Burden of dengue among febrile patients at the time of chikungunya introduction in Piedecuesta, Colombia.

OBJECTIVE: To estimate the age-specific incidence of symptomatic dengue and chikungunya in Colombia. METHOD: A passive facility-based fever surveillance study was conducted among individuals with undifferentiated fever. Confirmatory diagnostics included serological and molecular tests in paired samples, and surveillance's underreporting was assessed using capture-recapture methods. RESULTS: Of 839 febrile participants 686 completed the study. There were 33.2% (295/839) dengue infections (51% primary infections), and 35.9% (191/532) of negative dengue cases there were chikungunya cases. On average, dengue cases were younger (median = 18 years) than chikungunya cases (median = 25 years). Thrombocytopaenia and abdominal pain were the main dengue predictors, while presence of rash was the main predictor for chikungunya diagnosis. Underreporting of dengue was 31%; the estimated expansion factors indicate an underreporting rate of dengue cases of threefold for all cases and of almost sixfold for inpatients. CONCLUSIONS: These findings highlight the ongoing coexistence of both arboviruses, a distinct clinical profile of each condition in the study area that could be used by clinicians to generate a differential diagnosis, and the presence of underreporting, mostly among hospitalised cases.

Training, supervision, and experience of coaches offering digital guided self-help for mental health concerns.

Accessible, low-cost intervention options are necessary to address the rise in mental health problems among college students. Digital guided self-help, or coached, programs have been developed to provide such services, with many commercially available. As such, there are a large and growing number of individuals coaching these programs. However, an unmet need is to evaluate and assess best practices for training and supervising individuals in these positions. To this end, we describe how we recruited, trained, and supervised coaches as part of a large randomized controlled trial using a widely available digital commercial platform. Coaches were trained to provide digital guided self-help for depression, anxiety, and/or eating disorders for college students. Coaches initially attended three live training sessions over 2-3 weeks, viewed multiple training videos, and read a detailed coaching manual developed by our team. Thereafter, they attended weekly supervision. Following their term, coaches completed an exit survey to assess their supervision and training experiences. A total of 37 of 70 (53%) graduate-level student coaches completed the survey. The experience was reported as very positive (95%). In particular, the majority reported feeling well prepared, more confident, and felt they had developed useful skills for their own practice.

Genetic risk for dengue hemorrhagic fever and dengue fever in multiple ancestries.

BACKGROUND: Genetic risk factors for dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) and dengue fever (DF) are limited, in particular there are sparse data on genetic risk across diverse populations. METHODS: We conducted a genome-wide association study (GWAS) in a derivation and validation sample of 7, 460 participants of Latin American, South Asian, and South East Asian ancestries. We then developed a weighted polygenic risk score (PRS) for each participant in each of the validation cohorts of the three ancestries to predict the risk of DHF/DSS compared to DF, DHF/DSS compared to controls, and, DF compared to controls. FINDINGS: The risk of DHF/DSS was significantly increased, odds ratio [OR] 1.84 (95%CI 1.47 to 2.31) (195 SNPs), compared to DF, fourth PRS quartile versus first quartile, in the validation cohort. The risk of DHF/DSS compared to controls was increased (OR=3.94; 95% CI 2.84 to 5.45) (278 SNPs), as was the risk of DF compared to controls (OR=1.97; 95%CI 1.63 to 2.39) (251 SNPs). Risk increased in a dose-dependent manner with increase in quartiles of PRS across comparisons. Significant associations persisted for PRS built within ancestries and applied to the same or different ancestries as well as for PRS built for one outcome (DHF/DSS or DF) and applied to the other. INTERPRETATION: There is a strong genetic effect that predisposes to risk of DHF/DSS and DF. The genetic risk for DHF/DSS is higher than that for DF when compared to controls, and this effect persists across multiple ancestries.

Clinical Indicators of Fatal Dengue in Two Endemic Areas of Colombia: A Hospital-Based Case-Control Study.

According to the World Health Organization, 98% of fatal dengue cases can be prevented; however, endemic countries such as Colombia have recorded higher case fatality rates during recent epidemics. We aimed to identify the predictors of mortality that allow risk stratification and timely intervention in patients with dengue. We conducted a hospital-based, case-control (1:2) study in two endemic areas of Colombia (2009-2015). Fatal cases were defined as having either 1) positive serological test (IgM or NS1), 2) positive virological test (RT-PCR or viral isolation), or 3) autopsy findings compatible with death from dengue. Controls (matched by state and year) were hospitalized nonfatal patients and had a positive serological or virological dengue test. Exposure data were extracted from medical records by trained staff. We used conditional logistic regression (adjusting for age, gender, disease's duration, and health-care provider) in the context of multiple imputation to estimate exposure to case-control associations. We evaluated 110 cases and 217 controls (mean age: 35.0 versus 18.9; disease's duration pre-admission: 4.9 versus 5.0 days). In multivariable analysis, retro-ocular pain (odds ratios [OR] = 0.23), nausea (OR = 0.29), and diarrhea (OR = 0.19) were less prevalent among fatal than nonfatal cases, whereas increased age (OR = 2.46 per 10 years), respiratory distress (OR = 16.3), impaired consciousness (OR = 15.9), jaundice (OR = 32.2), and increased heart rate (OR = 2.01 per 10 beats per minute) increased the likelihood of death (AUC: 0.97, 95% confidence interval: 0.96, 0.99). These results provide evidence that features of severe dengue are associated with higher mortality, which strengthens the recommendations related to triaging patients in dengue-endemic areas.

Development of standard clinical endpoints for use in dengue interventional trials.

Dengue is a major public health problem worldwide. Although several drug candidates have been evaluated in randomized controlled trials, none has been effective and at present, early recognition of severe dengue and timely supportive care are used to reduce mortality. While the first dengue vaccine was recently licensed, and several other candidates are in late stage clinical trials, future decisions regarding widespread deployment of vaccines and/or therapeutics will require evidence of product safety, efficacy and effectiveness. Standard, quantifiable clinical endpoints are needed to ensure reproducibility and comparability of research findings. To address this need, we established a working group of dengue researchers and public health specialists to develop standardized endpoints and work towards consensus opinion on those endpoints. After discussion at two working group meetings and presentations at international conferences, a Delphi methodology-based query was used to finalize and operationalize the clinical endpoints. Participants were asked to select the best endpoints from proposed definitions or offer revised/new definitions, and to indicate whether contributing items should be designated as optional or required. After the third round of inquiry, 70% or greater agreement was reached on moderate and severe plasma leakage, moderate and severe bleeding, acute hepatitis and acute liver failure, and moderate and severe neurologic disease. There was less agreement regarding moderate and severe thrombocytopenia and moderate and severe myocarditis. Notably, 68% of participants agreed that a 50,000 to 20,000 mm3 platelet range be used to define moderate thrombocytopenia; however, they remained divided on whether a rapid decreasing trend or one platelet count should be case defining. While at least 70% agreement was reached on most endpoints, the process identified areas for further evaluation and standardization within the context of ongoing clinical studies. These endpoints can be used to harmonize data collection and improve comparability between dengue clinical trials.

Tuberculosis de muñeca, una infección poco frecuente / Tuberculosis of the wrist, a rare infection

Resumen La tuberculosis es una infección que afecta a millones de personas en el mundo cada año, provocando una alta carga de morbimortalidad. La localización pulmonar corresponde a más del 80 % de los casos. Su diagnóstico y tratamiento aún representa un desafío para los clínicos, especialmente en sus localizaciones extrapulmonares. Presentamos un caso de tuberculosis de muñeca izquierda, la cual fue diagnosticada con biopsia de hueso y tratada de forma exitosa con cuatro drogas por seis meses.

Abstract Tuberculosis is an infection that affects millions of people worldwide every year, causing a high burden of morbidity and mortality. The pulmonary localization accounts for more than 80 % of the cases. Its diagnosis and treatment still represent a challenge for clinicians, especially for its extrapulmonary presentations. We present the case of a patient with tuberculosis of the left wrist, which was diagnosed with bone biopsy and successfully treated with four drugs during six months.

Presentación de bacterias resistentes en hemocultivos en pacientes con patología médica en un hospital de tercer nivel

Introducción. Las bacteriemias afectan a pacientes dentro del ámbito hospitalario y se reportan tasas de mortalidad del 35%. Los microorganismos productores de beta-lactamasas de espectro extendido son cada vez más resistentes a los antibióticos. Materiales y métodos. Estudio observacional descriptivo de corte transversal en pacientes mayores de 14 años con hemocultivos positivos en el Hospital Universitario de Santander, entre 2014 y 2016. Resultados. Se analizaron 148 historia clínicas, la edad promedio fue de 55,5 años, el 51,4% eran mujeres. La proporción de gérmenes resistentes fue del 23,6%, la producción de beta-lactamasas de espectro extendido en E. coli y K. pneumoniae fue del 40%. El 100% de los pacientes con gérmenes resistentes tenía un índice de PITT severo. El S. aureus mostró un 50% de resistencia a la oxacilina. Conclusión. El 23,6% de los pacientes tenía una infección por gérmenes resistentes, los más comunes fueron E. coli y K. pneumoniae, la mortalidad general fue del 30%.

Introduction: Bacteremia affects patients in the hospital, with mortality rates reported in 35%. Microorganisms that produce beta- lactamases of extended spectrum are each time more resistant to antibiotics. Method: Observational and descriptive study in patients older tan 14 years old with positive blood cultures in Hospital Universitario de Santander, between 2014 and 2016. Results: 148 clinic records were analyzed, the mean age was 55.5 years. 51.4% were women. The proportion of resistant germs was of 23.6%, the production of beta-lactamases of extended spectrum in E. coli and K. pneumoniae was 40%. 100% of patients with resistant germs had a rate of severe PITT. S. aureus showed a 50% of resistance to oxacillin. Conclusion: 23.6% of patients had an infection for resistant germs, the most common were E. coli and K. pneumoniae. General mortality was of 30%.

Introdução: as bactérias afetam pacientes do contexto hospitalar e relatam taxas de mortalidade de 35%. Os micro-organismos produtores de beta-lactamasas de espectro estendido são cada vez mais resistentes aos antibióticos. Materiais e métodos: estudo observacional descritivo de corte transversal com pacientes maiores de 14 anos com hemoculturas positivas, no Hospital Universitario de Santander, Colômbia, entre 2014 e 2016. Resultados: foram analisados 148 prontuários; a idade média foi de 55,5 anos; 51,4 % eram mulheres. A proporção de germens resistentes foi de 23,6 %; a produção de beta-lactamasas de espectro estendido em E. coli e K. pneumoniae foi de 40%. 100% dos pacientes com germens resistentes tinham um índice de PITT severo. O S. aureus mostrou 50% de resistência à oxacilina. Conclusão: 23,6% dos pacientes tinham uma infecção por germens resistentes, os mais comuns foram E. coli e K. pneumoniae; a mortalidade geral foi de 30%.

Bacteriemias en pacientes con VIH en un hospital de tercer nivel en Colombia, 2014-2016 / Bacteremias en HIV-patients in a third level hospital in Colombia, 2014-2016

Resumen: ANTECEDENTES Las infecciones del torrente sanguíneo son un problema creciente y actualmente una amenaza para la salud pública. Las bacteriemias representan 15% de todas las infecciones nosocomiales. En los pacientes con VIH el grado de inmunosupresión continúa siendo el factor de riesgo más importante. OBJETIVO Describir las características clínicas, microbiológicas y epidemiológicas de los pacientes con infección por VIH y bacteriemias. MATERIAL Y MÉTODO Estudio observacional, descriptivo, de pacientes mayores de 14 años con hemocultivos positivos del servicio de Medicina Interna del Hospital Universitario de Santander, Colombia, durante los años 2014 a 2016, con infección por VIH y que cumplieran los criterios del CDC para infección del torrente sanguíneo. RESULTADOS Se revisaron 450 expedientes, con 44 pacientes con el diagnóstico confirmado. El 59% eran hombres, el promedio de edad fue de 42 años. La mediana de linfocitos T CD4+ fue de 29 cél/mm3 y 55.8% no tenía tratamiento antirretroviral al ser diagnósticos nuevos. La mortalidad fue de 31.8%. El índice de severidad de PITT se clasificó como leve en 68.1%. El grupo de bacterias más frecuente fueron las enterobacterias, entre ellas destacó K. pneumoniae con 25%. El porcentaje de gérmenes resistentes (E. coli y K. pneumoniae BLEE, P. aeuruginosa MDR, A. baumanii MDR y S. aureus MR) fue de 26.9%. CONCLUSIONES El grupo de pacientes con VIH en la institución es superior al de otras series. Uno de cada cuatro pacientes con infección por VIH y bacteriemias tiene microorganismos resistentes.

Abstract: BACKGROUND Bloodstream infections are a growing problem and currently a threat to public health. Bacteremia accounts for 15% of all nosocomial infections. In patients with HIV, the degree of immunosuppression continues to be the most important risk factor. OBJECTIVE To describe the clinical microbiological and epidemiological characteristics of patients with HIV infection and bacteremia. MATERIAL AND METHOD A descriptive observational study with patients over 14 years of age with positive blood cultures from the internal medicine service of the Hospital Universitario de Santander, Colombia, between 2014 and 2016, with HIV infection and who met the CDC criteria for torrent infection. RESULTS We reviewed 450 records, 44 patients with confirmed diagnosis. 59% were men; the mean age was 42 years. The median of CD4+T lymphocytes count was 29 cells/mm3, 55.8% had no antiretroviral treatment because they were new diagnoses. The mortality rate was 31.8%. The PITT severity index was classified as mild at 68.1%. The most frequent group of bacteria was the Enterobacteriaceae including K. pneumoniae with 25%. The percentage of resistant germs (E. coli and K. pneumoniae BLEE, P. aeuruginosa MDR, A. baumanii MDR and S. aureus MR) was 26.9%. CONCLUSIONS The group of patients with HIV in our institution is superior to other series. One in four patients with HIV infection and bacteremia have resistant microorganism.

Prevalencia de infecciones oportunistas en pacientes con VIH-SIDA con base en el estudio microscópico de médula ósea / Prevalence of opportunistic infections in HIV-AIDS patients based on microscopic examination of bone marrow

Introducción: la utilidad diagnóstica del estudio de médula ósea en pacientes con VIH ha sido evaluada en pocos estudios en Latinoamérica. Se desconoce la frecuencia con la que este estudio aporta a la identificación de infecciones oportunistas en nuestro medio. Diseño: estudio analítico de corte transversal. Métodos: revisión retrospectiva de historias clínicas de pacientes VIH-SIDA, hospitalizados en el Hospital Universitario de Santander entre 2009 y 2012, quienes fueron sometidos a estudio de médula ósea para evaluar citopenias. Se excluyeron casos con historia de neoplasia y quimioterapia tres meses antes del aspirado. Se calculó tamaño de muestra para evaluación de asociaciones. Resultados: se evaluaron 92 muestras de médula ósea de 83 pacientes, encontrando una prevalencia de infección oportunista de 23% con examen directo y 34.5% cuando se realizaron cultivos. La histoplasmosis fue la infección más frecuente 20.6%, seguida de Mycobacterias 10.8%e infección por Criptococcus spp 3.2%. La clínica hematológica que predominó en casos positivos para oportunista fue pancitopenia febril en 41% y monocitopenia en 32%. La deshidrogenasa láctica ≥ 600 UI/dL, se asoció con un diagnóstico positivo para infección oportunista en el estudio microscópico de médula ósea, con OR 5.42 (IC95% 1.09-26.9 p =0.03). Conclusión: el estudio de médula ósea en los pacientes con VIH-SIDA permitió un diagnóstico de infección oportunista en una cuarta parte de los casos, siendo especialmente útil para la identificación temprana de histoplasmosis. Se requieren estudios para evaluar el impacto en estancia hospitalaria, desenlaces clínicos y costos del uso de este examen de forma temprana en el abordaje de pacientes VIH hospitalizados en medicina interna. (Acta Med Colomb 2015; 40: 93-100).

Introduction: the diagnostic utility of the study of bone marrow in patients with HIV has been evaluated in a few studies in Latin America. The frequency with which this study contributes to the identification of opportunists in our country is unknown. Design: Analytical cross-sectional study. Methods: a retrospective review of medical records of HIV-AIDS patients hospitalized at the University Hospital of Santander between 2009 and 2012 who underwent bone marrow study to evaluate cytopenia. Cases with a history of malignancy and chemotherapy three months before vacuuming were excluded. Sample size for evaluation of partnerships was calculated. Results: 92 samples of bone marrow of 83 patients were evaluated, finding a prevalence of opportunistic infection in 23% with direct examination and 34.5% when cultures were performed. Histoplasmosis was the most common infection with 20.6%, followed by 10.8% Mycobacteria and Cryptococcus spp infection 3.2%. The hematologic clinic that prevailed in the positive cases for opportunist was pancitopenia febril (in 41% of the cases) and monocitopenia (in 32% of the cases). The LDH ≥ 600 IU / dL was associated with a positive diagnosis for opportunistic infection in the microscopic study of bone marrow, with OR 5.42 (95% CI 1.09-26.9 p = 0.03). Conclusion: the study of bone marrow in patients with HIV-AIDS allowed a diagnosis of opportunistic infection in a quarter of cases, and is especially useful for early identification of histoplasmosis. Studies to assess the impact on hospital stay, clinical outcomes and costs of using this test early in the approach to HIV patients hospitalized in Internal Medicine are required. (Acta Med Colomb 2015; 40: 93-100).

[Association between glutathione peroxidase levels and clinical manifestations of dengue]. / Correlación entre los niveles de glutatión peroxidasa, un marcador de estrés oxidativo, y la presentación clínica del dengue.

BACKGROUND: Glutathione peroxidase (GP) can be used as a marker of oxidative stress in infectious diseases. AIM: To evaluate the association between the levels of glutathione peroxidase (GP) and the manifestations and complications of dengue. PATIENTS AND METHODS: Between April 2003 and December 2004, 161 patients with dengue were prospectively evaluated. In the first evaluation, within 48 and 96 hours of disease onset, a plasma sample was obtained to measure the GP levels. The association between GP levels, clinical manifestations and complications was evaluated during the follow up. RESULTS: Mean GP values were 1198 U/L (95% confidence interval 1089-1306). Values greater than 1200 U/L were associated with headache, arthralgias and increased heart rate. There was a negative association between GP levels and serum triglycerides. During follow up, patients with GP >1200 U/L had a higher frequency of spontaneous hemorrhages. In a logistic regression analysis arthralgias, fever and increased heart rate, were independently associated with levels >1200 U/L. CONCLUSIONS: GP levels was associated to some of the manifestations of dengue. This finding suggests that the intensity of oxidative stress can influence the clinical presentation of dengue.

Correlación entre los niveles de glutatión peroxidasa, un marcador de estrés oxidativo, y la presentación clínica del dengue / Association between glutathione peroxidase levels and clinical manifestations of dengue

Background: Glutathione peroxidase (GP) can be used as a marker of oxidative stress in infectious diseases. Aim: To evaluate the association between the levels of glutathione peroxidase (GP) and the manifestations and complications of dengue. Patients and Methods: Between April 2003 and December 2004, 161 patients with dengue were prospectively evaluated. In the first evaluation, within 48 and 96 hours of disease onset, a plasma sample was obtained to measure the GP levels. The association between GP levels, clinical manifestations and complications was evaluated during the follow up. Results: Mean GP values were 1198 U/L (95 percent confidence interval 1089-1306). Values greater than 1200 U/L were associated with headache, arthralgias and increased heart rate. There was a negative association between GP levels and serum triglycerides. During follow up, patients with GP >1200 U/L had a higher frequency of spontaneous hemorrhages. In a logistic regression analysis arthralgias, fever and increased heart rate, were independently associated with levels >1200 U/L. Conclusions: GP levels was associated to some of the manifestations of dengue. This finding suggests that the intensity of oxidative stress can influence the clinical presentation of dengue.

Histoplasmosis intestinal em el sindrome de inmunodeficiencia adquirida: presentacion de una caso, Hospital Simon Bolivar, Santa Fe de Bogota / Intestinal histoplasmosis in AIDS

La histoplasmosis intestinal en pacientes con síndrome de inmunodeficiencia adquirida es una entidad rara. Se han descrito pocos casos en la literatura. La mayoría de los pacientes presenta dolor abdominal, pérdida de peso, diarrea, fiebre y hemorragia de vías digestivas. Presentamos el caso de un paciente de sexo masculino, HIV positivo, que desarrolló histoplasmosis colónica y revisamos la literatura.

Transtornos de la secreción ácido-gástrica: nueva forma de inhibirla

La inhibición de la bomba ácida o bomba de protones, como paso definitivo en la regulación de la secresión de ácido clorhídrico, gana cada día más adeptos en la selección del tratamiento más eficaz de la enfermedad ácido péptica. Tres fármacos estan a dispocicion del cuerpo médico: omeprazol, lansoprazol y el más reciente, el pantoprazol

Mesotelioma maligno peritoneal en un jóven sin factores de riesgo: informe de un caso

Se informa el caso de un hombre de 21 años de edad, natural y procedente de Bogotá, ayudante de conductor, quien fue remitido al Hospital Regional Simón Bolívar por cuadro de un mes de evolución consistente en pérdida de peso, febrícula, distención abdominal y desde ocho días antes del ingreso, estreñimiento. Al examen físico se encontró ascitis, acompañada de circulación colateral. El liquido ascítico era de aspecto hemorrágico y el citoquímico compatible con exudado. La ecografía abdominal reportó engrosamiento difuso del peritoneo. En la escanografía abdominal se observó una masa de densidad heterogénea que ocupaba la totalidad de la cavidad, comprometiendo espacios extra e intramesentéricos. Biopsias por punción fueron compatibles con sarcoma mal diferenciado, el estudio histopatológico del tejido posible de resecar durante la cirugía fue concluyente de mesotelioma maligno. No se identificaron factores de riesgo para el desarrollo de este tipo de neoplasia

Genotipos del virus de la Hepatitis C (HCV) en Santa Fe de Bogotá

Con el propósito de conocer el genotipo predominante y las características epidemiológicas del HCV en Santa Fe de Bogotá, se estudiaron 60 muestras de pacientes estudiados previamente por los investigadores y quienes eran anti-HCV positivos. A todos los pacientes se les realizó el HCV RNA por PCR y a los positivos Genotipificación. De las muestras iniciales 33 por ciento fueron negativas para el anti. HCV. El genotipo predominante fue el ib que se encontró en 57.5 por ciento de las muestras seguido por el 1§, en 12.5 por ciento de estas. El promedio de edad de todo el grupo fue de 42 años y 87 por ciento de ellos habían recibido transfusiones de sangre. La duración promedio de la infección fue de 13.5 años. Se encontró hepatitis crónica en 67 por ciento de los casos y Cirrosis Hepática en 33 por ciento. Estos resultados tiene serias implicaciones para la historia natural y el tratamiento del HCV en Colombia