Development of Spatio-Temporal Land Use Regression Models for Fine Particulate Matter and Wood-Burning Tracers in Temuco, Chile.

Biomass burning is common in much of the world, and in some areas, residential wood-burning has increased. However, air pollution resulting from biomass burning is an important public health problem. A sampling campaign was carried out between May 2017 and July 2018 in over 64 sites in four sessions, to develop a spatio-temporal land use regression (LUR) model for fine particulate matter (PM) and wood-burning tracers levoglucosan and soluble potassium (Ksol) in a city heavily impacted by wood-burning. The mean (sd) was 46.5 (37.4) µg m-3 for PM2.5, 0.607 (0.538) µg m-3 for levoglucosan, and 0.635 (0.489) µg m-3 for Ksol. LUR models for PM2.5, levoglucosan, and Ksol had a satisfactory performance (LOSOCV R2), explaining 88.8%, 87.4%, and 87.3% of the total variance, respectively. All models included sociodemographic predictors consistent with the pattern of use of wood-burning in homes. The models were applied to predict concentrations surfaces and to estimate exposures for an epidemiological study.

Temporal and Spatial Trends of Adverse Pregnancy and Birth Outcomes in a Sample of Births from a Public Hospital in Chile.

Understanding temporal and spatial trends in pregnancy and birth outcomes within an urban area is important for the monitoring of health indicators of a population. We conducted a retrospective cohort study of all births in the public hospital of Temuco, a medium-sized city in Southern Chile between 2009 and 2016 (n = 17,237). Information on adverse pregnancy and birth outcomes, as well as spatial and maternal characteristics (insurance type, employment, smoking, age, and overweight/obesity), was collected from medical charts. Home addresses were geocoded and assigned to neighborhood. We tested whether births and prevalence of adverse pregnancy outcomes changed over time, whether birth events were spatially clustered (Moran's I statistic), and whether neighborhood deprivation was correlated to outcomes (Spearman's rho). We observed decreases in eclampsia, hypertensive disorders of pregnancy, and small for gestational age, while gestational diabetes, preterm birth, and low birth weight increased over the study period (all p < 0.01 for trend), with little changes after adjusting for maternal characteristics. We observed neighborhood clusters for birth rate, preterm birth, and low birth weight. Neighborhood deprivation was negatively correlated with low birth weight and preterm birth, but not correlated with eclampsia, preeclampsia, hypertensive disorders of pregnancy, small for gestational age, gestational diabetes, nor stillbirth. Several encouraging downward trends and some increases in adverse pregnancy and birth outcomes, which, overall, were not explained by changes in maternal characteristics were observed. Identified clusters of higher adverse birth outcomes may be used to evaluate preventive health coverage in this setting.

Adverse pregnancy and perinatal outcomes in Latin America and the Caribbean: systematic review and meta-analysis.

Objective: To estimate the point prevalence and likely ranges of pregnancy-induced hypertension, pre-eclampsia, gestational diabetes, low birth weight and preterm delivery in Latin America and the Caribbean, and evaluate the heterogeneity of the estimates. Methods: We conducted a systematic review and meta-analysis of observational studies reporting the prevalence of maternal and perinatal adverse outcomes in populations in Latin American and the Caribbean published between 2000 and 2019 in English, Spanish, or Portuguese. We searched PubMed, Embase, and LILACS. We estimated the point prevalence and evaluated overall heterogeneity and, in sub-group analyses, heterogeneity by study design and level of bias. Results: Of 1087 records retrieved, 50 articles were included in the review: two on hypertensive disorders of pregnancy, 14 on pre-eclampsia, six on gestational diabetes, nine on low birth weight and 19 on preterm birth. No meta-analysis for hypertensive disorders of pregnancy could be done because of the small number of studies. Point prevalence estimates and 95% confidence intervals (CIs) for pre-eclampsia, gestational diabetes, low birth weight, and preterm birth were: 6.6% (95% CI: 4.9%, 8.6%), 8.5% (95% CI: 3.9%, 14.7%), 8.5% (95% CI: 7.2%, 9.8%), and 10.0% (95% CI: 8.0%, 12.0%), respectively. We observed substantial heterogeneity overall and by study design. No major differences in estimates were observed by level of bias. Conclusions: The results of this study provide updated estimates of some of the most prevalent adverse pregnancy and perinatal outcomes in Latin America and the Caribbean. They highlight that important heterogeneity exists in prevalence estimates, which may reflect the diversity of populations in the region.

Quality of automatic geocoding tools: a study using addresses from hospital record files in Temuco, Chile.

Automatic geocoding methods have become popular in recent years, facilitating the study of the association between health outcomes and the place of living. However, rather few studies have evaluated geocoding quality, with most of them being performed in the US and Europe. This article aims to compare the quality of three automatic online geocoding tools against a reference method. A subsample of 300 handwritten addresses from hospital records was geocoded using Bing, Google Earth, and Google Maps. Match rates were higher (> 80%) for Google Maps and Google Earth compared with Bing. However, the accuracy of the addresses was better for Bing with a larger proportion (> 70%) of addresses with positional errors below 20m. Generally, performance did not vary for each method for different socioeconomic status. Overall, the methods showed an acceptable, but heterogeneous performance, which may be a warning against the use of automatic methods without assessing quality in other municipalities, particularly in Chile and Latin America.

Quality of automatic geocoding tools: a study using addresses from hospital record files in Temuco, Chile / Calidad de las herramientas automáticas de geocodificación: un estudio usando direcciones de fichas de registro hospitalario en Temuco, Chile / A qualidade das ferramentas de geocodificação automática: um estudo utilizando endereços de prontuários hospitalares em Temuco, Chile

Abstract: Automatic geocoding methods have become popular in recent years, facilitating the study of the association between health outcomes and the place of living. However, rather few studies have evaluated geocoding quality, with most of them being performed in the US and Europe. This article aims to compare the quality of three automatic online geocoding tools against a reference method. A subsample of 300 handwritten addresses from hospital records was geocoded using Bing, Google Earth, and Google Maps. Match rates were higher (> 80%) for Google Maps and Google Earth compared with Bing. However, the accuracy of the addresses was better for Bing with a larger proportion (> 70%) of addresses with positional errors below 20m. Generally, performance did not vary for each method for different socioeconomic status. Overall, the methods showed an acceptable, but heterogeneous performance, which may be a warning against the use of automatic methods without assessing quality in other municipalities, particularly in Chile and Latin America.

Resumen: Los métodos automáticos de geocodificación se han convertido en algo popular durante los últimos años para facilitar el estudio de la asociación entre resultados de salud y lugar para vivir. No obstante, más bien pocos estudios han evaluado la calidad de la geocodificación, siendo realizados la mayoría de ellos en EE.UU. y Europa. El objetivo de este artículo es comparar la calidad de tres herramientas automáticas de geocodificación en línea frente a un método de referencia. La submuestra de 300 direcciones escritas a mano, procedentes del registro hospitalario, se geocodificaron usando Bing, Google Earth y Google Maps. Los porcentajes de coincidencia fueron mayores (> 80%) en el caso de Google Maps y Google Earth comparados con Bing. Sin embargo, la precisión de las direcciones fue mejor con Bing, en una proporción más grande (> 70%) de direcciones que tenían errores de posición por debajo de 20m. En general, el rendimiento no varió en cada método para diferentes niveles estatus socioeconómico. En general, los métodos mostraron un rendimiento aceptable, pero heterogéneo. Esto previene contra el uso de métodos automáticos sin evaluar la calidad en otras ciudades, particularmente en Chile y Latinoamérica.

Resumo: Os métodos de geocodificação automática se tornaram populares nos últimos anos para facilitar o estudo da associação entre desfechos de saúde e lugar de residência. Entretanto, poucos estudos avaliaram a qualidade da geocodificação, e a maioria dos estudos existentes foi realizada nos Estados Unidos e Europa. O estudo teve como objetivo comparar a qualidade de três ferramentas de geocodificação eletrônica automática em relação a um método de referência. Foi geocodificada uma subamostra de 300 endereços anotados à mão em prontuários hospitalares, usando Bing, Google Earth e Google Maps. As taxas de correspondência dos registros foram mais altas (> 80%) com Google Maps e Google Earth, comparado com Bing. Entretanto, a acurácia dos endereços foi melhor com Bing, com uma proporção maior (> 70%) de endereços com erros de localização menores que 20 metros. Em geral, o desempeno não variou para cada método de acordo com condição socioeconômica. Os métodos apresentaram desempenho geral aceitável, porém heterogêneo. Os resultados servem de alerta contra o uso de métodos automáticos sem avaliar a qualidade em outras cidades, particularmente no Chile e no resto da América Latina.

Adverse pregnancy and perinatal outcomes in Latin America and the Caribbean: systematic review and meta-analysis / Resultados adversos perinatales y del embarazo en América Latina y el Caribe: revisión sistemática y metanálisis / Desfechos gestacionais e perinatais adversos na América Latina e no Caribe: revisão sistemática e metanálise

ABSTRACT Objective. To estimate the point prevalence and likely ranges of pregnancy-induced hypertension, pre-eclampsia, gestational diabetes, low birth weight and preterm delivery in Latin America and the Caribbean, and evaluate the heterogeneity of the estimates. Methods. We conducted a systematic review and meta-analysis of observational studies reporting the prevalence of maternal and perinatal adverse outcomes in populations in Latin American and the Caribbean published between 2000 and 2019 in English, Spanish, or Portuguese. We searched PubMed, Embase, and LILACS. We estimated the point prevalence and evaluated overall heterogeneity and, in sub-group analyses, heterogeneity by study design and level of bias. Results. Of 1087 records retrieved, 50 articles were included in the review: two on hypertensive disorders of pregnancy, 14 on pre-eclampsia, six on gestational diabetes, nine on low birth weight and 19 on preterm birth. No meta-analysis for hypertensive disorders of pregnancy could be done because of the small number of studies. Point prevalence estimates and 95% confidence intervals (CIs) for pre-eclampsia, gestational diabetes, low birth weight, and preterm birth were: 6.6% (95% CI: 4.9%, 8.6%), 8.5% (95% CI: 3.9%, 14.7%), 8.5% (95% CI: 7.2%, 9.8%), and 10.0% (95% CI: 8.0%, 12.0%), respectively. We observed substantial heterogeneity overall and by study design. No major differences in estimates were observed by level of bias. Conclusions. The results of this study provide updated estimates of some of the most prevalent adverse pregnancy and perinatal outcomes in Latin America and the Caribbean. They highlight that important heterogeneity exists in prevalence estimates, which may reflect the diversity of populations in the region.

RESUMEN Objetivo. Estimar la prevalencia puntual y los rangos probables de hipertensión provocada por embarazo, preeclampsia, diabetes gestacional, peso bajo al nacer y parto prematuro en América Latina y el Caribe, y evaluar la heterogeneidad de las estimaciones. Métodos. Se llevó a cabo una revisión sistemática y metanálisis de los estudios de observación que notificaron la prevalencia de resultados adversos perinatales y maternos en poblaciones de América Latina y el Caribe, publicados entre los años 2000 y 2019 en inglés, español o portugués. Se realizaron búsquedas en PubMed, Embase y LILACS. Se estimó la prevalencia puntual y se evaluó la heterogeneidad general y, en los análisis de subgrupos, la heterogeneidad según el diseño del estudio y nivel de sesgo. Resultados. De 1 087 registros recuperados, se incluyeron 50 artículos en la revisión: 2 sobre los trastornos hipertensivos en el embarazo, 14 sobre preeclampsia, 6 sobre la diabetes gestacional, 9 sobre peso bajo al nacer y 19 sobre parto prematuro. No se pudo realizar ningún metanálisis de los trastornos hipertensivos del embarazo debido al número reducido de estudios. Las estimaciones de prevalencia puntual y los intervalos de confianza (IC) del 95% para la preeclampsia, la diabetes gestacional, el peso bajo al nacer y el parto prematuro fueron: 6,6% (IC de 95%: 4,9%, 8,6%), 8,5% (IC de 95%: 3,9%, 14,7%), 8,5% (IC de 95%: 7,2%, 9,8%) y 10,0% (IC de 95%: 8,0%, 12,0%), respectivamente. Se observó una heterogeneidad significativa en general, así como según el diseño del estudio. No se advirtieron grandes diferencias en las estimaciones según el nivel del sesgo. Conclusiones. Los resultados de este estudio ofrecen cálculos actualizados de algunos de los resultados adversos perinatales y del embarazo con mayor prevalencia en América Latina y el Caribe. Estos resultados ponen de manifiesto que existe una gran heterogeneidad en las estimaciones de prevalencia, que podría reflejar la diversidad de la población de la región.

RESUMO Objetivo. Estimar a prevalência pontual e os intervalos prováveis de hipertensão induzida pela gravidez, pré-eclâmpsia, diabetes gestacional, baixo peso ao nascer e parto prematuro na América Latina e no Caribe e avaliar a heterogeneidade das estimativas. Métodos. Realizou-se uma revisão sistemática com metanálise de estudos observacionais que relatam a prevalência de desfechos maternos e perinatais adversos em populações da América Latina e do Caribe, publicados entre 2000 e 2019 em inglês, espanhol ou português. Os bancos de dados PubMed, Embase e LILACS foram pesquisados. Estimou-se a prevalência pontual e avaliou-se a heterogeneidade geral, bem como, em análises de subgrupo, a heterogeneidade por delineamento do estudo e o nível de viés. Resultados. De 1 087 registros encontrados, 50 artigos foram incluídos na revisão: dois sobre distúrbios hipertensivos da gravidez, 14 sobre pré-eclâmpsia, seis sobre diabetes gestacional, nove sobre baixo peso ao nascer e 19 sobre parto prematuro. Não foi possível realizar metanálise para distúrbios hipertensivos da gravidez devido ao pequeno número de estudos. As estimativas de prevalência pontual e intervalos de confiança de 95% (IC) para pré-eclâmpsia, diabetes gestacional, baixo peso ao nascer e parto prematuro foram: 6,6%; (IC 95%: 4,9-8,6%), 8,5% (IC 95%: 3,9-14,7%), 8,5% (IC 95%: 7,2-9,8%) e 10,0% (IC 95%: 8,0-12,0%), respectivamente. Observou-se heterogeneidade considerável, tanto em geral como por delineamento de estudo. Não foram observadas diferenças importantes nas estimativas por nível de viés. Conclusões. Os resultados deste estudo fornecem estimativas atualizadas de alguns dos desfechos gestacionais e perinatais adversos mais prevalentes na América Latina e no Caribe. Destacam a existência de uma importante heterogeneidade nas estimativas de prevalência, o que pode refletir a diversidade das populações da região.

Telemedicine in Liver Disease and Beyond: Can the COVID-19 Crisis Lead to Action?

Evidence strongly supports that access to specialty gastroenterology or hepatology care in cirrhosis is associated with higher adherence to guideline-recommended care and improves clinical outcomes. Presently, only about one half of acute care hospitalizations for cirrhosis-related complications result in inpatient specialty care, and the current hepatology workforce cannot meet the demand of patients with liver disease nationwide, particularly in less densely populated areas and in community-based practices not affiliated with academic centers. Telemedicine, defined as the delivery of health care services at a distance using electronic means for diagnosis and treatment, holds tremendous promise to increase access to broadly specialty care. The technology is cheap and easy to use, although it is presently limited in scale by interstate licensing restrictions and reimbursement barriers. The outbreak of severe acute respiratory syndrome coronavirus 2 and coronavirus disease 2019 has, in the short term, accelerated the growth of telemedicine delivery as a public health and social distancing measure. Herein, we examine whether this public health crisis can accelerate the national conversation about broader adoption of telemedicine for routine medical care in non-crisis situations, using a case series from our telehepatology program as a pragmatic example.

Surface ozone climatology of South Eastern Brazil and the impact of biomass burning events.

In the austral spring, biomass fires affect a vast area of South America each year. We combined in situ ozone (O3) data, measured in the states of São Paulo and Paraná, Brazil, in the period 2014-2017, with aerosol optical depth, co-pollutants (NOx, PM2.5 and PM10) and air backtrajectories to identify sources, transport and geographical patterns in the air pollution data. We applied cluster analysis to hourly O3 data and split the investigation area of approximately 290,000 km2 into five groups with similar features in terms of diurnal, weekly, monthly and seasonal O3 concentrations. All groups presented a peak in September and October, associated with the fire activities and enhanced photochemistry. The highest mean O3 concentrations were measured inland whilst, besides having lower concentrations, the coastal group was also associated with the smallest diurnal and seasonal variations. The latter was attributed to lower photochemical activity due to frequently occurring overcast weather situation. The mean annual regional contribution of O3 over the area was 61 µg/m3, with large seasonal and intersite variabilities (from 35 to 84 µg/m3). The long-range transport of smoke contributed with between 23 and 41% of the total O3 during the pollution events. A pollution outbreak in September 2015 caused many-fold increases in O3, PM2.5 and PM10 across the investigation area, which exceeded the World Health Organisation recommendations. We show that the regional transport of particulates and gas due to biomass burning overlays the local emissions in already highly polluted cities. Such an effect can outweigh local measures to curb anthropogenic air pollution in cities.

Colonization factors among enterotoxigenic Escherichia coli isolates from children with moderate-to-severe diarrhea and from matched controls in the Global Enteric Multicenter Study (GEMS).

BACKGROUND: Enterotoxigenic Escherichia coli (ETEC) encoding heat-stable enterotoxin (ST) alone or with heat-labile enterotoxin (LT) cause moderate-to-severe diarrhea (MSD) in developing country children. The Global Enteric Multicenter Study (GEMS) identified ETEC encoding ST among the top four enteropathogens. Since the GEMS objective was to provide evidence to guide development and implementation of enteric vaccines and other interventions to diminish diarrheal disease morbidity and mortality, we examined colonization factor (CF) prevalence among ETEC isolates from children age <5 years with MSD and from matched controls in four African and three Asian sites. We also assessed strength of association of specific CFs with MSD. METHODOLOGY/PRINCIPAL FINDINGS: MSD cases enrolled at healthcare facilities over three years and matched controls were tested in a standardized manner for many enteropathogens. To identify ETEC, three E. coli colonies per child were tested by polymerase chain reaction (PCR) to detect genes encoding LT, ST; confirmed ETEC were examined by PCR for major CFs (Colonization Factor Antigen I [CFA/I] or Coli Surface [CS] antigens CS1-CS6) and minor CFs (CS7, CS12, CS13, CS14, CS17, CS18, CS19, CS20, CS21, CS30). ETEC from 806 cases had a single toxin/CF profile in three tested strains per child. Major CFs, components of multiple ETEC vaccine candidates, were detected in 66.0% of LT/ST and ST-only cases and were associated with MSD versus matched controls by conditional logistic regression (p≤0.006); major CFs detected in only 25.0% of LT-only cases weren't associated with MSD. ETEC encoding exclusively CS14, identified among 19.9% of 291 ST-only and 1.5% of 259 LT/ST strains, were associated with MSD (p = 0.0011). No other minor CF exhibited prevalence ≥5% and significant association with MSD. CONCLUSIONS/SIGNIFICANCE: Major CF-based efficacious ETEC vaccines could potentially prevent up to 66% of pediatric MSD cases due to ST-encoding ETEC in developing countries; adding CS14 extends coverage to ~77%.

Virologic, clinical and immunologic responses following failure of first-line antiretroviral therapy in Haiti.

BACKGROUND: Since HIV-1 RNA (viral load) testing is not routinely available in Haiti, HIV-infected patients receiving antiretroviral therapy (ART) are monitored using the World Health Organization (WHO) clinical and/or immunologic criteria. Data on survival and treatment outcomes for HIV-1 infected patients who meet criteria for ART failure are limited. We conducted a retrospective study to compare survival rates for patients who experienced failure on first-line ART by clinical and/or immunologic criteria and switched to second-line ART vs. those who failed but did not switch. METHODS: Patients receiving first-line ART at the GHESKIO Center in Port-au-Prince, Haiti, who met WHO clinical and immunologic criteria for failure were identified. Survival and treatment outcomes were compared in patients who switched their ART regimen and those who did not. Cox regression analysis was used to determine predictors of mortality after failure of first-line ART. RESULTS: Of 3126 patients who initiated ART at the GHESKIO Center between 1 March 2003 and 31 July 2008, 482 (15%) met WHO immunologic and/or clinical criteria for failure. Among those, 195 (41%) switched to second-line ART and 287 (59%) did not. According to Kaplan-Meier survival analysis, the probability of survival to 12 months after failure of first-line ART was 93% for patients who switched to second-line ART after failure and 88% for patients who did not switch. Predictors of mortality after failure of first-line ART were weight in the lowest quartile for sex, CD4 T cell count ≤ 100, adherence<90% at the time of failure and not switching to second-line ART. CONCLUSIONS: Patients who failed first-line ART based on clinical and/or immunologic criteria and did not switch to second-line therapy faced a higher mortality than those who switched after failure. To decrease mortality, interventions to identify patients in whom ART may be failing earlier are needed urgently. In addition, there is a major need to optimize second-line antiretroviral regimens for improved potency, lower toxicity and greater convenience for patients.

Fimbrial Adhesins Produced by Atypical Enteropathogenic Escherichia coli Strains

Atypical enteropathogenic Escherichia coli (aEPEC) has emerged as a significant cause of pediatric diarrheaworldwide; however, information regarding its adherence mechanisms to the human gut mucosa is lacking. Inthis study, we investigated the prevalence of several (fimA, ecpA, csgA, elfA, and hcpA) fimbrial genes in 71aEPEC strains isolated from children with diarrhea (54 strains) and healthy individuals (17 strains) in Braziland Australia by PCR. These genes are associated with adhesion and/or biofilm formation of pathogenic andcommensal E. coli. Here, the most prevalent fimbrial genes found, in descending order, were hcpA (98.6%), ecpA(86%), fimA (76%), elfA (72%), and csgA (19.7%). Phenotypic expression of pili in aEPEC strains was assessedby several approaches. We were not able to detect the hemorrhagic coli pilus (HCP) or the E. coli lamininbindingfimbriae (ELF) in these strains by using immunofluorescence. Type 1 pili and curli were detected in59% (by yeast agglutination) and 2.8% (by Congo red binding and immunofluorescence) of the strains,respectively. The E. coli common pilus (ECP) was evidenced in 36.6% of the strains on bacteria adhering toHeLa cells by immunofluorescence, suggesting that ECP could play an important role in cell adherence forsome aEPEC strains. This study highlights the complex nature of the adherence mechanisms of aEPEC strainsinvolving the coordinated function of fimbrial (e.g., ECP) and nonfimbrial (e.g., intimin) adhesins andindicates that these strains bear several pilus operons that could potentially be expressed in different nichesfavoring colonization and survival in and outside the host.

Fimbrial adhesins produced by atypical enteropathogenic Escherichia coli strains.

Atypical enteropathogenic Escherichia coli (aEPEC) has emerged as a significant cause of pediatric diarrhea worldwide; however, information regarding its adherence mechanisms to the human gut mucosa is lacking. In this study, we investigated the prevalence of several (fimA, ecpA, csgA, elfA, and hcpA) fimbrial genes in 71 aEPEC strains isolated from children with diarrhea (54 strains) and healthy individuals (17 strains) in Brazil and Australia by PCR. These genes are associated with adhesion and/or biofilm formation of pathogenic and commensal E. coli. Here, the most prevalent fimbrial genes found, in descending order, were hcpA (98.6%), ecpA (86%), fimA (76%), elfA (72%), and csgA (19.7%). Phenotypic expression of pili in aEPEC strains was assessed by several approaches. We were not able to detect the hemorrhagic coli pilus (HCP) or the E. coli laminin-binding fimbriae (ELF) in these strains by using immunofluorescence. Type 1 pili and curli were detected in 59% (by yeast agglutination) and 2.8% (by Congo red binding and immunofluorescence) of the strains, respectively. The E. coli common pilus (ECP) was evidenced in 36.6% of the strains on bacteria adhering to HeLa cells by immunofluorescence, suggesting that ECP could play an important role in cell adherence for some aEPEC strains. This study highlights the complex nature of the adherence mechanisms of aEPEC strains involving the coordinated function of fimbrial (e.g., ECP) and nonfimbrial (e.g., intimin) adhesins and indicates that these strains bear several pilus operons that could potentially be expressed in different niches favoring colonization and survival in and outside the host.

Early versus standard antiretroviral therapy for HIV-infected adults in Haiti.

BACKGROUND: For adults with human immunodeficiency virus (HIV) infection who have CD4+ T-cell counts that are greater than 200 and less than 350 per cubic millimeter and who live in areas with limited resources, the optimal time to initiate antiretroviral therapy remains uncertain. METHODS: We conducted a randomized, open-label trial of early initiation of antiretroviral therapy, as compared with the standard timing for initiation of therapy, among HIV-infected adults in Haiti who had a confirmed CD4+ T-cell count that was greater than 200 and less than 350 per cubic millimeter at baseline and no history of an acquired immunodeficiency syndrome (AIDS) illness. The primary study end point was survival. The early-treatment group began taking zidovudine, lamivudine, and efavirenz therapy within 2 weeks after enrollment. The standard-treatment group started the same regimen of antiretroviral therapy when their CD4+ T-cell count fell to 200 per cubic millimeter or less or when clinical AIDS developed. Participants in both groups underwent monthly follow-up assessments and received isoniazid and trimethoprim-sulfamethoxazole prophylaxis with nutritional support. RESULTS: Between 2005 and 2008, a total of 816 participants--408 per group--were enrolled and were followed for a median of 21 months. The CD4+ T-cell count at enrollment was approximately 280 per cubic millimeter in both groups. There were 23 deaths in the standard-treatment group, as compared with 6 in the early-treatment group (hazard ratio with standard treatment, 4.0; 95% confidence interval [CI], 1.6 to 9.8; P=0.001). There were 36 incident cases of tuberculosis in the standard-treatment group, as compared with 18 in the early-treatment group (hazard ratio, 2.0; 95% CI, 1.2 to 3.6; P=0.01). CONCLUSIONS: Early initiation of antiretroviral therapy decreased the rates of death and incident tuberculosis. Access to antiretroviral therapy should be expanded to include all HIV-infected adults who have CD4+ T-cell counts of less than 350 per cubic millimeter, including those who live in areas with limited resources. (ClinicalTrials.gov number, NCT00120510.)

Characterisation of Shiga toxin-producing Escherichia coli O157 strains isolated from humans in Argentina, Australia and New Zealand.

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) is an important cause of bloody diarrhoea (BD), non-bloody diarrhoea (NBD) and the haemolytic uraemic syndrome (HUS). In Argentina and New Zealand, the most prevalent STEC serotype is O157:H7, which is responsible for the majority of HUS cases. In Australia, on the other hand, STEC O157:H7 is associated with a minority of HUS cases. The main aims of this study were to compare the phenotypic and genotypic characteristics of STEC O157 strains isolated between 1993 and 1996 from humans in Argentina, Australia and New Zealand, and to establish their clonal relatedness. RESULTS: Seventy-three O157 STEC strains, isolated from HUS (n = 36), BD (n = 20), NBD (n = 10), or unspecified conditions (n = 7) in Argentina, Australia and New Zealand, were analysed. The strains were confirmed to be E. coli O157 by biochemical tests and serotyping. A multiplex polymerase chain reaction (PCR) was used to amplify the stx1, stx2 and rfbO157 genes and a genotyping method based on PCR-RFLP was used to determine stx1 and stx2 variants. This analysis revealed that the most frequent stx genotypes were stx2/stx2c (vh-a) (91%) in Argentina, stx2 (89%) in New Zealand, and stx1/stx2 (30%) in Australia. No stx1-postive strains were identified in Argentina or New Zealand. All strains harboured the eae gene and 72 strains produced enterohaemolysin (EHEC-Hly). The clonal relatedness of strains was investigated by phage typing and pulsed-field gel electrophoresis (PFGE). The most frequent phage types (PT) identified in Argentinian, Australian, and New Zealand strains were PT49 (n = 12), PT14 (n = 9), and PT2 (n = 15), respectively. Forty-six different patterns were obtained by XbaI-PFGE; 37 strains were grouped in 10 clusters and 36 strains showed unique patterns. Most clusters could be further subdivided by BlnI-PFGE. CONCLUSION: STEC O157 strains isolated in Argentina, Australia, and New Zealand differed from each other in terms of stx-genotype and phage type. Additionally, no common PFGE patterns were found in strains isolated in the three countries. International collaborative studies of the type reported here are needed to detect and monitor potentially hypervirulent STEC clones.

Survival, plasma HIV-1 RNA concentrations and drug resistance in HIV-1-infected Haitian adolescents and young adults on antiretrovirals.

OBJECTIVE: To assess outcomes after antiretroviral therapy (ART) in adolescents and youth in Haiti, a country with a generalized epidemic of infection with HIV-1. METHODS: An assessment was made of survival, plasma HIV-1 ribonucleic acid (RNA) concentrations and HIV-1 drug resistance patterns after 12 months of ART in patients aged 13-25 years who presented to a clinic in Port-au-Prince, Haiti, with AIDS between 1 March 2003 and 31 December 2005. Participants received ART in accordance with WHO guidelines. Kaplan-Meier analysis was used to estimate survival probabilities and their 95% confidence intervals (CI) for the period from ART initiation to death. FINDINGS: Of a total of 146 patients, 96 (66%) were female; the median CD4+ T-cell count at baseline was 129 cells/ml. By Kaplan-Meier analysis, 13% of the patients had died at 12 months, 17% at 24 months and 20% at 36 months. A plasma HIV-1 RNA concentration > or = 50 copies/ml was seen in 40 (51%) of 79 patients 12 months after treatment initiation and was associated with poor ART adherence. Among 29 patients with > 1000 copies/ml at 12 months, resistance mutations to non-nucleoside reverse transcriptase inhibitors (NNRTIs) were detected in 23 cases (79%); to both NNRTIs and lamivudine in 21 (72%) cases; and to NNRTIs, lamivudine and other nucleoside reverse transcriptase inhibitors in 10 (35%) cases. One hundred and six participants (73%) reported sexual intercourse without condoms, and 35 of the 96 women (36%) were pregnant during follow-up. CONCLUSION: Adolescents and youth with AIDS receiving ART are at risk of virologic failure and disease progression and can therefore transmit HIV-1 to sexual partners and infants. Strategies to target the special needs of this age group are urgently needed.

Teleradiología: la experiencia en Panamá / Teleradiology: the experience in Panamá

The technological advances have brought today procedures, that were not possible a few years ago. Telemedicine is one of them. Teleradiology in particular is one of the specialty where this application has been more important

[Teleradiology. The experience in Panamá]. / Teleradiología. La experiencia en Panamá.

The technological advances have brought today procedures, that were not possible a few years ago. Telemedicine is one of them. Teleradiology in particular is one of the specialty where this application has been more important.