B-type natriuretic peptide over N-terminal pro-brain natriuretic peptide to predict incident atrial fibrillation after cryptogenic stroke.

BACKGROUND AND PURPOSE: B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are well-known surrogates of atrial fibrillation (AF) detection but studies usually present data on either BNP or NT-proBNP. The aim was to determine and directly compare the validity of the two biomarkers as a tool to predict AF and guide prolonged cardiac monitoring in cryptogenic stroke patients. METHODS: Non-lacunar acute ischaemic stroke (<72 h) patients over 55 years of age with cryptogenic stroke after standard evaluation were included in the Crypto-AF study and blood was collected. BNP and NT-proBNP levels were determined by automated immunoassays. AF was assessed by 28 days' monitoring. Highest (optimizing specificity) and lowest (optimizing sensitivity) quartiles were used as biomarker cut-offs to build predictive models adjusted by sex and age. The integrated discrimination improvement index (IDI) and DeLong test were used to compare the performance of the two biomarkers. RESULTS: From 320 patients evaluated, 218 were included in the analysis. AF was detected in 50 patients (22.9%). NT-proBNP (P < 0.001) and BNP (P < 0.001) levels were higher in subjects with AF and their levels correlated (r = 0.495, P < 0.001). BNP showed an increased area under the curve (0.720 vs. 0.669; P = 0.0218) and a better predictive capacity (IDI = 3.63%, 95% confidence interval 1.36%-5.91%) compared to NT-proBNP. BNP performed better than NT-proBNP in a specific model (IDI = 3.7%, 95% confidence interval 0.87%-6.5%), whilst both biomarkers performed similarly in the case of a sensitive model. CONCLUSIONS: Both BNP and NT-proBNP were increased in cryptogenic stroke patients with AF detection. Interestingly, BNP outperforms NT-proBNP, especially in terms of specificity.

Selective Pressure by Rifampicin Modulates Mutation Rates and Evolutionary Trajectories of Mycobacterial Genomes.

Resistance to the frontline antibiotic rifampicin constitutes a challenge to the treatment and control of tuberculosis. Here, we analyzed the mutational landscape of Mycobacterium smegmatis during long-term evolution with increasing concentrations of rifampicin, using a mutation accumulation assay combined with whole-genome sequencing. Antibiotic treatment enhanced the acquisition of mutations, doubling the genome-wide mutation rate of the wild-type cells. While antibiotic exposure led to extinction of almost all wild-type lines, the hypermutable phenotype of the ΔnucS mutant strain (noncanonical mismatch repair deficient) provided an efficient response to the antibiotic, leading to high rates of survival. This adaptative advantage resulted in the emergence of higher levels of rifampicin resistance, an accelerated acquisition of drug resistance mutations in rpoB (ß RNA polymerase), and a wider diversity of evolutionary pathways that led to drug resistance. Finally, this approach revealed a subset of adaptive genes under positive selection with rifampicin that could be associated with the development of antibiotic resistance. IMPORTANCE Rifampicin is the most important first-line antibiotic against mycobacterial infections, including tuberculosis, one of the top causes of death worldwide. Acquisition of rifampicin resistance constitutes a major global public health problem that makes the control of the disease challenging. Here, we performed an experimental evolution assay under antibiotic selection to analyze the response and adaptation of mycobacteria, leading to the acquisition of rifampicin resistance. This approach explored the total number of mutations that arose in the mycobacterial genomes under long-term rifampicin exposure, using whole-genome sequencing. Our results revealed the effect of rifampicin at a genomic level, identifying different mechanisms and multiple pathways leading to rifampicin resistance in mycobacteria. Moreover, this study detected that an increase in the rate of mutations led to enhanced levels of drug resistance and survival. In summary, all of these results could be useful to understand and prevent the emergence of drug-resistant isolates in mycobacterial infections.

Whole-genome sequencing for TB source investigations: principles of ethical precision public health.

BACKGROUND: Whole-genome sequencing (WGS) of Mycobacterium tuberculosis allows rapid, accurate inferences about the sources, location and timing of transmission. However, in an era of heightened concern for personal privacy and science distrust, such inferences could result in unintended harm and undermine the public´s trust.METHODS: We held interdisciplinary stakeholder discussions and performed ethical analyses of real-world illustrative cases to identify principles that optimise benefit and mitigate harm of M. tuberculosis WGS-driven TB source investigations.RESULTS: The speed and precision with which real-time WGS can be used to associate M. tuberculosis strains with sensitive information has raised important concerns. While detailed understanding of transmission events could mitigate harm to vulnerable patients and communities when otherwise unfairly blamed for TB outbreaks, the precision of WGS can also identify transmission events resulting in social blame, fear, discrimination, individual or location stigma, and the use of defaming language by the public, politicians and scientists. Public health programmes should balance the need to safeguard privacy with public health goals, transparency and individual rights, including the right to know who infects whom or where.CONCLUSIONS: Ethical challenges raised by real-time WGS-driven TB source investigation requires public health authorities to move beyond their current legal mandate and embrace transparency, privacy and community engagement.

Specificity and mutagenesis bias of the mycobacterial alternative mismatch repair analyzed by mutation accumulation studies.

The postreplicative mismatch repair (MMR) is an almost ubiquitous DNA repair essential for maintaining genome stability. It has been suggested that Mycobacteria have an alternative MMR in which NucS, an endonuclease with no structural homology to the canonical MMR proteins (MutS/MutL), is the key factor. Here, we analyze the spontaneous mutations accumulated in a neutral manner over thousands of generations by Mycobacterium smegmatis and its MMR-deficient derivative (ΔnucS). The base pair substitution rates per genome per generation are 0.004 and 0.165 for wild type and ΔnucS, respectively. By comparing the activity of different bacterial MMR pathways, we demonstrate that both MutS/L- and NucS-based systems display similar specificity and mutagenesis bias, revealing a functional evolutionary convergence. However, NucS is not able to repair indels in vivo. Our results provide an unparalleled view of how this mycobacterial system works in vivo to maintain genome stability and how it may affect Mycobacterium evolution.

Genomic determinants of speciation and spread of the Mycobacterium tuberculosis complex.

Models on how bacterial lineages differentiate increase our understanding of early bacterial speciation events and the genetic loci involved. Here, we analyze the population genomics events leading to the emergence of the tuberculosis pathogen. The emergence is characterized by a combination of recombination events involving core pathogenesis functions and purifying selection on early diverging loci. We identify the phoR gene, the sensor kinase of a two-component system involved in virulence, as a key functional player subject to pervasive positive selection after the divergence of the Mycobacterium tuberculosis complex from its ancestor. Previous evidence showed that phoR mutations played a central role in the adaptation of the pathogen to different host species. Now, we show that phoR mutations have been under selection during the early spread of human tuberculosis, during later expansions, and in ongoing transmission events. Our results show that linking pathogen evolution across evolutionary and epidemiological time scales points to past and present virulence determinants.

A systematic review of methods for quantifying serum testosterone in patients with prostate cancer who underwent castration. / Métodos para cuantificar la testosterona sérica en pacientes con cáncer de próstata sometidos a castración: una revisión sistemática.

BACKGROUND: The clinical practice guidelines recommend measuring serum testosterone in patients with prostate cancer (PC) who undergo castration. The serum testosterone concentration should be <50ng/dL, a level established by using a radioimmunoassay method. The use of chemiluminescent immunoassays (IA) has become widespread, although their metrological characteristics do not seem appropriate for quantifying low testosterone concentrations. The objective of this review is to analyse the methods for quantifying testosterone and to establish whether there is scientific evidence that justifies measuring it in patients with PC who undergo castration, through liquid chromatography attached to a mass spectrometry in tandem (LC-MSMS). MATERIAL AND METHODS: We performed a search in PubMed with the following MeSH terms: measurement, testosterone, androgen suppression and prostate cancer. We selected 12 studies that compared the metrological characteristics of various methods for quantifying serum testosterone compared with MS detection methods. RESULTS: IAs are standard tools for measuring testosterone levels; however, there is evidence that IAs lack accuracy and precision for quantifying low concentrations. Most chemiluminescent IAs overestimate their concentration, especially below 100ng/dL. The procedures that use LC-MSMS have an adequate lower quantification limit and proper accuracy and precision. We found no specific evidence in patients with PC who underwent castration. CONCLUSIONS: LC-MSMS is the appropriate method for quantifying low serum testosterone concentrations. We need to define the level of castration with this method and the optimal level related to better progression of the disease.

A novel strategy based on genomics and specific PCR reveals how a multidrug-resistant Mycobacterium tuberculosis strain became prevalent in Equatorial Guinea 15 years after its emergence.

OBJECTIVE: Molecular epidemiology techniques in tuberculosis (TB) can identify high-risk strains that are actively transmitted. We aimed to implement a novel strategy to optimize the identification and control of multidrug-resistant (MDR) TB in a specific population. METHODS: We developed a strain-specific PCR tailored from whole genome sequencing (WGS) data to track a specific MDR prevalent strain in Equatorial Guinea (EG-MDR). RESULTS: The PCR was applied prospectively on remnants of GeneXpert reaction mixtures owing to the lack of culture facilities in Equatorial Guinea. In 147 (93%) of 158 cases, we were able to differentiate between infection by the EG-MDR strain or by any other strain and found that 44% of all rifampicin-resistant TB cases were infected by EG-MDR. We also analysed 93 isolates obtained from Equatorial Guinea 15 years ago, before MDR-TB had become the problem it is today. We found that two of the scarce historical MDR cases were infected by EG-MDR. WGS revealed low variability-six single nucleotide polymorphisms acquired by this strain over 15 years-likely because of the lack in the country of a specific program to treat MDR-TB. CONCLUSIONS: Our novel strategy, which integrated WGS analysis and strain-specific PCRs, represents a low-cost, rapid and transferable strategy that allowed a prospective efficient survey and fast historical analysis of MDR-TB in a population.

Fast and low-cost decentralized surveillance of transmission of tuberculosis based on strain-specific PCRs tailored from whole genome sequencing data: a pilot study.

Molecular epidemiology has transformed our knowledge of how tuberculosis (TB) is transmitted. Whole genome sequencing (WGS) has reached unprecedented levels of accuracy. However, it has increased technical requirements and costs, and analysis of data delays results. Our objective was to find a way to reconcile speed and ease of implementation with the high resolution of WGS. The targeted regional allele-specific oligonucleotide PCR (TRAP) assay presented here is based on allele-specific PCR targeting strain-specific single nucleotide polymorphisms, identified from WGS, and makes it possible to track actively transmitted Mycobacterium tuberculosis strains. A TRAP assay was optimized to track the most actively transmitted strains in a population in Almería, Southeast Spain, with high rates of TB. TRAP was transferred to the local laboratory where transmission was occurring. It performed well from cultured isolates and directly from sputa, enabling new secondary cases of infection from the actively transmitted strains to be detected. TRAP constitutes a fast, simple and low-cost tool that could modify surveillance of TB transmission. This pilot study could help to define a new model to survey TB transmission based on a decentralized multinodal network of local laboratories applying fast and low-cost TRAPs, which are developed by central reference centres, tailored to the specific demands of transmission at each local node.

[Noninvasive diagnosis of Takayasu's arteritis]. / Diagnóstico de la arteritis de Takayasu mediante técnicas no invasivas.

OBJECTIVES: Takayasu arteritis is a chronic inflammatory obliterative disease of the great vessels that mainly affects the aorta and its primary branches. In its early phase, the clinical presentation and laboratory tests are nonspecific, so accurate diagnosis frequently depends on imaging studies. The aim of this study was to review the main features of Takayasu's arteritis and the usefulness of different noninvasive imaging techniques in the early diagnosis and follow-up of this entity. MATERIAL AND METHODS: We included 12 patients diagnosed with Takayasu's arteritis at our center. We retrospectively reviewed the different imaging studies (color Doppler US, multislice CT, and magnetic resonance) employed in each case. RESULTS: The abdominal aorta and its main branches (renal arteries, superior mesenteric artery, and celiac trunk) were involved in 8 of the 12 patients studied. This involvement was detected as increased velocities in Doppler US that were suggestive of stenosis and was later confirmed on CT angiography and MR angiography. In four patients, CT angiography and MRI angiography demonstrated diffuse and homogeneous vessel wall thickening; in two patients, these techniques also showed enhancement of the thickened walls after contrast administration that suggested active inflammatory disease. Another frequent finding was supra-aortic trunk involvement, which was seen in six cases. CONCLUSION: Noninvasive imaging techniques are fundamental in the early diagnosis of patients with Takayasu's arteritis. CT angiography and MR angiography provide additional information about the inflammatory activity of the disease.

Métodos para cuantificar la testosterona sérica en pacientes con cáncer de próstata sometidos a castración: una revisión sistemática / A systematic review of methods for quantifying serum testosterone in patients with prostate cancer who underwent castration

Introducción: Las guías de práctica clínica recomiendan determinar la testosterona sérica en pacientes con cáncer de próstata (CP) sometidos a castración. Su concentración debe ser inferior a 50 ng/dL, nivel establecido utilizando un método de radioinmunoanálisis. Actualmente el uso de inmunoanálisis (IA) quimioluminiscentes se ha generalizado, aunque sus características metrológicas no parecen adecuadas para cuantificar concentraciones bajas de testosterona. El objetivo de esta revisión es analizar los métodos de cuantificación de testosterona y establecer si existe evidencia científica que justifique determinarla, en pacientes con CP sometidos a castración, mediante cromatografía líquida acoplada a espectrometría de masas en tándem (LC-MSMS). Material y métodos: Se ha realizado una revisión en PubMed con los términos MeSH: measurement, testosterone, androgen suppression y prostate cancer. Se seleccionaron 12 estudios que comparaban las características metrológicas de diversos métodos para cuantificar testosterona sérica respecto a métodos de detección con MS. Resultados: Los IA son una herramienta común para la medición de la concentración de testosterona; sin embargo, existe evidencia de que carecen de exactitud y precisión para cuantificar concentraciones bajas. La mayoría de los IA quimioluminiscentes sobrestiman su concentración, especialmente por debajo de 100ng/dL. Los procedimientos que utilizan LC-MSMS poseen un límite inferior de cuantificación adecuado y una correcta exactitud y precisión. No hemos encontrado evidencia específica en pacientes con CP sometidos a castración. Conclusiones: La LC-MSMS es el método adecuado para cuantificar concentraciones bajas de testosterona sérica. Es necesario definir el nivel de castración con este método y el nivel óptimo que se relaciona con la mejor evolución de la enfermeda

Background: The clinical practice guidelines recommend measuring serum testosterone in patients with prostate cancer (PC) who undergo castration. The serum testosterone concentration should be < 50 ng/dL, a level established by using a radioimmunoassay method. The use of chemiluminescent immunoassays (IA) has become widespread, although their metrological characteristics do not seem appropriate for quantifying low testosterone concentrations. The objective of this review is to analyse the methods for quantifying testosterone and to establish whether there is scientific evidence that justifies measuring it in patients with PC who undergo castration, through liquid chromatography attached to a mass spectrometry in tandem (LC-MSMS). Material and methods: We performed a search in PubMed with the following MeSH terms: measurement, testosterone, androgen suppression and prostate cancer. We selected 12 studies that compared the metrological characteristics of various methods for quantifying serum testosterone compared with MS detection methods. Results: IAs are standard tools for measuring testosterone levels; however, there is evidence that IAs lack accuracy and precision for quantifying low concentrations. Most chemiluminescent IAs overestimate their concentration, especially below 100ng/dL. The procedures that use LC-MSMS have an adequate lower quantification limit and proper accuracy and precision. We found no specific evidence in patients with PC who underwent castration. Conclusions: LC-MSMS is the appropriate method for quantifying low serum testosterone concentrations. We need to define the level of castration with this method and the optimal level related to better progression of the disease

Secuestro broncopulmonar intralobar del lóbulo inferior derecho: reporte de tres casos / Intralobar broncopulmonary sequestration of the right lower lobe: report of three cases

Presentamos una serie de tres pacientes con secuestros pulmonares intralobares del lóbulo inferior derecho, correlacionándolos con la clínica, los hallazgos histológicos de los pacientes sometidos a cirugía y los hallazgos radiológicos en pacientes tratados mediante embolización, una alternativa actual en el tratamiento de esta entidad (AU)

A series of three patients is presented with intralobar pulmonary sequestration of the right lower lobe, correlating with the clinical and histological findings of patients undergoing surgery and the radiological findings in patients treated by arterial embolization, the current alternative in the treatment of this problem (AU)

Diagnóstico de la arteritis de Takayasu mediante técnicas no invasivas / Noninvasive diagnosis of Takayasu´s arteritis

Objetivos: La arteritis de Takayasu es una enfermedad crónica, inflamatoria y obliterativa de los grandes vasos, con predilección por la aorta y sus ramas principales. La frecuente inespecificidad clínica y analítica hace que el diagnóstico final dependa, en gran medida, de los estudios de imagen. Este trabajo pretende revisar las manifestaciones de esta enfermedad, así como la utilidad de las distintas pruebas de imagen no invasivas en el diagnóstico y seguimiento de estos pacientes. Material y métodos: Se incluyen 12 pacientes diagnosticados de arteritis de Takayasu en nuestro centro, y se revisan retrospectivamente los distintos estudios de imagen realizados: ecografía Doppler color, tomografía computarizada (TC) multicorte y resonancia magnética (RM).Resultados: En 8 de los 12 pacientes revisados se detectó como alteración fundamental la afectación de la aorta abdominal y sus ramas principales (arterias renales, arteria mesentérica superior y tronco celíaco). Dicha afectación se detectó como un aumento de las velocidades en el estudio Doppler-color sugestivo de estenosis, que se confirmó con angio-TC y angio-RM. En 4 casos la angio-TC y la angio-RM mostraron engrosamiento difuso y homogéneo de la pared, en 2 de ellos se apreció captación de contraste, como signo sugestivo de inflamación activa. Otra manifestación frecuente fue la afectación de troncos supraaórticos, que se objetivó en 6 pacientes. Conclusión: Las técnicas de imagen no invasivas son fundamentales en el diagnóstico inicial de los pacientes con enfermedad de Takayasu. La angiografía por TC y RM aporta datos adicionales al ser una herramienta útil para valorar la actividad inflamatoria del proceso (AU)

Objectives: Takayasu arteritis is a chronic inflammatory obliterative disease of the great vessels that mainly affects the aorta and its primary branches. In its early phase, the clinical presentation and laboratory tests are nonspecific, so accurate diagnosis frequently depends on imaging studies. The aim of this study was to review the main features of Takayasu's arteritis and the usefulness of different noninvasive imaging techniques in the early diagnosis and follow-up of this entity. Material and methods: We included 12 patients diagnosed with Takayasu's arteritis at our center. We retrospectively reviewed the different imaging studies (color Doppler US, multislice CT, and magnetic resonance) employed in each case. Results: The abdominal aorta and its main branches (renal arteries, superior mesenteric artery, and celiac trunk) were involved in 8 of the 12 patients studied. This involvement was detected as increased velocities in Doppler US that were suggestive of stenosis and was later confirmed on CT angiography and MR angiography. In four patients, CT angiography and MRI angiography demonstrated diffuse and homogeneous vessel wall thickening; in two patients, these techniques also showed enhancement of the thickened walls after contrast administration that suggested active inflammatory disease. Another frequent finding was supra-aortic trunk involvement, which was seen in six cases. Conclusion: Noninvasive imaging techniques are fundamental in the early diagnosis of patients with Takayasu's arteritis. CT angiography and MR angiography provide additional information about the inflammatory activity of the disease (AU)

Intervención en el estreñimiento en Atención Primaria de Salud / Treatment of constipation in Primary Health Care

Objetivo: determinar si una intervención de educación sanitaria(centrada en el ejercicio, la dieta, uso de laxantes, hábitos defecatorios,etc.) disminuiría la prevalencia de estreñimiento crónico primario,así como su intensidad.Material y método: estudio de intervención tipo antes-despuéssobre individuos adultos del ABS Río de Janeiro 8B que padecíanestreñimiento crónico primario. Se eligieron 20 individuos a travésde un muestreo consecutivo.La variable independiente era la intervención educativa y como variablesdependientes se encontraban tanto las manifestaciones dedependencia del estreñimiento como sus factores relacionados.Además se estudiaron las variables edad y sexo. Como fuente dedatos se utilizó la encuesta directa y la Historia Clínica de AtenciónPrimaria. Se computaron índices de estadística descriptiva (media,porcentajes, etc.) a través de la aplicación informática SPSS.Resultados: el 80% de los individuos con estreñimiento eran mujeres,la media de edad era de 57 años. Todos los individuos despuésde la intervención consiguieron evacuar cada día o cada dosdías sin esfuerzo. La consistencia y el sangrado son otras de lasmanifestaciones de dependencia que mejoraron más, aunque elresto (dolor, distensión, flatulencias y ruidos intestinales) tambiénmejoraron. La media de fibra consumida al día se incrementó en10 gramos y la ingesta de agua en 6 vasos. Todos realizaron ejerciciofísico moderado. El 46,6% empezó a adoptar una postura adecuadaen el wc, el 80% estableció un horario, pero un 20% continuabademorando la hora de defecar.Conclusiones: los resultados permiten demostrar la eficacia de laeducación sanitaria en la disminución de la prevalencia del estreñimento.Después de la intervención todos los individuos comunicaronmejoría en todas las manifestaciones de dependencia (fundamentalmenteen el ritmo deposicional, en el dolor al defecar y enel esfuerzo al defecar) y en los factores relacionados con el estreñimiento(especialmente en el aumento en de fibra y agua, la intensidaddel ejercicio, la adopción de postura correcta y en el establecimientode un horariolo para defecar)

Objectives: to determine whether a health education intervention(based on exercise, dieting, the use of laxatives, bowel movementshabits, etc.) would decrease the prevalence and intensity of primarychronic constipation.Material and methods: before and after interventional study onadult individuals in the Río de Janeiro 8B health care district withprimary chronic constipation. Twenty individuals were selectedthrough consecutive sampling.The independent variable was an educational intervention and thedependent variables were the dependence manifestations of constipationas well as other related factors. Other variables such asage and gender were also studied. A direct survey and the medicalhistory were used as data sources for the retrieval of information.Descriptive statistics indexes were computed (mean value, percentages,etc.) using the SPSS software.Results: 80% of the individuals with constipation were women,mean age was 57 years. All the individuals were able to have abowel movement each day or every other day without much effortafter the intervention. The consistency and bleeding were otherdependence manifestations that improved the most, even thoughthe rest (pain, distension, flatulence and intestinal sounds) improvedalso. The mean amount of fibre consumed per day increasedby 10 grams while the water intake increased by 6 glasses.All subjects performed moderate exercise. 56,6% started to adoptproper body positioning in the WC, 80% established a schedule,but 20% continued to delay the defecation time.Conclusions: the results demonstrate that health education hasbeen proven to be effective to decrease the prevalence of constipation.After the intervention, all the subjects reported improvementin all the dependence manifestations (basically in the rhythmto defecate, the pain to defecate, and the effort to defecate) andimprovement in the constipation-related factors (especially in increasedintake of fibre and water, the intensity of exercise, theadoption of the right posture and the establishment of certainhours to have the bowel movements)