Exome Sequencing Data Analysis and a Case-Control Study in Mexican Population Reveals Lipid Trait Associations of New and Known Genetic Variants in Dyslipidemia-Associated Loci.

Background: Plasma lipid levels are a major risk factor for cardiovascular diseases. Although international efforts have identified a group of loci associated with the risk of dyslipidemia, Latin American populations have been underrepresented in these studies. Objective: To know the genetic variation occurring in lipid-related loci in the Mexican population and its association with dyslipidemia. Methods: We searched for single-nucleotide variants in 177 lipid candidate genes using previously published exome sequencing data from 2838 Mexican individuals belonging to three different cohorts. With the extracted variants, we performed a case-control study. Logistic regression and quantitative trait analyses were implemented in PLINK software. We used an LD pruning using a 50-kb sliding window size, a 5-kb window step size and a r2 threshold of 0.1. Results: Among the 34251 biallelic variants identified in our sample population, 33% showed low frequency. For case-control study, we selected 2521 variants based on a minor allele frequency ≥1% in all datasets. We found 19 variants in 9 genes significantly associated with at least one lipid trait, with the most significant associations found in the APOA1/C3/A4/A5-ZPR1-BUD13 gene cluster on chromosome 11. Notably, all 11 variants associated with hypertriglyceridemia were within this cluster; whereas variants associated with hypercholesterolemia were located at chromosome 2 and 19, and for low high density lipoprotein cholesterol were in chromosomes 9, 11, and 19. No significant associated variants were found for low density lipoprotein. We found several novel variants associated with different lipemic traits: rs3825041 in BUD13 with hypertriglyceridemia, rs7252453 in CILP2 with decreased risk to hypercholesterolemia and rs11076176 in CETP with increased risk to low high density lipoprotein cholesterol. Conclusions: We identified novel variants in lipid-regulation candidate genes in the Mexican population, an underrepresented population in genomic studies, demonstrating the necessity of more genomic studies on multi-ethnic populations to gain a deeper understanding of the genetic structure of the lipemic traits.

Composition-Dependent Cytotoxic and Antibacterial Activity of Biopolymer-Capped Ag/Au Bimetallic Nanoparticles against Melanoma and Multidrug-Resistant Pathogens.

Nanostructured silver (Ag) and gold (Au) are widely known to be potent biocidal and cytotoxic agents as well as biocompatible nanomaterials. It has been recently reported that combining both metals in a specific chemical composition causes a significant enhancement in their antibacterial activity against antibiotic-resistant bacterial strains, as well as in their anticancer effects, while preserving cytocompatibility properties. In this work, Ag/Au bimetallic nanoparticles over a complete atomic chemical composition range were prepared at 10 at% through a green, highly reproducible, and simple approach using starch as a unique reducing and capping agent. The noble metal nanosystems were thoroughly characterized by different analytical techniques, including UV-visible and FT-IR spectroscopies, XRD, TEM/EDS, XPS and ICP-MS. Moreover, absorption spectra simulations for representative colloidal Ag/Au-NP samples were conducted using FDTD modelling. The antibacterial properties of the bimetallic nanoparticles were determined against multidrug-resistant Escherichia coli and methicillin-resistant Staphylococcus aureus, showing a clear dose-dependent inhibition even at the lowest concentration tested (5 µg/mL). Cytocompatibility assays showed a medium range of toxicity at low and intermediate concentrations (5 and 10 µg/mL), while triggering an anticancer behavior, even at the lowest concentration tested, in a process involving reactive oxygen species production per the nanoparticle Au:Ag ratio. In this manner, this study provides promising evidence that the presently fabricated Ag/Au-NPs should be further studied for a wide range of antibacterial and anticancer applications.

Ten-Week Sucralose Consumption Induces Gut Dysbiosis and Altered Glucose and Insulin Levels in Healthy Young Adults.

Sucralose consumption alters microbiome and carbohydrate metabolism in mouse models. However, there are no conclusive studies in humans. Our goals were to examine the effect of sucralose consumption on the intestinal abundance of bacterial species belonging to Actinobacteria, Bacteroidetes, and Firmicutes and explore potential associations between microbiome profiles and glucose and insulin blood levels in healthy young adults. In this open-label clinical trial, volunteers randomly drank water, as a control (n = 20), or 48 mg sucralose (n = 20), every day for ten weeks. At the beginning and the end of the study, participants were subjected to an oral glucose tolerance test (OGTT) to measure serum glucose and insulin every 15 min for 3 h and provided fecal samples to assess gut microbiota using a quantitative polymerase chain reaction. Sucralose intake altered the abundance of Firmicutes without affecting Actinobacteria or Bacteroidetes. Two-way ANOVA revealed that volunteers drinking sucralose for ten weeks showed a 3-fold increase in Blautia coccoides and a 0.66-fold decrease in Lactobacillus acidophilus compared to the controls. Sucralose consumption increased serum insulin and the area under the glucose curve compared to water. Long-term sucralose ingestion induces gut dysbiosis associated with altered insulin and glucose levels during an OGTT.

Quasi-Saturated Layer: Implications for Estimating Recharge and Groundwater Modeling.

This study presents an extension of the concept of "quasi-saturation" to a quasi-saturated layer, defined as the uppermost dynamic portion of the saturated zone subject to water table fluctuations. Entrapped air here may cause substantial reductions in the hydraulic conductivity (K) and fillable pore water. Air entrapment is caused by a rising water table, usually as a result of groundwater recharge. The most significant effects of entrapped air are recharge overestimation based on methods that use specific yield (Sy ), such as the water table fluctuation method (WTF), and reductions in K values. These effects impact estimation of fluid flow velocities and contaminant migration rates in groundwater. In order to quantify actual groundwater recharge rates and the effects of entrapped air, numerical simulations with the FEFLOW (Version 7.0) groundwater flow model were carried out using a quasi-saturated layer for a pilot area in Rio Claro, Brazil. The calculated recharge rate represented 16% of the average precipitation over an 8-year period, approximately half of estimates using the WTF method. Air entrapment amounted to a fillable porosity of 0.07, significant lower that the value of 0.17 obtained experimentally for Sy . Numerical results showed that the entrapped air volume in the quasi-saturated layer can be very significant (0.58 of the air fraction) and hence can significantly affect estimates of groundwater recharge and groundwater flow rates near the water table.

Genetic variability of five ADRB2 polymorphisms among Mexican Amerindian ethnicities and the Mestizo population.

The Mexican population is characterized by high and particular admixture, and the picture of variants associated with disease remains unclear. Here we investigated the distribution of single nucleotide polymorphisms (SNPs) in the Mexican population. We focused on two non-synonymous and three synonymous SNPs in the beta-2 adrenergic receptor gene (ADRB2), which plays key roles in energy balance regulation. These SNPs were genotyped in 2,011 Mexican Amerindians (MAs) belonging to 62 ethnic groups and in 1,980 geographically matched Mexican Mestizos (MEZs). The frequency distribution of all five ADRB2 variants significantly differed between MAs, MEZs, and other continental populations (CPs) from the 1000 Genomes database. Allele frequencies of the three synonymous SNPs rs1042717A, rs1042718A, and rs1042719C were significantly higher in Mexican individuals, particularly among MAs, compared to in the other analyzed populations (P<0.05). The non-synonymous ADRB2 Glu27 allele (rs1042714G), which is associated with several common conditions, showed the lowest frequency in MAs (0.03) compared to other populations worldwide. Among MEZs, this allele showed a frequency of 0.15, intermediate between that in MAs and in Iberians (0.43). Moreover, Glu27 was the only SNP exhibiting a geographic gradient within the MEZ population (from 0.22 to 0.11), reflecting admixed mestizo ancestry across the country. Population differentiation analysis demonstrated that Glu27 had the highest FST value in MAs compared with Europeans (CEU) (0.71), and the lowest between MAs and Japanese (JPT) (0.01), even lower than that observed between MAs and MEZs (0.08). This analysis demonstrated the genetic diversity among Amerindian ethnicities, with the most extreme FST value (0.34) found between the Nahuatls from Morelos and the Seris. This is the first study of ADRB2 genetic variants among MA ethnicities. Our findings add to our understanding of the genetic contribution to variability in disease susceptibility in admixed populations.

Toxic shock syndrome caused by Streptococcus dysgalactiae subsp. equisimilis in a Mexican preschool patient / Síndrome de choque tóxico por Streptococcus dysgalactiae subsp. equisimilis en un paciente preescolar mexicano

Abstract Background: Severe infections due to Streptococcus dysgalactiae subsp. equisimilis (SDSE) have been identified in adults and may cause toxic shock syndrome, although with a low frequency. Case report: A preschool-age female patient, who started with an upper respiratory tract infection developing a gradual deterioration in the following three days, is described. She was admitted to the hospital in severe conditions, with tachypnea, tachycardia (200/min), hypotension (blood pressure 68/40 mmHg), capillary refill of 7 s, and erythematous maculopapular rash in thorax, abdomen and lower extremities. She received intensive management with an inadequate response. Furthermore, she developed multiple organ failure and died 8 h after admission. The blood culture was positive for S. dysgalactiae subsp. equisimilis. Conclusions: SDSE is a rare pathogen in children. In Mexico, cases of SDSE have not been reported probably due to an inaccurate identification. Mexican pediatricians should be alert to this situation.

Resumen Introducción: En adultos, se han identificado infecciones graves por Streptococcus dysgalactiae subsp. equisimilis (SDSE), que pueden causar el síndrome de choque tóxico causado por SDSE, aunque es de baja frecuencia. Caso clínico: Paciente de sexo femenino en edad preescolar. Comenzó con una infección del tracto respiratorio superior, y desarrolló un deterioro gradual en los siguientes tres días. Ingresó en el hospital en condiciones graves, con taquipnea, taquicardia (200/min), hipotensión (tensión arterial, TA 68/40 mmHg), llenado capilar de 7 s y erupción maculopapular eritematosa en el tórax, abdomen y extremidades inferiores. Recibió manejo intensivo, sin una buena respuesta. Posteriormente, desarrolló datos de falla orgánica múltiple y murió 8 h después de su ingreso. El hemocultivo fue positivo para S. dysgalactiae subsp. equisimilis. Conclusiones: El SDSE es un patógeno raro en los niños. En México, no se han reportado casos de SDSE probablemente debido a una identificación errónea. Los pediatras mexicanos deben estar atentos a esta situación.

Toxic shock syndrome caused by Streptococcus dysgalactiae subsp. equisimilis in a Mexican preschool patient.

Background: Severe infections due to Streptococcus dysgalactiae subsp. equisimilis (SDSE) have been identified in adults and may cause toxic shock syndrome, although with a low frequency. Case report: A preschool-age female patient, who started with an upper respiratory tract infection developing a gradual deterioration in the following three days, is described. She was admitted to the hospital in severe conditions, with tachypnea, tachycardia (200/min), hypotension (blood pressure 68/40 mmHg), capillary refill of 7 s, and erythematous maculopapular rash in thorax, abdomen and lower extremities. She received intensive management with an inadequate response. Furthermore, she developed multiple organ failure and died 8 h after admission. The blood culture was positive for S. dysgalactiae subsp. equisimilis. Conclusions: SDSE is a rare pathogen in children. In Mexico, cases of SDSE have not been reported probably due to an inaccurate identification. Mexican pediatricians should be alert to this situation..

Introducción: En adultos, se han identificado infecciones graves por Streptococcus dysgalactiae subsp. equisimilis (SDSE), que pueden causar el síndrome de choque tóxico causado por SDSE, aunque es de baja frecuencia. Caso clínico: Paciente de sexo femenino en edad preescolar. Comenzó con una infección del tracto respiratorio superior, y desarrolló un deterioro gradual en los siguientes tres días. Ingresó en el hospital en condiciones graves, con taquipnea, taquicardia (200/min), hipotensión (tensión arterial, TA 68/40 mmHg), llenado capilar de 7 s y erupción maculopapular eritematosa en el tórax, abdomen y extremidades inferiores. Recibió manejo intensivo, sin una buena respuesta. Posteriormente, desarrolló datos de falla orgánica múltiple y murió 8 h después de su ingreso. El hemocultivo fue positivo para S. dysgalactiae subsp. equisimilis. Conclusiones: El SDSE es un patógeno raro en los niños. En México, no se han reportado casos de SDSE probablemente debido a una identificación errónea. Los pediatras mexicanos deben estar atentos a esta situación.

Fiebre manchada de montañas rocosas: experiencia en 5 años de vigilancia activa en un hospital pediátrico de segundo nivel en el noreste de México / Rocky mountain spotted fever: five years of active surveillance experience in a second level pediatric hospital in northeastern Mexico

Resumen: Introducción: La fiebre manchada de las montañas rocosas (FMMR) es causada por Rickettsia rickettsii. En Coahuila, la región de la Comarca Lagunera se considera una zona endémica. No se han reportado casos en la zona sur del estado, específicamente en la ciudad de Saltillo. Métodos: Estudio prospectivo, reporte de casos. Se incluyeron los casos de niños atendidos en el Hospital del Niño Dr. Federico Gómez Santos en la ciudad de Saltillo, Coah., del mes de septiembre de 2012 a septiembre 2017 con diagnóstico confirmado clínicamente y por reacción en cadena de la polimerasa (PCR) de FMMR. Se presentan los antecedentes epidemiológicos, las características clínicas y evolución de los pacientes. Resultados: Se confirmaron 14 pacientes. La relación masculino:femenino fue de 1.8:1, la edad promedio de los pacientes fue de 7.6 años (18 meses a 13 años). El 42.8% de los pacientes refirió el contacto con perros y el 57.1% afirmó tener contacto con garrapatas. En todos los casos hubo fiebre y exantema purpúrico; alrededor del 70% manifestaron mialgias y artralgias; el 28% tuvo sangrado del tubo digestivo, y el 11% alteraciones neurológicas graves. El 64.2% de los casos recibió tratamiento adecuado con doxiciclina. Fallecieron 8 pacientes, con una tasa de letalidad de 57.1%. Conclusiones: La zona sur de Coahuila debe considerarse una zona endémica para FMMR. El retraso en el diagnóstico y tratamiento favorecen una mayor letalidad.

Abstract: Background: Rocky Mountain Spotted Fever (RMSF) is caused by Rickettsia rickettsii. In Coahuila, Comarca Lagunera is considered an endemic zone; no cases have been reported in the southern zone of the state, specifically in the city of Saltillo­. Methods: Prospective study, cases report. Children evaluated in the Hospital del Niño Dr. Federico Gómez Santos from September 2012 to September 2017, with clinically and laboratory (by polymerase chain reaction, PCR) confirmed diagnosis of FMMR were included. The epidemiological antecedents, clinical characteristics and patient's evolution are presented. Results: 14 patients were confirmed. The male: female ratio was 1.8: 1, the average age of the patients was 7.6 years (18 months to 13 years). 42.8% reported contact with dogs and 57.1% confirmed contact with ticks. In all cases, there was fever and purpuric rash; around 70% manifested myalgias and arthralgias; 28% presented digestive tract bleeding and 11% had severe neurological alterations. 64.2% of the cases received adequate treatment with doxycycline. Eight patients died with a case fatality rate of 57.1%. Conclusions: The southern zone of Coahuila should be considered an endemic area for FMMR. The delay in diagnosis and treatment favor a greater lethality.

Gene variants in AKT1, GCKR and SOCS3 are differentially associated with metabolic traits in Mexican Amerindians and Mestizos.

Amerindian ancestry appears to be a risk factor for metabolic diseases (MetD), making Mexicans an ideal population to better understand the genetic architecture of metabolic health. In this study, we determine the association of genetic variants previously reported with metabolic entities, in two Mexican populations, including the largest sample of Amerindians reported to date. We investigated the association of eigth single-nucleotide polymorphisms (SNPs) in AKT1, GCKR, and SOCS3 genes with different metabolic traits in 1923 Mexican Amerindians (MAs) belonging to 57 ethnic groups, and 855 Mestizos (MEZs). The allele frequency of 7/8 SNPs showed significant differences between MAs and MEZs. Interestingly, some alleles were monomorphic in particular ethnic groups, and highly frequent in other ones. With the exception of GCKR rs1260326T, as expected, all SNP frequencies in the MEZ population had intermediate values between its two main ancestral populations (MAs and Iberian populations in Spain [IBS]). We detected ethnic differences in linkage disequilibrium patterns and haplotype structure between MAs and MEZs, possibly due to the high genetic heterogeneity in these populations. Remarkably, AKT1 was associated with hypertension in MEZs, but not in MAs. GCKR was associated with protection against type 2 diabetes (T2D) in MAs, and with hypertriglyceridemia and protection against low HDL Cholesterol (HDL-C) levels in MEZs. The CAT haplotype in SOCS3 was associated with metabolic syndrome (MetS) in MEZs, and correlated with protection against high blood pressure (HBP) and risk for high waist circumference and T2D in MAs. Our results show differential genetic associations with metabolic traits between MAs and MEZs, possibly due to the differences in genetic structure between these Mexican populations.

[Fiebre manchada de montañas rocosas: experiencia en 5 años de vigilancia activa en un hospital pediátrico de segundo nivel en el noreste de México]. / Rocky mountain spotted fever: five years of active surveillance experience in a second level pediatric hospital in northeastern Mexico.

Introducción: La fiebre manchada de las montañas rocosas (FMMR) es causada por Rickettsia rickettsii. En Coahuila, la región de la Comarca Lagunera se considera una zona endémica. No se han reportado casos en la zona sur del estado, específicamente en la ciudad de Saltillo. Métodos: Estudio prospectivo, reporte de casos. Se incluyeron los casos de niños atendidos en el Hospital del Niño Dr. Federico Gómez Santos en la ciudad de Saltillo, Coah., del mes de septiembre de 2012 a septiembre 2017 con diagnóstico confirmado clínicamente y por reacción en cadena de la polimerasa (PCR) de FMMR. Se presentan los antecedentes epidemiológicos, las características clínicas y evolución de los pacientes. Resultados: Se confirmaron 14 pacientes. La relación masculino:femenino fue de 1.8:1, la edad promedio de los pacientes fue de 7.6 años (18 meses a 13 años). El 42.8% de los pacientes refirió el contacto con perros y el 57.1% afirmó tener contacto con garrapatas. En todos los casos hubo fiebre y exantema purpúrico; alrededor del 70% manifestaron mialgias y artralgias; el 28% tuvo sangrado del tubo digestivo, y el 11% alteraciones neurológicas graves. El 64.2% de los casos recibió tratamiento adecuado con doxiciclina. Fallecieron 8 pacientes, con una tasa de letalidad de 57.1%. Conclusiones: La zona sur de Coahuila debe considerarse una zona endémica para FMMR. El retraso en el diagnóstico y tratamiento favorecen una mayor letalidad. Background: Rocky Mountain Spotted Fever (RMSF) is caused by Rickettsia rickettsii. In Coahuila, Comarca Lagunera is considered an endemic zone; no cases have been reported in the southern zone of the state, specifically in the city of ­Saltillo. Methods: Prospective study, cases report. Children evaluated in the Hospital del Niño Dr. Federico Gómez Santos from September 2012 to September 2017, with clinically and laboratory (by polymerase chain reaction, PCR) confirmed diagnosis of FMMR were included. The epidemiological antecedents, clinical characteristics and patient's evolution are presented. Results: 14 patients were confirmed. The male: female ratio was 1.8: 1, the average age of the patients was 7.6 years (18 months to 13 years). 42.8% reported contact with dogs and 57.1% confirmed contact with ticks. In all cases, there was fever and purpuric rash; around 70% manifested myalgias and arthralgias; 28% presented digestive tract bleeding and 11% had severe neurological alterations. 64.2% of the cases received adequate treatment with doxycycline. Eight patients died with a case fatality rate of 57.1%. Conclusions: The southern zone of Coahuila should be considered an endemic area for FMMR. The delay in diagnosis and treatment favor a greater lethality.

Initiating a Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods Study.

Background:Few data exist for referral processes in resource-limited settings. We utilized mixed-methods to evaluate the impact of a standardized algorithm and training module developed for locally identified needs in referral/counter-referral procedures between primary health centers (PHCs) and a Guatemalan referral hospital. Methods: PHC personnel and hospital physicians participated in surveys and focus groups pre-implementation and 3, 6, and 12 months post-implementation to evaluate providers' experience with the system. Referred patient records were reviewed to evaluate system effectiveness. Results: A total of 111 initial focus group participants included 96 (86.5%) from PHCs and 15 from the hospital. Of these participants, 53 PHC physicians and nurses and 15 hospital physicians initially completed written surveys. Convenience samples participated in follow-up. Eighteen focus groups achieved thematic saturation. Four themes emerged: effective communication; provision of timely, quality patient care with adequate resources; educational opportunities; and development of empowerment and relationships. Pre- and post-implementation surveys demonstrated significant improvement at the PHCs (P < .001) and the hospital (P = .02). Chart review included 435 referrals, 98 (22.5%) pre-implementation and 337 (77.5%) post-implementation. There was a trend toward an increased percentage of appropriately referred patients requiring medical intervention (30% vs 40%, P = .08) and of patients requiring intervention who received it prior to transport (55% vs 73%, P = .06). Conclusions: Standardizing a referral/counter-referral system improved communication, education, and trust across different levels of pediatric health care delivery. This model may be used for extension throughout Guatemala or be modified for use in other countries. Mixed-methods research design can evaluate complex systems in resource-limited settings.

Timing, method and discontinuation of hydrocortisone administration for septic shock patients.

AIM: To characterize the prescribing patterns for hydrocortisone for patients with septic shock and perform an exploratory analysis in order to identify the variables associated with better outcomes. METHODS: This prospective cohort study included 59 patients with septic shock who received stress-dose hydrocortisone. It was performed at 2 critical care units in academic hospitals from June 1st, 2015, to July 31st, 2016. Demographic data, comorbidities, medical management details, adverse effects related to corticosteroids, and outcomes were collected after the critical care physician indicated initiation of hydrocortisone. Univariate comparison between continuous and bolus administration of hydrocortisone was performed, including multivariate analysis, as well as Kaplan-Meier analysis to compare the proportion of shock reversal at 7 d after presentation. Receiver operating characteristic (ROC) curves determined the best cut-off criteria for initiation of hydrocortisone associated with the highest probability of shock reversal. We addressed the effects of the taper strategy for discontinuation of hydrocortisone, noting risk of shock relapse and adverse effects. RESULTS: All-cause 30-d mortality was 42%. Hydrocortisone was administered as a continuous infusion in 54.2% of patients; time to reversal of shock was 49 h longer in patients who were given a bolus administration [59 h (range, 47.5-90.5) vs 108 h (range, 63.2-189); P = 0.001]. The maximal dose of norepinephrine after initiation of hydrocortisone was lower in patients on continuous infusion [0.19 µg/kg per minute (range, 0.11-0.28 µg)] compared with patients who were given bolus [0.34 µg/kg per minute (range, 0.16-0.49); P = 0.004]. Kaplan-Meier analysis revealed a higher proportion of shock reversal at 7 d in patients with continuous infusion compared to those given bolus (83% vs 63%; P = 0.004). There was a good correlation between time to initiation of hydrocortisone and time to reversal of shock (r = 0.80; P < 0.0001); ROC curve analysis revealed that the best criteria for prediction of shock reversal was a time to initiation of hydrocortisone of ≤ 13 h after administration of norepinephrine, with an area under the curve of 0.81 (P < 0.001). The maximal dose of norepinephrine at initiation of hydrocortisone with the highest association with shock reversal was ≤ 0.28 µg/kg per minute, with an area under the curve of 0.75 (P = 0.0002). On a logistic regression model, hydrocortisone taper was not associated with a lower risk of shock relapse (RR = 1.29; P = 0.17) but was related to a higher probability of hyperglycemia [odds ratio (OR), 5.3; P = 0.04] and hypokalemia (OR = 10.6; P = 0.01). CONCLUSION: Continuous infusion of hydrocortisone could hasten the resolution of septic shock compared to bolus administration. Earlier initiation corresponds with a higher probability of shock reversal. Tapering strategy is unnecessary.

Self-assembly of a supramolecular network with pseudo-rotaxane cross-linking nodes and its transformation into a mechanically locked structure by rotaxane formation.

A main chain poly(crown ether) macromolecule has been cross-linked with a two binding site guest to afford a stimuli-responsive supramolecular polymeric network with pseudo-rotaxane nodes. This network forms gels and films that are responsive to temperature and solvent polarity; however, the materials can be shielded against both effects by transforming the pseudo-rotaxane junctions into rotaxane links, creating a mechanically locked structure.

Regional scale-up of an Emergency Triage Assessment and Treatment (ETAT) training programme from a referral hospital to primary care health centres in Guatemala.

OBJECTIVE: Emergency Triage Assessment and Treatment (ETAT) was developed by the WHO to teach paediatric assessment, triage and initial management to healthcare workers (HCWs) in resource-limited hospital-based settings. This study sought to evaluate the extension of ETAT training from a regional hospital to paediatric HCWs at local primary care health centres (PHCs) in Guatemala. METHODS: Prior to providing a 16 h ETAT training module, immediately after, and at 3, 6 and 12 months, we used written pre-tests and post-tests and five-point Likert surveys to evaluate, respectively, clinical knowledge and provider confidence in providing acute care paediatrics; hands-on clinical skills were tested at 3, 6 and 12 months. RESULTS: Fifty-two HCWs (14 general physicians, 38 nurses) from four regional PHCs participated; 65%, 60% and 46% completed 3-month, 6-month and 12-month follow-ups, respectively. Test scores show significant acquisition of clinical knowledge initially, which was retained over time when tested at 3, 6 and 12 months (46 vs 70, p<0.001). Hands-on clinical skills scores demonstrated retention at 3, 6 and 12 months. Although participants were more confident about acute care paediatrics immediately after training (66 vs 104, p<0.001), this decreased with time, though not to pre-intervention levels. CONCLUSIONS: ETAT trainings were successfully extended to PHCs in a resource-limited setting with significant knowledge acquisition and retention over time and improved HCW confidence with acute care paediatrics. This process could serve as a successful model for in-country and international scale-up of ETAT.

Quality and Effectiveness of a Pediatric Triage Training Program in a Guatemalan Public Hospital.

OBJECTIVES: This study aimed to develop and implement an Emergency Triage Assessment and Treatment (ETAT) training program at a Guatemalan public hospital. Collaborators included Baylor College of Medicine/Texas Children's Hospital, the Guatemalan Ministry of Health, and the Pan American Health Organization. METHODS: The ETAT is a World Health Organization program to teach pediatric assessment, triage, and initial management to health care workers in resource-limited settings. The Baylor College of Medicine/Texas Children's Hospital created ETAT training materials in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas [CETEP]) and conducted a train-the-trainer course for Hospital Nacional Pedro Bethancourt (HNPB) health care leadership. The HNPB subsequently conducted local trainings using a modified curriculum. Midcourse modifications based on evaluations and focus groups included distribution of manuals before training and an adding a day to the course.Course quality was assessed using participant evaluations and comparing pretest and posttest scores. Effectiveness was defined as 90% concordance between triage levels assigned by participants and facilitators. RESULTS: A total of 249 health care workers were trained by 24 HNPB facilitators. Mean pretest and posttest scores were 55 and 70, respectively (P < 0.001). On a 4-point scale, participants rated overall course quality and effectiveness as 3.6. Mean pretest (49 vs 58, P = 0.002) and posttest scores (68 vs 72, P = 0.01) improved for groups trained after modifications, as did evaluations for course quality (3.4 vs 3.7, P < 0.001) and effectiveness (3.4 vs 3.8, P < 0.001). Triage levels were assigned with 95% concordance (confidence interval, 91.9-97.3) between participants and facilitators. CONCLUSIONS: Hospital Nacional Pedro Bethancourt experts conducted high-quality trainings with locally relevant CETEP (ETAT) material. Trainings were effective and well received. The pediatric emergency department at HNPB now uses a triage system based on CETEP (ETAT).

Impact of an Emergency Triage Assessment and Treatment (ETAT)-based triage process in the paediatric emergency department of a Guatemalan public hospital.

BACKGROUND: Triage process implementation has been shown to be effective at improving patient outcomes. This study sought to develop, implement and assess the impact of an Emergency Triage Assessment and Treatment (ETAT)-based emergency triage process in the paediatric emergency department (PED) of a public hospital in Guatemala. METHODS: The study was a quality improvement comparison with a before/after design. Uptake was measured by percentage of patients with an assigned triage category. Outcomes were hospital admission rate, inpatient length of stay (LOS), and mortality as determined by two distinct medical record reviews for 1 year pre- and post-intervention: a random sample (RS) of all PED patients and records for all critically-ill (CI) children [serious diagnoses or admission to the paediatric intensive care unit (PICU)]. Demographics, diagnoses and disposition were recorded. RESULTS: The RS totalled 1027 (51.4% male); median ages pre- and post-intervention were 2.0 and 2.4 years, respectively. There were 196 patients in the CI sample, of whom 56.6% were male and one-third were neonates; median ages of the CI group pre- and post-intervention were 3.1 and 5.6 months, respectively. One year after implementation, 97.5% of medical records had been assigned triage categories. Triage categories (RS/CI) were: emergency (2.9%/54.6%), priority (47.6%/44.4%) and non-urgent (49.4%/1.0%). The CI group was more frequently diagnosed with shock (25%/1%), seizures (9%/0.5%) and malnutrition (6%/0.5%). Admission rates for the RS (8% vs 4%, P=0.01) declined after implementation. For the CI sample, admission rate to the PICU (47% vs 24%, P=0.002) decreased and LOS (7.3 vs 5.7 days, P=0.09) and mortality rates (12% vs 6%, P=0.15) showed trends toward decreasing post-implementation. CONCLUSIONS: Paediatric-specific triage algorithms can be implemented and sustained in resource-limited settings. Significant decreases in admission rates (both overall and for the PICU) and trends towards decreased LOS and mortality rates of critically ill children suggest that ETAT-based triage systems have the potential to greatly improve patient care in Latin America.

Similarities and differences among the chromosomes of the wild guinea pig Cavia tschudii and the domestic guinea pig Cavia porcellus (Rodentia, Caviidae).

Cavia tschudii Fitzinger, 1867 is a wild guinea pig species living in South America that according to the analysis of mitochondrial genes is the closest wild form of the domestic guinea pig. To investigate the genetic divergence between the wild and domestic species of guinea pigs from a cytogenetic perspective, we characterized and compared the C, G and AgNOR banded karyotypes of molecularly identified Cavia tschudii and Cavia porcellus Linnaeus, 1758 specimens for the first time. Both species showed 64 chromosomes of similar morphology, although C. tschudii had four medium size submetacentric pairs that were not observed in the C. porcellus karyotype. Differences in the C bands size and the mean number of AgNOR bands between the karyotypes of the two species were detected. Most of the two species chromosomes showed total G band correspondence, suggesting that they probably represent large syntenic blocks conserved over time. Partial G band correspondence detected among the four submetacentric chromosomes present only in the C. tschudii karyotype and their subtelocentric homologues in C. porcellus may be explained by the occurrence of four pericentric inversions that probably emerged and were fixed in the C. tschudii populations under domestication. The role of the chromosomal and genomic differences in the divergence of these two Cavia species is discussed.