Towards a standardized initial training program in experimental microsurgery for pediatric surgeons. / Hacia un programa inicial de formación estandarizadoen microcirugía experimental para cirujanos pediátricos.

OBJECTIVE: To describe a basic training program in microsurgery and to analyze the learning curve through the process, including improvement in operating times and functional outcome. MATERIALS AND METHODS: Our learning program included basic, transitional, and experimental models. The experimental model included tail vein cannulation, intestinal resection and anastomosis, dissection, division and anastomosis of the cava and aorta. Wistar rats (66.7% male; 406.9 ± 38.9 grams) were used. The program adhered to the 3R principle and obtained animal welfare committee approval. RESULTS: Mean tail vein cannulation time was 2.4 ± 1.2 minutes. Mean intestinal resection and jejunocolic anastomosis time was 14.8 ± 2.7 minutes and 10.4 ± 3 minutes, respectively. All anastomoses were functionally valid. Mean vessel dissection time was 22.9 ± 7.7 minutes, aortic artery anastomosis was 17.2 ± 7.1 minutes, and vena cava anastomosis was 25.9 ± 7.3 minutes. 66.7% of vena cava anastomoses were functionally valid vs. 88.9% for the aorta. The time required for all procedures decreased after the third attempt, except for vena cava anastomoses, which remained similar in all 9 procedures. CONCLUSIONS: Our model demonstrated that the procedures were suitable for trainer progression in terms of surgical time and functional outcome. Microsurgical training would benefit from standardized programs to optimize results.

OBJETIVO: Describimos un programa de formación básica en microcirugía y analizamos la curva de aprendizaje a través del proceso, incluyendo la mejora en los tiempos operatorios y en el resultado funcional del procedimiento. MATERIAL Y METODOS: Nuestro programa de aprendizaje incluye modelos básicos, de transición y experimentales. Dentro del modelo experimental se incluyeron: canulación de la vena de la cola, resección y anastomosis intestinal, disección, sección y anastomosis de la cava y la aorta. Se emplearon ratas Wistar (66,7% machos; 406,9 ± 38,9 gramos), el programa se adhirió al principio de las 3R y obtuvo la aprobación del comité de bienestar animal. RESULTADOS: El tiempo medio de canulación de la vena de la cola fue de 2.4 ± 1,2 minutos. El tiempo medio de resección intestinal y anastomosis yeyunocólica de 14.8 ± 2,7 minutos y 10.4 ± 3 minutos, respectivamente. Todas las anastomosis fueron funcionalmente válidas. El tiempo medio de la disección de vasos fue de 22,9 ± 7,7 minutos, la anastomosis de la arteria aorta de 17,2 ± 7,1 minutos, mientras que la anastomosis de la vena cava fue de 25,9 ± 7,3 minutos. El 66,7% de las anastomosis de la vena cava fueron funcionalmente válidas en comparación con el 88,9% de la aorta. El tiempo requerido para todos los procedimientos disminuyó después del tercer intento, excepto para las anastomosis de vena cava, que se mantuvo similar en los 9 procedimientos. CONCLUSIONES: Nuestro modelo demostró que los procedimientos eran adecuados para la progresión del entrenador en términos de tiempo quirúrgico y resultado funcional. La formación microquirúrgica se beneficiaría de programas estandarizados para optimizar los resultados.

Hacia un programa inicial de formación estandarizado en microcirugía experimental para cirujanos pediátricos / Towards a standardized initial training program in experimental microsurgery for pediatric surgeons

Objetivo: Describimos un programa de formación básica en microcirugía y analizamos la curva de aprendizaje a través del proceso,incluyendo la mejora en los tiempos operatorios y en el resultado funcional del procedimiento. Material y métodos: Nuestro programa de aprendizaje incluyemodelos básicos, de transición y experimentales. Dentro del modeloexperimental se incluyeron: canulación de la vena de la cola, reseccióny anastomosis intestinal, disección, sección y anastomosis de la cava y laaorta. Se emplearon ratas Wistar (66,7% machos; 406,9 ± 38,9 gramos),el programa se adhirió al principio de las 3R y obtuvo la aprobación delcomité de bienestar animal. Resultados: l tiempo medio de canulación de la vena de la cola fuede 2.4 ± 1,2 minutos. El tiempo medio de resección intestinal y anastomosis yeyunocólica de 14.8 ± 2,7 minutos y 10.4 ± 3 minutos, respectivamente. Todas las anastomosis fueron funcionalmente válidas. El tiempomedio de la disección de vasos fue de 22,9 ± 7,7 minutos, la anastomosisde la arteria aorta de 17,2 ± 7,1 minutos, mientras que la anastomosisde la vena cava fue de 25,9 ± 7,3 minutos. El 66,7% de las anastomosisde la vena cava fueron funcionalmente válidas en comparación con el88,9% de la aorta. El tiempo requerido para todos los procedimientosdisminuyó después del tercer intento, excepto para las anastomosis devena cava, que se mantuvo similar en los 9 procedimientos. Conclusiones: Nuestro modelo demostró que los procedimientoseran adecuados para la progresión del entrenador en términos de tiempo quirúrgico y resultado funcional. La formación microquirúrgica sebeneficiaría de programas estandarizados para optimizar los resultados.(AU)

Objective: To describe a basic training program in microsurgery andto analyze the learning curve through the process, including improve-ment in operating times and functional outcome. Materials and methods: Our learning program included basic,transitional, and experimental models. The experimental model includedtail vein cannulation, intestinal resection and anastomosis, dissection,division and anastomosis of the cava and aorta. Wistar rats (66.7% male;406.9 ± 38.9 grams) were used. The program adhered to the 3R principleand obtained animal welfare committee approval. Results: Mean tail vein cannulation time was 2.4 ± 1.2 minutes.Mean intestinal resection and jejunocolic anastomosis time was14.8 ± 2.7 minutes and 10.4 ± 3 minutes, respectively. All anastomoseswere functionally valid. Mean vessel dissection time was 22.9 ± 7.7minutes, aortic artery anastomosis was 17.2 ± 7.1 minutes, and vena cavaanastomosis was 25.9 ± 7.3 minutes. 66.7% of vena cava anastomoseswere functionally valid vs. 88.9% for the aorta. The time required forall procedures decreased after the third attempt, except for vena cavaanastomoses, which remained similar in all 9 procedures. Conclusions: Our model demonstrated that the procedures weresuitable for trainer progression in terms of surgical time and functionaloutcome. Microsurgical training would benefit from standardized pro-grams to optimize results.(AU)

Community-associated methicillin-resistant Staphylococcus aureus: risk factors for infection, and long-term follow-up.

Uncertainty persists about risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in Europe and the long-term efficacy of decolonization strategies. To evaluate risk factors for CA-MRSA in Geneva, Switzerland, a hospital-based, retrospective case-control study of 26 patients with CA-MRSA infection and 60 control patients was performed. To evaluate the long-term effect of a systematic decolonization strategy (with and without concomitant systemic antibiotic therapy) for CA-MRSA patients, a prospective cohort study of 79 patients with Panton-Valentine leukocidin-producing CA-MRSA isolates was conducted. Nationality other than European Union or Swiss (adjusted OR 6.09; 95% CI 1.07-34.65) and absence of healthcare contact (adjusted OR 0.11, 95% CI 0.02-0.59) were independent predictors of CA-MRSA infection. Forty-five cases were followed (median, 22 months) to assess the long-term efficacy of the decolonization strategy; 39/45 (86.7%) had no clinical relapse and were MRSA-negative at their last follow-up, whereas six remained MRSA-positive. Five of these six cases belonged to a family cluster. Decolonization rates were similar between infected patients and asymptomatic carriers (92.6% vs. 77.8%, p = 0.20). This study shows a lack of readily modifiable risk factors for CA-MRSA infection in this population, and suggests the potential usefulness of conducting decolonization procedures in a setting with sporadic CA-MRSA infection. Further studies are needed to elucidate the role of migration as a factor contributing to the emergence of CA-MRSA in Europe.

A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators--the need for integrated service provision.

The first global overview of basic water and sanitation indicators in refugee camps is presented (using data from 2003-2006) and compared with selected health and nutrition indicators. This demonstrates that average levels of water and sanitation provision are acceptable at camp level but many refugee operations are suffering from gaps that cross-cut these sectors; e.g. typically poor sanitation provision is corresponding with low per capita availability of water. These findings were confirmed at household level with two household surveys undertaken in African refugee camps; households reporting a case of diarrhoea within the previous 24 hours collect on average 26% less water than those not reporting any cases. In addition, typically higher levels of morbidity of one infectious agent are also reflected across other infectious agents; this is reinforced by comparing the relationship between morbidity and nutrition status from selected camps. The importance that hygiene, environmental conditions and local settings have on health (both of refugees and also local communities) is underlined. Interventions to improve indicators across the water, sanitation, health and nutrition sectors rely not only on increased and sustained resources but must entail an integrated approach to simultaneously tackle short-comings across all these vital sectors.

Community-acquired methicillin-resistant Staphylococcus aureus in Switzerland: first surveillance report.

Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging community pathogen. Community-acquired MRSA (CA-MRSA) has been associated with virulent strains producing Panton-Valentine leukocidin (PVL) and a variety of other exotoxins. In Geneva, PVL-producing CA-MRSA was first reported in 2002 and a surveillance system based on voluntary reporting was set up. Each MRSA-positive culture result with an antibiotic resistance profile different from the endemic strain prevailing in the Geneva healthcare setting diagnosed in a patient without a history of hospital admission in the previous 12 months was notified to the local health department. A questionnaire was completed by the attending physician with demographic, clinical and exposure information. From January 2002 until December 2004, data on 58 cases were reported, including 26 cases grouped in 13 distinct transmission clusters. Most were family related and for two of them, colonisation persisted over a 12 month period despite treatment. Thirty three patients (57%) were male. Median age was 32 years, 22% being younger than 10 years. Forty one cases (71%) were infected and 17 (29%) colonised. Symptomatic skin lesions such as furunculosis, impetigo or abscess were present in 40 (97%) of the 41 infected cases. Most cases had no underlying disease. Thirty eight cases (65%) had travelled abroad. Forty (69%) of 58 isolates carried the PVL toxin. CA-MRSA infections in Geneva appear to be an emerging problem in the canton. Surveillance should continue and should possibly be extended to other parts of the country to better describe transmission patterns and the spread of this pathogen. Prevention and control of CA-MRSA infections represent a challenge for the future, requiring contact tracing, education and treatment of infected and colonised contacts.

Community-acquired methicillin-resistant Staphylococcus aureus in Switzerland : first surveillance report.

Methicillin resistant Staphylococcus Aureus (MRSA) infection is an emerging community pathogen. Community-acquired MRSA (CA-MRSA) has been associated with virulent strains producing Panton-Valentine leukocidin (PVL) and a variety of other exotoxins. In Geneva, PVL-producing CA-MRSA was first reported in 2002 and a surveillance system based on voluntary reporting was set up.

[Consequences of an unsufficient range of immunity in "pediatric" infectious diseases--example with measles]. / Die Folgen einer ungenügenden Herdimmunität bei "pädiatrischen" Infektionskrankheiten--Beispiel einer Masernepidemie.

From January to February 2005, the healthcare authorities of the Canton of Geneva were alerted to 15 cases of measles, in contrast to one single case in 2004. The adult status (17-44 years) of the affected persons years was unusual. Four were health care workers at the same hospital who were infected after contact with a 44-year-old patient in a single night during his stay in the emergency room. The presumption that measles are only a paediatric disease had made the diagnosis difficult. None of all these adults was immune according to the actual recommendations. Despite a federal vaccine policy, repetition of recommendations, good results of available vaccines and reimbursement of the cost by health insurance companies, voluntary vaccination prevalence is too small in Switzerland to prevent the outbreak of epidemics. In contrast to the goals of the World Health Organization (WHO) and the Swiss Federal Office of Public Health, the country is unfortunately far from displaying a sufficiently high herd immunity to prevent health care-associated and economic damage by sporadic epidemics.

[Sexual behavior risk in Spanish international travelers]. / Riesgo del comportamiento sexual de los viajeros españoles al extranjero.

BACKGROUND: To know the sexual behavior of Spanish international travelers and its association with geographical destinations and sexually transmitted disease acquisition. PATIENTS AND METHOD: 1,008 consecutive patients who attended a tropical out-patient clinic during 26 months were surveyed by means of a previously designed clinical questionnaire that included specific questions regarding sexual practices during the trip. RESULTS: 19% of travelers had sexual intercourse; 53.6% of them having employed a condom. There were no differences regarding gender or destination. 3.4% of travelers who had unprotected sexual intercourse acquired HIV. CONCLUSIONS: A high proportion of travelers have unprotected, risk sexual contacts. A low but alarm

[Population and the environment: perspectives and proposals]. / Poblacion y medio ambiente: perspectivas y propuestas.

PIP: This work reflects on the relationship between population and the environment at different stages of development and proposes guidelines for community-level integrated programs that would be better able than existing programs to respond to local needs. Growing concern in recent decades about population growth, the environment, sustainable development, and similar topics represents continuation of a debate first formulated at the dawn of the industrial era. The first portion of the work examines the extent to which the catastrophic predictions of Malthus and other "pessimists" have been realized in the areas of explosive population growth, deteriorating consumption, and irreversible environmental degradation. Insufficient historical data is available to answer the question of whether, as maintained by the "optimists", technological progress is capable of providing improving living standards for most of the population, reducing growth, and avoiding irreversible environmental damage. Some of the variables implicated in the debate can, however, be examined: population growth and the demographic transition in developing and developed countries, and the impact of population growth on agriculture and the supply of land, forests, and water. The evidence reveals the gravity and also the complexity and diversity of demographic and economic processes affecting the environment. The next section discusses a model designed to illustrate the interaction between population, consumption, technology, and environmental impact at different historical periods and stages of development. It is concluded that the developed countries are mainly responsible for pollution originating in industrialization and energy use, but the more urbanized developing countries are increasingly responsible for air and water pollution, deforestation, and soil erosion. The final section proposes an integrated focus for reproductive health and environmental programs at the community level in developing countries. The discussion identifies criteria for selecting populations, community participation, program focus, and technology transfers for programs capable of furthering the objectives of both the health and development components.^ieng

[Approaches to low-income groups' sexuality: a comparative study of women in three low-income contexts in Peru]. / Aproximaciones a la sexualidad popular: estudio comparativo de mujeres de tres contextos populares del Peru.

"This work...examines the cultural dimension of sexuality and fertility of women from [low-income] sectors in Peru. It intends to explain the cultural processes that fall into the intermediate variables of fertility, such as marriage rate, contraception, breastfeeding and...abortion. These dimensions of sexual and reproductive life are analyzed according to two explanatory dimensions: generation and cultural context of socialization. The general hypothesis is that a cultural process of homogenization of the values and behaviors has been taking place over sexuality, in such a way that the younger generations will show similar standard behaviors and values no matter their context of socialization; in the meantime, in the older groups there will exist contextual differences in these dimensions." (SUMMARY IN ENG)

[Fertility transition in Peru]. / La transicion de la fecundidad en Peru.

PIP: Data from national censuses and sample surveys are the basis for this examintion of differential fertility and the fertility transition in Peru. Changes in the level and structure of fertility in the 3 major geographic regions are compared, and the role of contraceptive usage and nuptiality changes in the fertility decline are analyzed. Peru's total fertility rate was estimated at 6.85 in 1965 and has since declined to 6.56 in 1965-70, 6.00 in 1970-75, 5.30 in 1975-80, 4.65 in 1980-85, and 4.00 in 1985-90. The fertility decline varied in intensity and timing in the geographic regions. A clear fertility decline began among upper and middle income groups in the principal cities in the 1960s, spreading gradually to the urban low income sectors. Not until the late 1970s did the fertility decline spread to the rest of the population, coinciding with the years of severe economic crisis. The urban total fertility rate declined from 6 to 3.77 during 1961-86, but rural fertility increased through 1972 to 8.12, before declining slightly to 7.62 in 1981 and more markedly to 6.65 in 1986. Sociocultural and economic differences between Peru's natural regions are appreciable, and account for the contrasts in fertility trends. The greatest changes occurred in metropolitan Lima, which already had relatively low fertility in 1961. Its total fertility rate declined 44% from 5.6 in 1961 to 3.13 in 1986. Fertility declined by slightly under 40% in the rest of the coast, by almost 25% in the jungle, and by scarcely 14% in the sierra. The total fertility rates in 1961 and 1986, respectively, were 6.38 and 4.13 on the coast, 6.64 and 6.45 in the highlands, and 7.92 and 5.97 in the lowlands. The fertility decline, especially in the lower classes, was a response initially to the process of cultural modernization which in slightly over 2 decades saw a profound transformation of Peru from a rural, Andean, illiterate, and agrarian society to an urban, coastal, literate, and commercial society. From 1972 on, the fertility decline spread in the rural sectors and was intensified as a response to the profound economic crisis experienced in Peru from 1975 to the present. Increased contraceptive usage was apparently the most important cause of Peru's fertility decline. Overall prevalence increased from 31% in 1977-78 to 46% in 1986, and use of modern methods by women in union doubled in the same years. Regional fertility differences are correlated strongly to contraceptive prevalence and especially to prevalence of modern methods. The 3 most recent national fertility surveys and a series of more limited surveys suggest that women have an increasingly strong desire to control their fertility. The greatest barriers to use of modern contraception are fears of health effects and lack of knowledge.^ieng

[Adolescent sexuality in Peru]. / La sexualidad en la adolescencia en el Peru

PIP: 22% of the population of Peru, or 4.25 million individuals, is between the ages of 11 and 19 years. A survey was performed on a sample of 6,000 adolescents living in Lima, Cajamarca, Huarez, and Supe. Surveys were performed in a variety of locations, including school classrooms, maternity wards, schools, and work places. The questionnaire was constructed based on a format that had been tested in Nigeria; questions dealt with socioeconomic background, sex behavior, contraceptive behavior, pregnancy history, and health practices and knowledge. 60% of the adolescents were women and 40% were men. 41% had had at least 1 sexual experience; among 18-year-olds, this % rose to 55. Only 10% were in stable union. Married adolescents tended to have begun sexual relations sooner in life. Early sexual relations were more common among men than among women, and more common among non-religious adolescents than among Catholics. Fewer than 12% of the adolescents had at 1 time used contraceptives. Contraceptive use was more prevalent among adolescents from wealthier socioeconomic groups, and more prevalent in Lima than in other regions surveyed. Of adolescents using contraceptives, 38% used condoms, 24% used oral contraceptives, and 15% used rhythm methods. Most adolescents who did not use contraceptives failed to do so because of lack of knowledge. Almost 1/4 of the young women had had a pregnancy. 18.5 of these had abortions, usually in a hospital. The importance of supporting educational prevention programs is underlined.^ieng

Protocole de Système dÆalertes: Epidémie de Choléra. Haïti: Draft

Ce document est une version du protocole de système dÆalertes et réponse face à l'épidémie de choléra qui a débuté en octobre 2010 en Haïti. Il a été élaboré par lÆOPS/OMS dans le cadre de lÆassistance et appui au MSPP. L'objectif est de mettre en place un système dÆalertes et détection précoce des cas et décès par choléra pour lÆimplémentation des mesures de réponse urgente et prise en charge pour réduire lÆimpact en termes de morbidité et de mortalité.