Archaeogenomic distinctiveness of the Isthmo-Colombian area.

The recently enriched genomic history of Indigenous groups in the Americas is still meager concerning continental Central America. Here, we report ten pre-Hispanic (plus two early colonial) genomes and 84 genome-wide profiles from seven groups presently living in Panama. Our analyses reveal that pre-Hispanic demographic events contributed to the extensive genetic structure currently seen in the area, which is also characterized by a distinctive Isthmo-Colombian Indigenous component. This component drives these populations on a specific variability axis and derives from the local admixture of different ancestries of northern North American origin(s). Two of these ancestries were differentially associated to Pleistocene Indigenous groups that also moved into South America, leaving heterogenous genetic footprints. An additional Pleistocene ancestry was brought by a still unsampled population of the Isthmus (UPopI) that remained restricted to the Isthmian area, expanded locally during the early Holocene, and left genomic traces up to the present day.

Suicide trends and self-harm in Panama: results from the National Mortality Registry and hospital-based data.

PURPOSE: We aimed to (1) to investigate mortality trends due to suicide in Panama at the national and regional levels from 2001 to 2016, (2) to describe the sociodemographic and clinical characteristics of admitted patients with non-fatal self-harm from 2009 to 2017 in a regional hospital, and (3) to examine the association between mental health diagnoses and intentional self-harm, lethality, self-harm repetition and all-cause mortality within this population. METHODS: Using the national mortality registry, annual percentage changes (APC) with 95% confidence intervals (CI) were estimated to evaluate suicide trends over time. Self-harm cases were assessed by trained psychiatrists at a referral hospital through interviews. Logistic regression models were used to estimate the association between mental diagnosis with intent-to-die and lethality, expressed as odds ratios (OR) and 95% CI. Cox proportional hazards models were used to calculate hazard ratios (HR) with 95% CI for self-harm repetition and all-cause mortality. RESULTS: The trend of suicide in women declined, with an APC of - 4.8, 95% CI - 7.8, - 1.7, while the trend began to decline from 2006 in men; APC - 6.9, 95% CI - 8.9, - 4.9. Self-harm repetition over 12 months was 1.8%. Having a mental health diagnosis was associated with intentional self-harm (OR 1.5; 95% CI 1.0-2.4) and self-harm repetition (HR 2.7, 95% CI 1.3-5.8). Medication overdose was the preferred method for self-harm, while intentional self-harm by hanging was the preferred method for suicide. CONCLUSIONS: Strategies for prevention and early intervention after self-harm deserve attention. Our findings highlight the importance of data to inform action.

Analysis of the human Y-chromosome haplogroup Q characterizes ancient population movements in Eurasia and the Americas.

BACKGROUND: Recent genome studies of modern and ancient samples have proposed that Native Americans derive from a subset of the Eurasian gene pool carried to America by an ancestral Beringian population, from which two well-differentiated components originated and subsequently mixed in different proportion during their spread in the Americas. To assess the timing, places of origin and extent of admixture between these components, we performed an analysis of the Y-chromosome haplogroup Q, which is the only Pan-American haplogroup and accounts for virtually all Native American Y chromosomes in Mesoamerica and South America. RESULTS: Our analyses of 1.5 Mb of 152 Y chromosomes, 34 re-sequenced in this work, support a "coastal and inland routes scenario" for the first entrance of modern humans in North America. We show a major phase of male population growth in the Americas after 15 thousand years ago (kya), followed by a period of constant population size from 8 to 3 kya, after which a secondary sign of growth was registered. The estimated dates of the first expansion in Mesoamerica and the Isthmo-Colombian Area, mainly revealed by haplogroup Q-Z780, suggest an entrance in South America prior to 15 kya. During the global constant population size phase, local South American hints of growth were registered by different Q-M848 sub-clades. These expansion events, which started during the Holocene with the improvement of climatic conditions, can be ascribed to multiple cultural changes rather than a steady population growth and a single cohesive culture diffusion as it occurred in Europe. CONCLUSIONS: We established and dated a detailed haplogroup Q phylogeny that provides new insights into the geographic distribution of its Eurasian and American branches in modern and ancient samples.

Development of anthracycline-induced dilated cardiomyopathy due to mutation on LMNA gene in a breast cancer patient: a case report.

BACKGROUND: Anthracyclines are highly effective anticancer medication prescribed for the treatment of breast cancer. Nevertheless, the use of anthracyclines as chemotherapeutic agents involves a risk for development of cardiac toxicity which may cause restrictive and dilated cardiomyopathy. Currently, genetic predisposition is not considered as a risk factor for cardiotoxicity associated to the use of anthracyclines. CASE PRESENTATION: We report the case of a 37-years old Panamanian female patient diagnosed with breast cancer who developed clinical signs of severe heart failure after treatment with doxorubicin. A diagnosis of anthracycline induced cardiomyopathy was made and treatment was initiated accordingly. A whole exome sequencing study performed to the patient showed the presence of a missense mutation in LMNA gene, which codifies for lamin A/C. Our results points to a correlation between the LMNA variant and the anthracycline cardiotoxicity developed by the woman. Improvement of the clinical symptoms and the left ventricle ejection fraction was observed after proper treatment. CONCLUSIONS: This case report suggests for the first time a potential genetic predisposition for anthracyclines induced cardiomyopathy in patients with mutations in LMNA gene. Perhaps chemotherapies accelerate or deliver the "second-hit" in the development of DCM in patients with genetic mutations. More data is needed to understand the contribution of LMNA variants that predispose to DCM in patients receiving cardiotoxic therapies.

Social determinants and cardiovascular disease mortality in Panama, 2012-2016.

BACKGROUND: The aims of this study were to determine the geographic and time variation of social determinants of health (SDH) and cardiovascular disease (CVD) mortality in Panama from 2012 to 2016, and to identify which of the SDH has the strongest correlation with a socioeconomic index (SEI). METHODS: We conducted an ecological study obtaining mortality from the National Mortality Register and socioeconomic variables derived from the National Household Survey (NHS). The International Classification of Diseases 10th revision codes I20-I25 and I60-I69 were used for ischemic heart disease (IHD) and stroke, respectively. Standardized age-adjusted mortality rates were calculated by direct method. Mortality rates and socioeconomic variables were evaluated together in a panel data model. A SEI was developed from factorial analysis by principal components with a polychoric correlation matrix. Provinces and regions were categorized in tertiles according to median value of the SEI score. RESULTS: The NHS evaluated an average of 15,919 households per year. The mean of age throughout the study period was 41 years. The average monthly income increased, from US$ (SD) 331.94 (5.38) in 2012, to 406.24 (5.81) in 2016, whereas the social security health coverage remained in a range of 57-58%. The mean number of school years was twelve. Significant geographical and temporal variations in social determinants and mortality rates were observed throughout the country. Colon, categorized in the middle tertile according to the SEI, presented higher IHD mortality rates. Darién (in the lowest SEI tertile) Colón and Herrera had higher stroke mortality rates. The SEI categorized indigenous territories in the lowest tertile. Total years of education was the strongest correlated variable with the SEI, when we excluded the population living in indigenous territories. However, when this population was included, social security coverage had the strongest correlation with the SEI. CONCLUSION: We observed geographical and temporal disparities in SDH and CVD mortality rates. Further epidemiological studies are warranted in the provinces of Colón, Darien, Herrera and Los Santos to explore in-depth the higher CVD mortality rates observed in these provinces.

Prevalence of obesity in panama: some risk factors and associated diseases.

BACKGROUND: To estimate the prevalence of obesity in Panama and determine some risk factors and associated diseases in adults aged 18 years and older. METHODS: A cross-sectional descriptive study was conducted in the provinces of Panama and Colon where 60.4 % of all Panamanians 18 years or older reside, by administering a survey regarding the consumption of protective and predisposing foods and assessing the development of obesity by measuring the weight, height, and waist circumference of 3590 people. A single-stage, probabilistic, and randomized sampling strategy employing multivariate stratification was used. Individuals with a body mass index ≥ 30 kg/m(2) (men and women) were considered obese. Prevalence and descriptive analysis were conducted according to sex using Odds Ratio, with statistical significance set at a p value ≤ 0.05. RESULTS: The general prevalence of obesity was 27.1 % (30.9 % women and 18.3 % men). In women, obesity was associated with living in urban areas, being 40-59 years of age, being Afro-Panamanian, consuming beverages / foods rich in sugar, being physically inactive and having a family history of obesity. In men, obesity was associated with living in urban areas, consuming beverages/foods rich in sugar, and having a family history of obesity. Almost the totality of obese women (97.9 %), and 80.0 % of men with obesity had abdominal obesity according to the WHO classification. In both sexes, obesity was a risk factor associated to type 2 Diabetes Mellitus, hypertension, LDL values ≥ 100 mg/dL, and low HDL values (<50 mg/dL for women and < 40 mg/dL for men), Odds Ratio > 1.0; P < 0.05. CONCLUSIONS: Obesity represents a very serious threat to Panamanian public health. Our study confirms a direct association in Panama between excess weight, hypertension, type 2 Diabetes Mellitus, LDL values ≥ 100 mg/dL and low HDL values for women and men (<50 mg/dL and < 40 mg/dL, respectively). Intervention / treatment programs should be targeted, specially, to Afro-Panamanian women, whom are 40-59 years old, living in urban areas, and those having a family history of obesity.

[Indications for liver transplant]. / Indicaciones de trasplante hepático.

Liver transplantation (LT) is the treatment of choice in selected patients with end-stage liver disease and in some with acute liver failure, hepatocellular carcinoma (HCC) and other diseases with no synthetic liver failure. Currently, LT has an overall survival > 90 % at 1 year. Proper selection of LT candidates is important given the shortage in organ donation. The allocation and priorization of organs to patients with chronic liver failure (CLF) in waiting lists, is determined by the MELD priority score (Model of End Stage Liver Disease). Indications for LT in patients with CLF are the same regardless of the etiology (any type of hepatic decompensation or development of HCC). Priority MELD is a variant to this classification used only in special cases such as in those with stable hepatopathy but severe extra-hepatic features (e.g., HCC or hepato-pulmonary syndrome). The indication for LT in patients with acute liver failure (ALF) and acute failure associated to chronic liver failure (ACLF) are not fully established; there are prognostic factors that may guide the decision for urgent LT and some centers, like the King's College Hospital criteria in the UK. Currently, LT is a therapeutic modality in some primary liver tumors (HCC, cholangiocarcinoma) and neuroendocrine liver metastatic tumors. These protocols have provided significant opportunities for long-term survival (> 70% at 5 years). The high demand and shortage of organs have fostered the development of new strategies to benefit more patients, such as the use of extended criteria donors, or "domino" transplants. This review focuses on the most relevant data on the different indications of LT.

Diabetes mortality in Panama and related biological and socioeconomic risk factors.

OBJECTIVE: To estimate mortality from diabetes mellitus (DM) for the period 2001-2011 in the Republic of Panama, by province/indigenous territory, and determine its relationship with biological and socioeconomic risk factors. METHODS: Cases for the years 2001-2011 with DM listed as the principal cause of death were selected from Panama's National Mortality Registry. Crude and adjusted mortality rates were generated by sex, age, and geographic area. Linear regression analyses were performed to determine the relationship between DM mortality and biological and socioeconomic risk factors. A composite health index (CHI) calculated from biological and socioeconomic risk factors was estimated for each province/indigenous territory in Panama. RESULTS: DM mortality rates did not increase for men or women during 2001-2011. Of the biological risk factors, being overweight had the strongest association with DM mortality. Of the socioeconomic risk factors, earning less than US$ 100 per month had the strongest association with DM mortality. The highest socioeconomic CHI scores were found in a province that is predominantly rural and in areas with indigenous populations. The highest biological CHI scores were found in urban-rural provinces and those with the highest percentage of elderly people. CONCLUSIONS: Regional disparities in the association between DM mortality and DM risk factors reaffirm the heterogeneous composition of the Panamanian population and the uneven distribution of biological and social determinant risk factors in the country and point to the need to vary management strategies by geographic area for this important cause of disability and death in Panama.

Diabetes mellitus, its prevalence, awareness, and control in Panama: Data from ENSPA 2019, a national cross-sectional study.

Diabetes mellitus (DM) represents an important global burden of disease. In Panama, DM was investigated in 1 study utilizing questionnaires and in another using biomarkers, but at subnational level. Using data from a recent cross-sectional country-wide population-based study that included biomarkers, we estimated the prevalence of DM, its awareness, and control; evaluating possible risk factors. We used data from 4400 participants aged 18 years or older from the National Health Study of Panama (ENSPA) study conducted in 2019 at a national level. Weighted prevalence and 95% confidence intervals for DM, awareness, and control were estimated by sociodemographic factors, family history of DM, tobacco and alcohol use, nutritional status, and hypertension. Odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression models to assess the possible risk factors associated with DM prevalence and awareness. We generated OR estimates by pooling ENSPA data with a previous regional study, prevalence of cardiovascular risk factors. The prevalence of DM was estimated to be 12.4% (10.9%-14.05%). In both men and women, age, family history of diabetes (OR in men: 4.0 ([2.4-6.7]; OR in women 3.5 [2.5-4.8]), and obesity (OR in men: 2.6 [1.4-5.1]; OR in women: 2.0 [0.9-4.5]) were associated with DM. Diagnosed and controlled hypertension was associated with DM only in women (OR: 2.1 [1.2-3.6]). DM awareness was estimated to be 62.6% (56.3%-68.9%). In both men and women, DM awareness was associated with age and a family history of diabetes (OR in men: 6.6 [2.4-18.4]; OR in women 1.9 ([1.1-3.6]). In women, having secondary education (OR: 1.9 [0.9-3.9]) and being diagnosed with uncontrolled hypertension (OR: 3.3 [1.2-9.5]) was also associated to DM awareness. Men in the ENSPA study were less likely to be aware of DM than those in the prevalence of cardiovascular risk factors (OR: 0.2 [0.0-0.7]). Less than half of the individuals diagnosed with DM had their condition controlled (39.6% [31.4%-47.8%]). This study revealed that the prevalence, awareness, and control of DM were similar to recent estimates reported in other Latin American countries. It also provides a baseline regarding DM and associated risk factors in Panama at a country-level knowledge that is essential for health policy development and useful in clinical practice.

Description of the National Mortality Register of Panama.

Introduction: The National Mortality Register (NMR) of Panama is a key element in demographic analysis and in acquiring an updated picture of population health in Panama. The main objectives of this study are to characterize the NMR and to enumerate its strengths and weaknesses. Methods: We describe the history, processes, and structure of the Vital Statistics Section of the National Institute of Statistics and Census (the curator of the NMR database). In addition, we discuss publication punctuality, underregistration of the data, the proportion of registered deaths certified by medical doctors, and the top 5 causes of death according to the 80 groups of the International Classification of Diseases, Tenth Revision. We also examine works derived from the register's data, from the first publication on its website (2002) until 2019. Results: The NMR procedures were described. The web reports of the NMR were performed with a delay of between 1 to 2 years. The underregistration of deaths in 2002-2019 was 14.7%, and the national yearly proportion of deaths certified by medical doctors was always above 90%. Hard-to-reach areas had higher underregistration proportions and fewer deaths certified by medical doctors. Information extracted from the NMR supports several national and international reports, geographic information systems, and studies. The most common causes of death between 2002 and 2019 were noncommunicable diseases. Conclusions: The NMR is a robust official information system. However, hard-to-reach areas require improvement in terms of the NMR. The NMR is used for publishing official reports, writing studies, and updating reports on the current health status of Panama in a timely fashion following international guidelines.

Medication Adherence in Hypertensive Individuals in Panama 2019: A National Cross-Sectional Study.

Poor medication adherence is a public health concern leading to a large burden of cardiovascular disease among persons with hypertension. Using data from 3281 persons with diagnosed hypertension (N = 622,581) from the Panamanian National Health Survey (ENSPA) collected in 2019, we assessed the national prevalence of low-moderate medication adherence in hypertensive individuals using the 4-scale Morisky Medication Adherence Scale (4-MMAS) and identifying gender-specific associated factors. Multivariate logistic regression models were used to estimate the association between possible risk factors and low-moderate medication adherence with odds ratios (OR) and 95% confidence intervals (95% CI) stratified by gender. The national prevalence of low-moderate medication adherence was 78.2% (95% CI: 74.7-81.0%); in men it was 74.4% (95% CI: 67.5-80.3%) and in women it was 81.4% (78.4-84.0%). In women, low-moderate medication adherence was associated with living in indigenous area (OR: 5.15; 95% CI: 1.40-18.98), educational level (OR no formal education: 0.77, 95% CI 0.28-2.14; OR for primary education: 0.76, 95% CI 0.38-1.56; OR for secondary education: 0.90, 95% CI 0.48-1.70; Higher education as reference), increased BMI (normal as reference, OR for overweight: 1.35, 95% CI: 0.73-2.50, OR for obesity: 1.65, 95% CI: 0.90-3.03) and medical diagnosis of anxiety/depression (OR: 4.89, 95% CI: 1.36-17.49). However, in men, it was associated with having secondary education (OR: 2.94; 95% CI: 1.03-8.36), currently smoking (OR: 16.74, 95% CI: 1.83-152.70), taking antihypertensive medication with denial of hypertension diagnosis (OR: 4.35, 95% CI: 1.11-17.11) and having less than three annual check-ups (OR for no health check-ups: 2.97, 95% CI: 0.63-13.88; OR for 1-2 check-ups: 1.61, 95% CI: 0.78-3.32: three or more health check-ups: reference). Time since diagnosis was inversely associated with low-moderate adherence. This study assesses for the first time the national prevalence of low-moderate medication adherence among hypertensive individuals in Panama. Low-moderate medication adherence is an important public health issue that should be addressed to achieve blood pressure control in patients diagnosed with hypertension, taking into account gender-specific factors.

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30-75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.

BACKGROUND: Recent estimates of hypertension in Panama remain unknown. We aim to describe the variation in prevalence and unawareness of hypertension in two Panamanian provinces using two different cross-sectional population-based studies and to investigate risk factors associated with hypertension unawareness. METHODS: Data were derived from a sub-national study conducted in the provinces of Panama and Colon (PREFREC-2010 [2,733 participants]) and from a nationally representative study (ENSPA-2019), in which we restricted our analyses to the same provinces (4,653 participants). Individuals aged 30-75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition. Multivariable logistic regression models were used to estimate the association between risk factors and unawareness, expressed as odds ratios (OR) and 95% confidence interval (CI). FINDINGS: In 2010, the prevalence and unawareness of hypertension in men were 51.6% (95% CI: 45.7-57.5) and 32.3% (25.4-40.1), respectively, and in women 46.0% (42.1-49.9) and 16.1% (12.6-20.4), respectively. In 2019, the prevalence and unawareness of hypertension in men were 46.5% (42.1-51.0) and 52.3% (45.9-58.6), and in women 42.1% (39.6-44.7) and 33.3% (29.8-37.0). Men (2010 and 2019), age <50 years (2010 and 2019), having no/primary education (2010), and living in a non-urban region (2019) were positively associated with hypertension unawareness, whereas obesity (2010), physical inactivity (2010), family history of hypertension (2019), and BP assessment in the year before study enrollment (2010 and 2019) were inversely associated with hypertension unawareness. INTERPRETATION: Benefits of a decrease in the prevalence of hypertension are being undermined by an increase in hypertension unawareness. Actions should be encouraged to strengthen the implementation of the existing healthcare program for cardiovascular risk factor control.

Social determinants of violence against women in Panama: results from population-based cross-sectional studies and a femicide registry.

BACKGROUND: We aimed to investigate the prevalence of violence against women (VAW) in Panama and its association with social determinants of health (SDH) and to estimate the femicide rates from 2014 to 2017. METHODS: Data were derived from three cross-sectional population-based studies. Logistic regression models were used to estimate the association between SDH and VAW, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). Age-standardized femicide rates were estimated using data from the Public Ministry. RESULTS: Compared to the reference categories, women in the lowest quintile (Q) of income distribution (Q1: OR 4.0 [95% CI 1.4-11.7], Q2: OR 3.0 [95% CI 1.1-7.9]), divorced/separated women (OR 1.5 [95% CI 1.0-2.1]) and those in the age categories 25-33 y and 34-49 y (OR 1.9 [95% CI 1.2-3.1]) were more likely to have experienced violence in the past year. Indigenous ethnicity (OR 2.3 [95% CI 1.3-4.1]), age 15-19 y (OR 1.8 [95% CI 1.1-2.9]) and lowest education levels (very low: OR 4.7 [95% CI 1.4-15.5]; low: OR 4.5 [95% CI 1.4-14.6]) were associated with permissive attitudes towards violence. Indigenous (OR 2.7 [95% CI 1.3-6.1]), Afro-Panamanians (OR 3.1 [95% CI 1.3-7.6]) and education level (low: OR 2.5 [95% CI 1.2-4.9]; medium: OR 3.0 [95% CI 1.4-6.6]) were associated with physical/sexual intimate partner violence. Standardized adjusted femicide rates (×100 000) from 2015 to 2017 were 1.5, 0.9 and 0.8, respectively. CONCLUSIONS: Our findings highlight the importance of prevention programmes.

Weaving Mitochondrial DNA and Y-Chromosome Variation in the Panamanian Genetic Canvas.

The Isthmus of Panama was a crossroads between North and South America during the continent's first peopling (and subsequent movements) also playing a pivotal role during European colonization and the African slave trade. Previous analyses of uniparental systems revealed significant sex biases in the genetic history of Panamanians, as testified by the high proportions of Indigenous and sub-Saharan mitochondrial DNAs (mtDNAs) and by the prevalence of Western European/northern African Y chromosomes. Those studies were conducted on the general population without considering any self-reported ethnic affiliations. Here, we compared the mtDNA and Y-chromosome lineages of a new sample collection from 431 individuals (301 males and 130 females) belonging to either the general population, mixed groups, or one of five Indigenous groups currently living in Panama. We found different proportions of paternal and maternal lineages in the Indigenous groups testifying to pre-contact demographic events and genetic inputs (some dated to Pleistocene times) that created genetic structure. Then, while the local mitochondrial gene pool was marginally involved in post-contact admixtures, the Indigenous Y chromosomes were differentially replaced, mostly by lineages of western Eurasian origin. Finally, our new estimates of the sub-Saharan contribution, on a more accurately defined general population, reduce an apparent divergence between genetic and historical data.

Occult hepatitis B virus infection and lamivudine-resistant mutations in isolates from renal patients undergoing hemodialysis.

BACKGROUND AND AIMS: Patients undergoing hemodialysis are at risk of infection with both hepatitis B virus (HBV) and hepatitis C virus (HCV). Occult HBV infection is usually associated with low levels of HBV and is frequently detected in HCV-infected patients. The aims of the present study were to compare the prevalence of occult HBV infection among anti-HCV-positive and anti-HCV-negative patients undergoing hemodialysis, and characterize the molecular patterns of HBV isolates from patients with occult infection. METHODS: Serum samples from 100 patients negative for hepatitis B surface antigen undergoing hemodialysis, half of whom were positive for anti-HCV antibodies, were tested for the presence of HBV-DNA using semi-nested polymerase chain reaction (PCR). PCR products of the S gene were directly sequenced. RESULTS: HBV-DNA was detected in 15 samples. There were no significant differences in HCV status, sex, age, time of dialysis, alanine aminotransferase levels or HBV serological markers between patients with or without occult HBV infection, with the exception of antibody to hepatitis B core antigen (anti-HBc)-only serological marker (P = 0.003). All six HBV isolates that could be sequenced were of genotype A/subgenotype A1. Four of these six HBV isolates contained mutations associated with lamivudine resistance in the DNA polymerase (two with L180M/M204V and two with rt173V/180M/204V) and a specific substitution (Y100C) in the HBV small surface protein. CONCLUSIONS: HBV isolates with the identified substitutions have the potential to spread silently by nosocomial transmission within the hemodialysis unit. These results have potential implications for the management of patients with occult HBV infection undergoing hemodialysis.

Detection and identification of rickettsial agents in ticks from domestic mammals in eastern Panama.

Several outbreaks of Rocky Mountain spotted fever have occurred in recent years in Colombian communities close to the border with Panama. However, little is known about rickettsiae and rickettsial diseases in eastern Panamanian provinces, the Darien Province and the Kuna Yala, located north of the endemic area in Colombia. In 2007, 289 ticks were collected in several towns from dogs, horses, mules, cows, and pigs. DNA was extracted from 124 Dermacentor nitens, 64 Rhipicephalus sanguineus, 43 Amblyomma ovale, 35 A. cajennense, 10 Boophilus microplus, 4 A. oblongoguttatum, and 9 A. cajennense nymphs. SYBR-Green polymerase chain reaction assays targeting a fragment of the OmpA and 16S rRNA genes were used for detection of DNA of the spotted fever group rickettsiae (SFGR) and Anaplasmataceae (Anaplasma and Ehrlichia), respectively. In total, 37.4% ticks were positive for SFGR, including 20.3% R. sanguineus, 27.9% A. ovale, 25.8% D. nitens, 50% B. microplus, 50% A. oblongoguttatum, and 100% A. cajennense. The presence of Rickettsia amblyommii DNA was confirmed by sequencing in A. cajennense, A. oblongoguttatum, A. ovale, B. microplus, and R. sanguineus. DNA of R. rickettsii was only detected in one D. nitens collected from a horse in Santa Fe, Darien Province. Prevalence of Anaplasmataceae varied from 6.3% in R. sanguineus to 26.5% in A. cajennense. DNA of Ehrlichia chaffensis was found in three D. nitens and three A. cajennense from horses. This is the first study providing molecular characterization and prevalence information on SFGR in ticks from these areas and thus will be helpful for future evaluations of the risk of rickettsial diseases for individuals living in this region.

End-stage renal disease-financial costs and years of life lost in Panama: a cost-analysis study.

OBJECTIVES: Central America is a region with an elevated burden of chronic kidney disease (CKD); however, the cost of treatment for end-stage renal disease (ESRD) remains an understudied area. This study aimed to investigate the direct costs associated with haemodialysis (HD) and peritoneal dialysis (PD) in public and private institutions in Panama in 2015, to perform a 5-year budget impact analysis and to calculate the years of life lost (YLL) due to CKD. DESIGN: A retrospective cost-analysis study using hospital costs and registry-based data. SETTING: Data on direct costs were derived from the public and private sectors from two institutions from Panama. Data on CKD-related mortality were obtained from the National Mortality Registry. METHODS: A budget impact analysis was performed from the payer perspective, and five scenarios were estimated, with the assumption that the mix of dialysis modality use shifts towards a greater use of PD over time. The YLL due to CKD was calculated using data recorded between 1 January 2015 and 31 December 2015. The linear method was utilised for the analyses with the population aged 20-77 years old. RESULTS: In 2015, the total costs for dialysis in the public sector ranged from ~US$7.9 million (PD) to US$62 million (HD). The estimated costs were higher in the scenario in which a decrease in PD was assumed. The average annual loss due to CKD was 25 501 808.40 US$-YLL. CONCLUSION: ESRD represents a major challenge for Panama. Our results suggest that an increased use of PD might provide an opportunity to substantially lower overall ESRD treatment costs.

Outbreak of acute renal failure in Panama in 2006: a case-control study.

OBJECTIVE: In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak. METHODS: Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls. FINDINGS: Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup. CONCLUSION: The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.

Does flavanol intake influence mortality from nitric oxide-dependent processes? Ischemic heart disease, stroke, diabetes mellitus, and cancer in Panama.

Substantial data suggest that flavonoid-rich food could help prevent cardiovascular disease and cancer. Cocoa is the richest source of flavonoids, but current processing reduces the content substantially. The Kuna living in the San Blas drink a flavanol-rich cocoa as their main beverage, contributing more than 900 mg/day and thus probably have the most flavonoid-rich diet of any population. We used diagnosis on death certificates to compare cause-specific death rates from year 2000 to 2004 in mainland and the San Blas islands where only Kuna live. Our hypothesis was that if the high flavanoid intake and consequent nitric oxide system activation were important the result would be a reduction in the frequency of ischemic heart disease, stroke, diabetes mellitus, and cancer--all nitric oxide sensitive processes. There were 77,375 deaths in mainland Panama and 558 deaths in the San Blas. In mainland Panama, as anticipated, cardiovascular disease was the leading cause of death (83.4 +/- 0.70 age adjusted deaths/100,000) and cancer was second (68.4 +/- 1.6). In contrast, the rate of CVD and cancer among island-dwelling Kuna was much lower (9.2 +/- 3.1) and (4.4 +/- 4.4) respectively. Similarly deaths due to diabetes mellitus were much more common in the mainland (24.1 +/- 0.74) than in the San Blas (6.6 +/- 1.94). This comparatively lower risk among Kuna in the San Blas from the most common causes of morbidity and mortality in much of the world, possibly reflects a very high flavanol intake and sustained nitric oxide synthesis activation. However, there are many risk factors and an observational study cannot provide definitive evidence.

Chronic Kidney Disease in Panama: Results From the PREFREC Study and National Mortality Trends.

INTRODUCTION: The magnitude of chronic kidney disease (CKD) in Panama has yet to be described. We investigated the association between sociodemographic and cardiovascular exposures with CKD in 2 Panamanian provinces. Further, we analyzed national trends of CKD mortality from 2001 to 2014. METHODS: Data were derived from Prevalencia de Factores de Riesgo de Enfermedad Cardiovascular (PREFREC [Survey on Risk Factors Associated With Cardiovascular Disease]), a cross-sectional study designed to analyze the prevalence of risk factors associated with cardiovascular disease. Biomarkers of kidney function were measured in 3590 participants. CKD was defined as an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 and/or albuminuria ≥30 mg/g creatinine. Odds ratios (ORs) with 95% confidence intervals (CIs) for CKD were calculated using logistic regression. We calculated age-standardized CKD mortality rates in the country using the National Mortality Register. Annual percentage change and 95% CIs were estimated to evaluate the trends over time. RESULTS: The prevalence of CKD was 12% (reduced eGFR: 3.3%; albuminuria; 9.9%). CKD was associated with hypertension (OR: 1.8; 95% CI: 1.2-2.7), age 60 years or older (OR: 1.9; 95% CI: 1.2-2.9), and previous myocardial infarction (OR: 2.4; 95% CI: 1.0-5.7), whereas monthly family income was inversely associated with CKD (OR: 0.4; 95% CI: 0.1-0.9) (adjusted). A sustained increase in the trend of CKD mortality was observed from 2001 to 2006, followed by a decreasing trend in subsequent years. Coclé province had the highest adjusted mortality rate. DISCUSSION: CKD poses a significant health problem for Panama. Health inequalities and an increase of cardiometabolic risk factors warrant robust epidemiological surveillance, improved diagnosis, and treatment. Further national studies aimed to address geographical disparities are necessary.