performance of a validated eczema symptom questionnaire and a standardized skin examination protocol employed in the second phase of the International Study of Asthma and Allergies in Childhood (ISAAC). METHODS: A total of 30,358 schoolchildren aged 8-12 years from 18 countries were examined for flexural eczema. Parents also completed an eczema symptom questionnaire. We compared prevalence estimates at the population level based on the questionnaire vs. physical examination. We also compared the skin examination and the ISAAC questionnaire in making a diagnosis of flexural eczema. RESULTS: The point prevalences for flexural eczema at centre level based on a single examination were lower than the questionnaire-based 12-month period prevalences (mean centre prevalence 3.9% vs. 9.4%). Correlation between prevalences of both outcome measures was high (r = 0.77, P < 0.001). At the individual level, questionnaire-derived symptoms of 'persistent flexural eczema in the past 12 months' missed < 10% of cases of flexural eczema detected on physical examination. However, between 33% and 100% of questionnaire-based symptoms of 'persistent flexural eczema in the past 12 months' were not confirmed on examination. CONCLUSIONS: ISAAC questionnaire-derived symptom prevalences are sufficiently precise for comparisons between populations. Where diagnostic precision at the individual level is important, questionnaires should be validated and potentially modified in those populations beforehand, or a standardized skin examination protocol should be used.

Metastases to the breast, an uncommon diagnosis: what do radiologists need to know? / Metástasis en la mama, un diagnóstico infrecuente. ¿Qué deben saber los radiólogos?

OBJECTIVE: To analyze the imaging characteristics of histologically diagnosed metastases to the breast. MATERIAL AND METHODS: We selected patients histologically diagnosed with metastases to the breast in our diagnostic and interventional breast imaging unit between March 2010 and September 2018. RESULTS: A total of 9 patients (all women; mean age, 60 y; age range, 28-89 y) were diagnosed with metastases to the breast. In 1 (11.11%) case, the primary disease was diagnosed from the breast lesion. The primary tumors were melanoma (n=5), neuroendocrine tumor (n=2, one from the small bowel and one from the cervix), lung adenocarcinoma (n=1), and ovarian cancer (n=1). The clinical and imaging manifestations depend on the type of dissemination of disease and can simulate benign and malignant primary breast lesions. CONCLUSION: There is no specific imaging pattern for metastases to the breast that would help to orient the diagnosis. It is important to consider this etiological possibility if the patient has a history of a primary tumor in another organ.

Normoglycemic diabetic ketoacidosis in pregnancy.

The clinical presentation of diabetic ketoacidosis in pregnancy is usually the same as in nonpregnant women, although the blood glucose may not be as high as in the nongravid state. We report a case of a pregnant woman who developed diabetic ketoacidosis with a normal blood glucose and review the pertinent medical literature. A 29-year-old woman with type I diabetes developed diabetic ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100 ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l(-1). Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but can occur with relatively low, or even normal, blood sugars and necessitates prompt recognition and treatment. In this case, the combination of an initial episode of hypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml led to a prolonged delay in the initiation of a planned insulin infusion for insulin coverage during the induction of labor. A significant ketoacidosis consequently developed, despite the absence of even a single elevated blood glucose measurement. This case illustrated the importance of not withholding insulin in a patient with type I diabetes for more than a few hours even if the blood glucose is normal.

Cancer incidence in Spain, 2015.

PURPOSE: Periodic cancer incidence estimates of Spain from all existing population-based cancer registries at any given time are required. The objective of this study was to present the current situation of cancer incidence in Spain. METHODS: The Spanish Network of Cancer Registries (REDECAN) estimated the numbers of new cancer cases occurred in Spain in 2015 by applying the incidence-mortality ratios method. In the calculus, incidence data from population-based cancer registries and mortality data of all Spain were used. RESULTS: In 2015, nearly a quarter of a million new invasive cancer cases were diagnosed in Spain, almost 149,000 in men (60.0%) and 99,000 in women. Globally, the five most common cancers were those of colon-rectum, prostate, lung, breast and urinary bladder. By gender, the four most common cancers in men were those of prostate (22.4%), colon-rectum (16.6%), lung (15.1%) and urinary bladder (11.7%). In women, the most common ones were those of breast (28.0%), colon-rectum (16.9%), corpus uteri (6.2%) and lung (6.0%). In recent years, cancer incidence in men seems to have stabilized due to the fact that the decrease in tobacco-related cancers compensates for the increase in other types of cancer like those of colon and prostate. In women, despite the stabilization of breast cancer incidence, increased incidence is due, above all, to the rise of colorectal and tobacco-related cancers. CONCLUSION: To reduce these incident cancer cases, improvement of smoking control policies and extension of colorectal cancer screening should be the two priorities in cancer prevention for the next years.

Effects of poor hygiene on cytokine phenotypes in children in the tropics.

We describe immune phenotypes (innate and adaptive cytokines) according to environmental exposure using latent class analysis. A total of 310 schoolchildren living in Ecuador were assayed for spontaneous cytokine production as well as mitogen (SEB)-stimulated cytokines in whole blood cultures. We collected data on environmental exposures by questionnaire and on intestinal parasites by examination of stool samples. Latent class analysis (LCA) was used to group children according to their innate (IL-6, IL-8, IL-10 and TNF-α) and adaptive (IL-5, IL-13, IL-17, IFN-γ and IL-10) cytokine profile. We also conducted multiple-group LCA and LCA with covariates to evaluate the effect of predictors on profile membership. We identified both hyporesponsive and Th2-modified immune phenotypes produced by peripheral blood leukocytes (PBLs) that were associated with intestinal worms and birth order, providing insights into how poor hygiene mediates immunologic effects on immune-mediated diseases.

Management and coordination of postacute medical care for electrical trauma survivors.

The clinical spectrum of electrical injury ranges from the absence of any external physical signs to severe multiple trauma. Reported neuropsychiatric sequelae can vary from vague complaints, which may seem unrelated to the injury in their occurrence over time or by their apparent severity, to sequelae consistent with brain injury accompanying an electrical trauma. In this report, a case study and discussion are presented on the management and coordination of post-acute care of an electrical trauma survivor. Expertise and a multidisciplinary team are essential to cohesive patient care. Patient monitoring for progressive changes and prompt intervention are needed to address the potential difficulties experienced by trauma survivors as they rehabilitate to return to their work and their activities of daily living.

Placebo controlled treatment of Ecuadorian cutaneous leishmaniasis.

Pentavalent antimony has been considered to be the standard treatment for leishmaniasis, but more recently, the orally administrable agent allopurinol ribonucleoside has been the subject of several clinical trials. In this study, these two agents were evaluated in patients with Ecuadorian cutaneous leishmaniasis. Patients were randomly assigned to the two treatment groups. The mean reduction in lesion size for the 28 patients treated with Pentostam (20 mg Sb/kg/day intramuscularly for 20 days) was 61%, 23%, and 11% after one, two, and three weeks, respectively. There was a wide range in the individual values, and some lesions markedly enlarged in the first week of therapy. An initially healed lesion was defined as one that had greater than 80% re-epithelialized by the 1.5-month post-treatment followup. All Pentostam patients demonstrated this degree of lesion resolution (100% initial healing rate), but one patient showed evidence of relapse at the three month followup resulting in a 96% complete healing rate for the 12 month observation period. Patients in the untreated control group demonstrated a strikingly high rate of healing with 9 of 12 patients having re-epithelialized all lesions after 1.5 months observation (75% initial healing rate). The mean reduction in lesion size for the untreated patients was 56%, 29%, and 25% after one, two, and three weeks, respectively. Twenty-one patients received allopurinol ribonucleoside (1,500 mg QID) plus probenecid (500 mg QID) for 28 days. Lesions in nine of these patients were healed at the time of the 1.5 month followup (41% healing rate).(ABSTRACT TRUNCATED AT 250 WORDS)

Human cutaneous leishmaniasis in Ecuador: identification of parasites by enzyme electrophoresis.

Twenty-six strains of Leishmania were isolated from cutaneous lesions in humans in 3 different geographical areas of Ecuador. The species were identified by enzyme electrophoresis as Leishmania braziliensis, L. panamensis, L. guyanensis, L. mexicana, and L. amazonensis.

Geohelminth infections protect against severe inflammatory diarrhoea in children.

We investigated the risk of severe inflammatory diarrhoea associated with geohelminth parasites in 1746 children attending a rural hospital in Ecuador from December 2000 to July 2002. Infections with geohelminths were strongly protective against the risk of severe inflammatory diarrhoea. Our findings suggest that geohelminth infections have important protective effects against enteroinvasive infections in young children.

Relationship between bacille Calmette-Guérin vaccination, Mantoux test positivity, and geohelminth infection.

To investigate the potential protective effects of Bacille Calmette-Guerin (BCG) vaccination scar and sensitization to tuberculin against geohelminth infections, we conducted a cross-sectional study among school age children in rural communities in Pichincha Province in Ecuador where BCG vaccination is routinely given at birth. A total of 944 children aged 8-14 years were evaluated for the presence of BCG scars and sensitization to tuberculin, and underwent faecal examination for geohelminth parasites. BCG scars were present in 88.2% of children and positive Mantoux tests were observed in 19.1% of children. Geohelminth prevalence was high with 70.3% infected with any parasite, 52.1% with Ascaris lumbricoides, 52.3% with Trichuris trichiura, 7.6% with Ancylostoma duodenale, and 3.0% with Strongyloides stercoralis. In multivariate analyses, the presence of BCG vaccine scars was not significantly associated with infections with any geohelminth parasite (adjusted odds ratio [AOR] = 0.74, 95% CI 0.43-1.28, P = 0.28), but an inverse association was observed for infections with S. stercoralis that was of borderline statistical significance (AOR = 0.38, 95% CI 0.15-1.00, P = 0.05). There were no associations between sensitization to tuberculin and infection with geohelminth parasites. The data provide little support for an important protective role of neonatal BCG vaccination or current mycobacterial sensitization against geohelminth infections.

Treatment of human pulmonary paragonimiasis with triclabendazole: clinical tolerance and drug efficacy.

An open clinical trial to determine the efficacy and tolerability of postprandial doses of triclabendazole against Paragonimus mexicanus in 62 patients with pulmonary paragonimiasis from the Ecuadorian Amazon region was performed. Praziquantel was used as therapeutic control. Patients were allocated at random to the following 4 therapeutic regimens: triclabendazole, 5 mg/kg once daily for 3 d (16 patients), 10 mg/kg twice on one day (15 patients), and 10 mg/kg in a single dose (16 patients), and praziquantel, 25 mg/kg thrice daily for 3 d (15 patients). Clinical tolerance, based on the frequency and severity of adverse reactions, was superior in all 3 triclabendazole regimens to that of praziquantel. No alteration was observed in hepato-renal functions or haematological values. The clinical symptoms resolved at a comparable rate in all 4 treatment groups. A more rapid parasitological response to treatment, as determined by the reduction in the average number of parasite eggs found in sputum, was seen in patients treated with triclabendazole than with praziquantel. By day 90, 60 patients had no egg detected in their sputum; 2 patients, treated with a single dose of 10 mg/kg, had a few and were re-treated with triclabendazole (5 mg daily for 3 d). On day 365, none of the patients had eggs in their sputum. Triclabendazole can be recommended as an alternative drug of choice for the treatment of pulmonary paragonimiasis; it is as effective as praziquantel in clearing infections and better tolerated.