The adoption of the HPV vaccine school-entry requirement in Puerto Rico: How practical lessons can inform future vaccine policies.

Vaccine requirements are policy-level strategies used to improve population health outcomes; however, discourse politicization of vaccines may hinder adoption and implementation. An example of the complexities related to adoption of vaccine policies in the United States (US) is the human papillomavirus (HPV) vaccine school-entry requirement. In 2018, Puerto Rico's (PR) Department of Health adopted this policy. This study assessed stakeholders' recommendations for adoption of the HPV vaccine school-entry requirement that could inform future vaccine policies. Stakeholders (e.g., researchers, members of medical and non-profit organizations) were interviewed from May to August 2018. Participants (n = 20) discussed recommendations for public health professionals interested in adopting such policy. Data were analyzed using applied thematic techniques. Participants emphasized the importance of raising HPV vaccine awareness and providing education prior to the requirement. They recommended using real stories and making the problem relevant by using local data. Participants recommended considering the local culture and government bureaucracies, and promoting multisectoral collaborations to combine limited resources. The combination of education efforts, local data, and multisectoral collaborations facilitated the adoption of the HPV vaccine school-entry requirement in PR. Findings highlight the need to understand the contextual distinctions of the communities where vaccination requirements may be adopted and implemented to anticipate barriers and leverage existing resources. Consideration of the politico-cultural context may be important as political beliefs have become entrenched with vaccine policy. These practical lessons can inform public health professionals and policymakers who are seeking to adopt and implement vaccine policies in other settings to ensure equitable vaccine access.

Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries.

INTRODUCTION: Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS: From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS: The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.

Immune response to Streptococcus pneumoniae in asthma patients: comparison between stable situation and exacerbation.

In Argentina, more than 3 million people suffer from asthma, with numbers rising. When asthma patients acquire viral infections which, in turn, trigger the asthmatic response, they may develop subsequent bacterial infections, mainly by Streptococcus (S.) pneumoniae. This encapsulated Gram(+) bacterium has been considered historically a T cell-independent antigen. Nevertheless, several papers describe the role of T cells in the immune response to S. pneumoniae. We evaluated the response to S. pneumoniae and compared it to the response to Mycobacterium (M.) tuberculosis, a different type of bacterium that requires a T helper type 1 (Th1) response, in cells from atopic asthmatic children, to compare parameters for the same individual under exacerbation and in a stable situation whenever possible. We studied asthma patients and a control group of age-matched children, evaluating cell populations, activation markers and cytokine production by flow cytometry, and cytokine concentration in serum and cell culture supernatants by enzyme-linked immunosorbent assay (ELISA). No differences were observed in γδ T cells for the same patient in either situation, and a tendency to lower percentages of CD4(+) CD25(hi) T cells was observed under stability. A significantly lower production of tumour necrosis factor (TNF)-α and a significantly higher production of interleukin (IL)-5 was observed in asthma patients compared to healthy individuals, but no differences could be observed for IL-4, IL-13 or IL-10. A greater early activation response against M. tuberculosis, compared to S. pneumoniae, was observed in the asthmatic patients' cells. This may contribute to explaining why these patients frequently acquire infections caused by the latter bacterium and not the former.

The role of cytokines in atopic asthma.

Atopic asthma results from airway inflammation triggered by an environmental allergen. Symptoms include wheezing, dyspnea and cough, airway narrowing and/or hyperresponsiveness to several inhaled stimuli. Inflammation develops in a two-phase fashion. The first phase after exposure to the allergen consists of degranulation and release of both histamine and other stored preformed inflammatory mediators as well as newly synthesized ones, including cytokines, all of which increase mucus secretion and smooth muscle contraction. The second phase occurs later and lasts longer; it is due to different molecules: several cytokines and chemokines, arachidonic acid derivatives, enzymes such as metalloproteinases and cell adhesion molecules. Cytokines are key players in the chronic inflammation in asthma patients, but details on their role and interactions still remain undetermined. Recent evidence suggests that allergic asthma is a multifaceted condition actively controlled by effector as well as regulatory T cells (Tregs). T helper (Th) 2 cells and Th17 cells increase airway inflammation, while Tregs are anti- inflammatory. Cytokines are involved in the development and activation of all T cell subpopulations. They are also involved directly or indirectly in most approaches to asthma treatment. Several cytokines have been tested as therapeutic targets and some of the currently used therapies like corticosteroids, beta agonists and allergen immunotherapy affect cytokine production. The increased knowledge on cytokine interplay and lymphocyte subsets should generate new therapeutic strategies in the near future.

Stage- and tissue-expression of genes involved in the biosynthesis and signalling of ethylene in reproductive organs of damson plum (Prunus domestica L. subsp. insititia).

In this work, four cDNA clones (Pd-ACS1,AJ890088; Pd-ETR1 and Pd-ERS1, AJ890092, AJ890091; and Pd-CTR1, AJ890089) encoding an ACC-synthase, two putative ethylene (ET) receptors, and a putative MAPKKK, respectively, were isolated and phylogenetically characterized in Prunus domestica L. subsp. insititia. Their expression was studied by real-time PCR during flower (closed, open and senescent) and fruit (early green, late green, maturation and ripening) development of damson plum, which is climateric. While two peaks of ET production were quantified at early green and ripening stages in whole fruits, the seed was not able to produce it during maturation and ripening stages. All studied genes were differentially expressed during flower and fruit development. In general, the level of transcripts of Pd-ACS1 was higher in fruits than in flowers. However, it was noteworthy that: (1) Pd-ACS1 expression was hardly detected in closed flowers and at low levels during early green stage; and fruit development provoked a notable differential expression in seeds, and pericarp; (2) the results of Pd-ACS1 expression during fruit development suggest a preponderant role of this gene from late green stage onward. The stamen was the only floral organ in which expression of both Pd-ETR1 and Pd-ERS1 receptor genes was not significantly altered during development; however, their expression decreased concomitantly with development of pistil (only floral organ to register a net ET production when fertilized) and during first days of ovary development (the highest ET production during all fruit development). Contrary to Pd-ERS1, the level of Pd-ETR1 mRNA was temporally quite similar in the seed. With regard Pd-ETR1, even its expression was very scarce during maturation of mesocarp, was stimulated during ripening. In the epicarp, Pd-ERS1 and Pd-ETR1 were low expressed during pit hardening increasing onward and decreasing during ripening. Pd-CTR1 expression was in the seed>mesocarp>>epicarp. Spatial and temporal levels of Pd-ACS1, Pd-ETR1, Pd-ERS1 and Pd-CTR1 mRNAs described in this work demonstrate that the expression of these genes is not always constitutive and that control of its transcription may play an important role in regulating the development of reproductive organs of damson plum.

[Temporal bone chondroblastoma. A clinical case and literature review]. / Condroblastoma de hueso temporal. Caso clínico y revisión de la literatura.

We report a clinical case of a 31 year old male with a left temporal painful mass of six months evolution. After radiologic diagnosis, intraoperatory biopsy and surgical removal, the anatomopathological result confirmed the histology of chondroblatoma, with a satisfactory postoperative evolution. The chondroblastoma is a benign bone tumor typically located in the epiphysis of long bones and the temporal bone is an excepcional location as we have verified through a literature review.

[Cancer of the parotid gland]. / Tumores malignos de la glándula parótida.

OBJECTIVE: To review our experience and results in the diagnosis and treatment of a low incidence pathology such as the cancer of the parotid gland. METHODS: The study reviewed 40 patients with malignant tumors of the parotid gland treated between 1991 and 2002 in our hospital. It was used the staging system TNM (American Joint Committee on Cancer 1997). RESULTS: The most common histological type in our series is the squamous cell carcinoma, in general unilateral and in the superficial lobe. Rapid tumor enlargement, fixation to the skin, cervical lymphadenopathy, pain and facial palsy are malignancy clinical findings. We obtained a 56% 5-year global survival rate, with a 68% for stages I and II, and 43% for stages III and IV. CONCLUSIONS: This pathology has a low incidence but high mortality. The staging and histological type are important prognostic factors. The surgery is the election treatment, associated with neck disection or radiotherapy.

[Geniculate ganglion tumors. Therapeutic and reconstructive management]. / Tumores del ganglio geniculado. Manejo terapéutico y reconstructivo.

We present five cases of patients diagnosed of a facial nerve tumoral lesion localised at the Geniculate Ganglion and all of which underwent surgical resection. The initial symptoms were in four cases of peripheral facial nerve paralysis and in the fifth case facial paresis. Two trans-mastoid extralabyrinthine approaches were performed and one through a combined path (middle fossa and trans-mastoid) with reconstruction of the facial nerve through a termino-terminal graft. In the fourth case, an approach through fossa media was done, and did not include nerve reconstruction but palliative treatment with a palpebral gold plaque. In the fifth case, a modified trans-labyrinthine approach with facial-hypoglossus termino-terminal anastomosis. Histological diagnosis was 3 neurinomas and 2 hemangiomas. Of the termino-terminal grafts two managed a functional Grade III of the House-Brackmann classification. The third one sustained a Grade VI and therefore a suspension with temporal muscle was carried out. The patient with facial-hypoglossus anastomosis is in a functional Grade IV. Geniculate ganglion tumors are in their majority benign and their treatment is the total resection of the tumor. Nerve reconstruction can be primary or deferred with the aid of a nerve graft or anastomosis, being necessary palliative techniques when resection is not possible.

Visual and semiquantitative analysis of 18F-fluorodeoxyglucose positron emission tomography using a partial-ring tomograph without attenuation correction to differentiate benign and malignant pulmonary nodules.

OBJECTIVE: Many studies have reported the use of attenuation-corrected positron emission tomography with 18F-fluorodeoxyglucose (FDG PET) with full-ring tomographs to differentiate between benign and malignant pulmonary nodules. We sought to evaluate FDG PET using a partial-ring tomograph without attenuation correction. METHODS: A retrospective review of PET images from 77 patients (range 38-84 years of age) with proven benign or malignant pulmonary nodules was undertaken. All images were obtained using a Siemens/CTI ECAT ART tomograph, without attenuation correction, after 185 MBq 18F-FDG was injected. Images were visually graded on a 5-point scale from "definitely malignant" to "definitely benign," and lesion-to-background (LB) ratios were calculated using region of interest analysis. Visual and semiquantitative analyses were compared using receiver operating characteristic analysis. RESULTS: Twenty lesions were benign and 57 were malignant. The mean LB ratio for benign lesions was 1.5 (range 1.0-5.7) and for malignant lesions 5.7 (range 1.2-14.1) (p < 0.001). The area under the ROC curve for LB ratio analysis was 0.95, and for visual analysis 0.91 (p = 0.39). The optimal cut-off ratio with LB ratio analysis was 1.8, giving a sensitivity of 95% and a specificity of 85%. For lesions thought to be "definitely malignant" on visual analysis, the sensitivity was 93% and the specificity 85%. Three proven infective lesions were rated as malignant by both techniques (LB ratio 2.6-5.7). CONCLUSIONS: FDG PET without attenuation correction is accurate for differentiating between benign and malignant lung nodules. Results using simple LB ratios without attenuation correction compare favourably with the published sensitivity and specificity for standard uptake ratios. Visual analysis is equally accurate.

[Prognostic factors in prostatic carcinoma treated with radical radiotherapy: stages A, B, and C]. / Factores pronósticos en el carcinoma de próstata tratado con radioterapia radical: estadios A, B y C.

Analysis of a series of 118 patients with histological diagnosis of prostate carcinoma, localized stages A2, B and C, treated with external radiotherapy with radical purpose between July 1964 and December 1991. The 5-year cause-specific survival was 69% years and 62% at 10 years. Disease-free survival was 56% and 48% at 5 and 10 years respectively. Local, locoregional and distant relapse-free survivals were 91%, 75% and 65% at 10 years respectively. Several factors characterize each tumour, influencing the therapy failure. In our series, non-differentiated, stage C tumours with pathological LDH levels at diagnosis and treated with AP-PA fields showed decreased survival and greater relapse ratios. Two separate factors influence on distant failure: LDH pathological levels at diagnosis and non-differentiated tumours. External radiotherapy is a therapeutical alternative in localized stages of prostate carcinoma, which offers little morbidity and good tolerance, similar results to those obtained with surgical treatment.

[Colorectal cancer: surgery or is there something else?]. / Cáncer de colón y recto: cirugía, hay algo Más?

The standard modality to treat colorectal cancer in potentially curable patients is, undoubtedly, surgery. The concept of precautional chemotherapy used in tumors located elsewhere, has put forward a clinical trial that proved its effectiveness and improved survival. We report the use of two modalities (chemotherapy and radiotherapy) along with surgery as part of a multidisciplinary treatment of patients with colorectal cancer.

Causas de mortalidad en el sector protegido de inmunoneutropénicos (SEPIN). I.N.E.N. (1989-1991) / Causes of death in the isolation unit

Entre enero 1989 y diciembre 1991, 243 pacientes fueron hospitalizados en el Instituto Nacional de Enfermedades Neoplásicas en la Unidad de Aislamiento Invertido (SEPIN), de ellos 171 (70.3 por ciento) eran portadores de leucemia aguda (LA) que ingresaron para tratamiento de inducción y/o consolidación. Tres pacientes ingresaron con hemorragia generalizada antes de iniciar tratamiento. La mortalidad general fue de 15.4 por ciento (26/168) y las causas fueron: sepsis en 15/26 (57.6 por ciento), sepsis + hemorragia en 5/26 (19.2 por ciento), hemorragia sola en 3/26 (11.5 por ciento) y hemorragia asociada a otras complicaciones en 3/26 (11.5 por ciento). En el caso de fallecidos por sepsis los focos infecciosos fueron: piel (5), pulmón (4), orofaringe (4), abdominal (4), otros (3). los gérmenes aislados fueron: Pseudomona (3), Enterobacter (3), Klebsiella (3), Estafilococo aureus (2), Acinetobacter (1) y Candida (1). Bacteremia estuvo presente en 4/20 (20 por ciento) y todos fueron Gram negativos. Hemorragia ocurrió por plaquetopenia severa (<20.000/mm3) o por coagulación intravascular diseminada, con compromiso multisistémico y principalmente del sistema nervioso central. Las causas más frecuentes de muerte en pacientes con leucenmia aguda en tratamiento con quimioterapia continúan siendo sepsis y hemorragia, y ambas requieren una estrategia permanente de manejo de las complicaciones infecciosas y un soporte hematológico oportuno, que les permita a estos pacientes superar el período de mielosupresión

A controlled trial of high-dose intravenous immune globulin infusions as treatment for dermatomyositis.

BACKGROUND: Dermatomyositis is a clinically distinct myopathy characterized by rash and a complement-mediated microangiopathy that results in the destruction of muscle fibers. In some patients the condition becomes resistant to therapy and causes severe physical disabilities. METHODS: We conducted a double-blind, placebo-controlled study of 15 patients (age, 18 to 55 years) with biopsy-proved, treatment-resistant dermatomyositis. The patients continued to receive prednisone (mean daily dose, 25 mg) and were randomly assigned to receive one infusion of immune globulin (2 g per kilogram of body weight) or placebo per month for three months, with the option of crossing over to the alternative therapy for three more months. Clinical response was gauged by assessing muscle strength, neuromuscular symptoms, and changes in the rash. Changes in immune-mediated muscle abnormalities were determined by repeated muscle biopsies. RESULTS: The eight patients assigned to immune globulin had a significant improvement in sores of muscle strength (P < 0.018) and neuromuscular symptoms (P < 0.035), whereas the seven patients assigned to placebo did not. With crossovers a total of 12 patients received immune globulin. Of these, nine with severe disabilities had a major improvement to nearly normal function. Their mean muscle-strength scores increased from 74.5 to 84.7, and their neuromuscular symptoms improved. Two of the other three patients had mild improvement, and one had no change in his condition. Of 11 placebo-treated patients, none had a major improvement, 3 had mild improvement, 3 had no change in their condition, and 5 had worsening of their condition. Repeated biopsies in five patients of muscles whose strength improved to almost normal showed an increase in muscle-fiber diameter (P < 0.04), an increase in the number and a decrease in the diameter of capillaries (P < 0.01), resolution of complement deposits on capillaries, and a reduction in the expression of intercellular adhesion molecule 1 and major-histocompatibility-complex class I antigens. CONCLUSIONS: High-dose intravenous immune globulin is a safe and effective treatment for refractory dermatomyositis.

The synapsis event in the homologous pairing of DNAs: RecA recognizes and pairs less than one helical repeat of DNA.

A key step in homologous recombination is the alignment and pairing of homologous DNAs. The Escherichia coli RecA protein initiates pairing by binding to single-strand DNA, forming a helical nucleoprotein filament. We demonstrate that in the presence of the nonhydrolyzable ATP analogue adenosine 5'-[gamma-thio]triphosphate and ADP, RecA can pair a homologous oligonucleotide 15 bases long with a duplex DNA to yield synaptic complexes consisting of the oligonucleotide and duplex DNA stabilized by RecA. RecA can pair as few as eight bases of homology to form such synaptic complexes. The homologous DNAs remain paired to each other upon removal of RecA provided that the length of shared homology is at least 26 base pairs. Based on our findings and the work of others, we propose that in vitro, one helical turn of a RecA nucleoprotein filament containing approximately six RecA monomers and 15 bases of single-strand DNA is the functional unit sufficient to carry out the homology search.

Computed tomographic study of cervical carotid calcification.

Contrast-enhanced computed tomography of the neck permits low-risk evaluation of morphologic complications of carotid plaque, including (and foremost) calcification. To investigate the patterns and clinical significance of calcified deposits in the cervical carotid arteries using computed tomography we studied 40 patients with unilateral symptoms of hemispheric ischemia. Calcium deposits observed in the external, internal, and common carotid arteries were oriented in space and individually scored. We found calcified deposits in 39 patients. Stepwise multiple regression of the data provided evidence strongly suggesting a correlation between advancing age and calcium scores. Calcium was more heavily concentrated in the posterior half of arteries (p less than 0.01), in particular of the internal and common carotid arteries, and always in relation to an atheromatous plaque, suggesting a causative link to hemodynamic forces within the arteries. There was no difference in calcification scores between symptomatic and asymptomatic sides, indicating that calcium deposits do not contribute to the development of symptoms.