Valor del lactato sérico como factor pronóstico de mortalidad en pacientes con sepsis

RESUMEN Introducción: el lactato sérico constituye uno de los biomarcadores más importantes en la sepsis. Objetivos: determinar el valor del lactato y su vinculación con la mortalidad en los pacientes con sepsis de cualquier origen y compararlos secundariamente con otras escalas. Metodología: se aplicó un diseño de casos (pacientes adultos con sepsis y óbito) y controles (pacientes adultos con sepsis vivos al alta) en Servicio de Clínica Médica, Servicio de Terapia Intensiva de Adultos y Departamento de Urgencias del Hospital Nacional (Itauguá, Paraguay) en los años 2015 a 2016. Resultados: se incluyeron 101 pacientes, 34 óbitos (casos) y 67 vivos (controles). No hubo diferencias estadísticamente significativas en el sexo y la media de edad entre casos y controles. Los focos infecciosos más frecuentes fueron pulmonar y abdominal. El lactato elevado se halló en 70% de los casos y en 30% de los controles (OR 4,5 IC95% 1,8-11) (p <0,001). Conclusiones: existe una asociación entre la concentración sérica de lactato al ingreso y la mortalidad hospitalaria en pacientes con sepsis, independientemente de la comorbilidad y la edad.

ABSTRACT Introduction: Serum lactate is one of the most important biomarkers of sepsis. Objectives: To determine the value of lactate and its association with mortality in patients with sepsis of any origin and to compare it secondarily with other scales. Methodology: A case (adult patients with sepsis and death) and control (adult patients with sepsis alive at discharge) design was applied in the Clinical Service, Adult Intensive Care Service and the Emergency Department of the National Hospital (Itauguá, Paraguay) from 2015 to 2016. Results: One hundred one patients, 34 dead (cases) and 67 alive (controls), were included. There were no statistically significant differences in sex and mean age between cases and controls. The most frequent infectious foci were pulmonary and abdominal. High lactate was found in 70% of the cases and in 30% of the controls (OR 4.5 CI95% 1.8-11) (p <0.001). Conclusions: There is an association between the serum lactate concentration at admission and hospital mortality in patients with sepsis, independently of comorbidity and age.

[Association between cutaneous leishmaniasis incidence and the human development index and its components in four endemic states of Venezuela]. / Asociación entre la incidencia de leishmaniosis cutánea y el índice de desarrollo humano y sus componentes en cuatro estados endémicos de Venezuela.

OBJECTIVES: Assess potential relationships between the Human Development Index (HDI) and its components and the incidence of cutaneous leishmaniasis (CL) in four endemic States of Venezuela (Mérida, Trujillo, Lara and Sucre) in the period 1994-2003. MATERIAL AND METHODS: Socioeconomical data (classified according the World Bank) was obtained from the National Institute of Statistics, and the epidemiological data from the Ministry of Health, both from Venezuela. For this ecological study the annual variation of the variables was assessed and also regression models were done. RESULTS: The HDI varied in the period from 0.6746 in 1994 to 0.8144 in 2003 (p=0.90). During this time an increase in the cumulative incidence of Leishmaniasis was observed, particularly from 1998 (7.3 cases/100,000 pop) to 1999 (11.3 cases/100,000 pop). Analyzing the linear regression models, it was observed that the relationship between epidemiological and social variables was different at States levels. For Mérida and Trujillo it was observed a significant decrease in the CL regard to the increase of literacy (p<0.05), of the gross combined enrollment (p<0.05), life expectancy (p<0.05), money income (p<0.05) and the HDI (p<0.05). CONCLUSION: This information reflects the significant influence of socioeconomical indicators on the CL incidence at Trujillo and Merida, being an inverse relationship between both types of variables; with an increase or improvement in the socioeconomical indicators, the disease incidence rate decreased.

Relationship of type 1 diabetes to ancestral proportions and HLA DR/DQ alleles in a sample of the admixed Cuban population.

BACKGROUND: Incidence of type 1 diabetes varies widely around the world, probably due to ethnic differences across populations among other factors. AIMS: To determine whether there is an association between disease and ancestry proportions; and to control disease-HLA associations for possible confounding by admixture or population stratification. SUBJECTS AND METHODS: 100 cases and 129 controls participated in the study. Ancestry informative markers, which have considerable differences in frequency between European, West African and Native American populations were used. Type 1 diabetes associated HLA susceptibility/protection alleles were ascertained by PCR using specific primers. Statistical analyses were conducted using STRUCTURE 2.1, ADMIXMAP 3.7, SPSS 16.0 and STRAT 1.0 packages. RESULTS: The results of logistic regression implemented in ADMIXMAP 3.7 indicated that European ancestry was associated with type 1 diabetes mellitus with an odds ratio of 5.7 corresponding to one unit change in European admixture proportion. Association was found between HLA alleles and disease, DQA1*0501, *0301 DQB1*0201 and DRB1*0301, *0401 being susceptibility alleles and DRB1*1501, DQA1*0102/3 and DQB1*0602 being protective alleles. CONCLUSIONS: We found an association between European ancestry and type 1 diabetes in our sample, indicating the contribution of ethnicity to incidence differences. Previously reported associations of HLA DR/DQ alleles with disease are confirmed for the admixed Cuban population.

Asociación entre la incidencia de leishmaniosis cutánea y el índice de desarrollo humano y sus componentes en cuatro estados endémicos de Venezuela / Association between cutaneous leishmaniasis incidence and the human development index and its components in four endemic states of Venezuela

Objetivos. Evaluar las posibles asociaciones entre el índice de desarrollo humano (IDH) y sus componentes, y la incidencia de Leishmaniosis cutánea (LC) en cuatro estados endémicos de Venezuela (Mérida, Trujillo, Lara y Sucre) en el período 1994 al 2003. Materiales y métodos. La data socioeconómica (clasificada de acuerdo al Banco Mundial) se obtuvo del Instituto Nacional de Estadística y la epidemiológica del Ministerio de Salud, ambos de Venezuela. Para este estudio ecológico se evaluó la variación anual de las variables y se realizó modelos de regresión. Resultados. El IDH varió en el período, de 0,6746 en 1994 a 0,8144 en 2003 (p=0,90), asimismo, se observó un aumento de la incidencia acumulada de Leishmaniosis, en especial del año 1998 (7,3 casos/100 000 hab) a 1999 (11,3 casos/100 000 hab). Al analizar con los modelos de regresión lineal, se observó que la relación entre las variables epidemiológicas y sociales era diferente a nivel de los Estados evaluados. Para Mérida y Trujillo se observó un descenso significativo de la incidencia de LC con relación al aumento del porcentaje de alfabetización (p menor que 0,05), de estudiantes matriculados (p menor que 0,05), la esperanza de vida (p menor que 0,05), su ingreso en USD per cápita por año (p menor que 0,05) e IDH (p minor that 0,05). Conclusión. Esta información refleja la influencia significativa de los indicadores socioeconómicos sobre la incidencia de la LC en los Estados Trujillo y Mérida, siendo inversa entre ambos tipos de variables; con el incremento o mejoría de los indicadores socioeconómicos, la incidencia acumulada de la enfermedad disminuyó.

Objectives. Assess potential relationships between the Human Development Index (HDI) and its components and the incidence of cutaneous leishmaniasis (CL) in four endemic States of Venezuela (Mérida, Trujillo, Lara and Sucre) in the period 1994-2003. Material and methods. Socioeconomical data (classified according the World Bank) wasobtained from the National Institute of Statistics, and the epidemiological data from the Ministry of Health, both fromVenezuela. For this ecological study the annual variation of the variables was assessed and also regression modelswere done. Results. The HDI varied in the period from 0.6746 in 1994 to 0.8144 in 2003 (p=0.90). During this time an increase in the cumulative incidence of Leishmaniasis was observed, particularly from 1998 (7.3 cases/100,000 pop) to 1999 (11.3 cases/100,000 pop). Analyzing the linear regression models, it was observed that the relationship betweenepidemiological and social variables was different at States levels. For Mérida and Trujillo it was observed a significantdecrease in the CL regard to the increase of literacy (p minor that 0.05), of the gross combined enrollment (p minor that 0.05), life expectancy (p minor that 0.05), money income (p minor that 0.05) and the HDI (p minor that 0.05). Conclusion. This information reflects the significant influence of socioeconomical indicators on the CL incidence at Trujillo and Merida, being an inverse relationship between both types of variables; with an increase or improvement in the socioeconomical indicators, the disease incidence rate decreased.

Malaria mortality in Venezuela: focus on deaths due to Plasmodium vivax in children.

Morbidity and mortality burden of malaria in the childhood represents a public health threat not only in countries with high levels of transmission, but also in those, such as Venezuela and others in Latin America, with moderate to low transmission. Usually its mortality has been attributed just to Plasmodium falciparum malaria, but the changing patterns of increase in Plasmodium vivax malaria morbidity and mortality are now causing concern. We studied malaria mortality by analyzing different epidemiological variables during a 10-year period in Venezuela, finding mortality rates ranging 0.10-0.36 deaths/100,000 population, with almost a third of deaths in children (<10 years old), corresponding 270 deaths to P. falciparum cases and 30 to P. vivax; but along the period with a decrease trend for P. falciparum and an increase trend for P. vivax.

Burden of zoonotic diseases in Venezuela during 2004 and 2005.

Emerging zoonotic diseases have increased in importance in human and animal health during the last 10 years. Each of these diseases has emerged from an unsuspected quarter and has caused severe problems. In countries, such as Venezuela, the burden of these zoonoses has been understudied. In this report we analyze the status of such diseases in Venezuela for the period 2004-2005. During this period a significant number of animal and human cases of these diseases have been found, particularly for rabies, encephalitis, leishmaniasis, and cysticercosis among others. Surveillance needs to be reinforced for these zoonoses.

HLA class I polymorphism in the Cuban population.

The extreme polymorphism found at some of the human leukocyte antigen (HLA) system loci makes it an invaluable tool for population genetic analyses. In the present study the genetic polymorphism of the Cuban population was estimated at HLA-A, -B, and -Cw loci by DNA typing. HLA class I allele and haplotype diversity were determined in 390 unrelated Cuban individuals (188 whites and 202 mulattos) from all over the country. In whites 19, 27, and 14 allele families for the HLA-A, -B, and -Cw loci, respectively, were identified. In mulattos, for the same loci, 20, 18, and 14 allele families were identified. Allele and haplotypes frequencies, comparisons with other worldwide populations based on genetic distances, neighbor-joining dendrograms, and correspondence analyses were estimated. Most of the identified allele groups and haplotypes are also common to sub-Saharan African and Europeans populations. However, Amerindian and Asian alleles were also detected at lower frequencies. The results clearly reveal the high diversity and interethnic admixture of the studied population. Our results provide useful information for the further studies of the Cuban population evolution and disease association in terms of HLA class I genes.

Trends in fatal snakebites in Venezuela, 1995-2002.

OBJECTIVE: There have been few studies evaluating snakebite mortality in Venezuela and South America. In this study we evaluate trends in fatal snakebites occurring in Venezuela between 1995 and 2002. METHODS: Epidemiological data for this study were retrieved from the records of the Ministry of Health of Venezuela. Using these data, we analyzed the impact of snakebites in Venezuela during the study period. RESULTS: During the study period, there were 266 reports of death due to snakebite; 79.7% were males, and 20.3% were females (P < .01). Annual mean deaths numbered 33 per year. Of total deaths, 24.1% occurred in victims 55-70 years old. Deaths in young children (<5 years old) accounted for 7.1% of the total. Mortality rate by age showed an age-dependent rate, with higher rates in older ages (P = .038). CONCLUSION: Snake envenomations are an important cause of injury and deaths in Venezuela as in many American countries. Surveillance of envenomations is essential for establishing guidelines, planning therapeutic supplies, and training medical staff on snakebite treatment, as well as assessing risk zones for travelers.

ACE I/D polymorphism study in a Cuban hypertensive population.

BACKGROUND: The angiotensin converting enzyme (ACE) is a key protein of the renin angiotensin system, whose main function is the conversion of angiotensin I to II. ACE is involved in the physiological control of blood pressure and it is a candidate gene for essential hypertension in humans. We tested the relevance of the ACE insertion/deletion (I/D) polymorphism in our population. METHODS: We recruited 243 hypertensive and 407 normotensive subjects in the city of Havana, matched according to age, sex and ethnic group. The ACE (I/D) polymorphism was determined by the polymerase chain reaction (PCR) technique. The fit of genotype frequencies to Hardy-Weinberg proportions was evaluated in all groups analyzed. The possible association between the ACE I/D polymorphism and hypertension status was tested by chi2 and odds ratio tests. RESULTS: All groups but black female cases were in Hardy-Weinberg equilibrium. The frequencies of the D allele in hypertensive/normotensive subjects were 0.61/0.59 in white males, 0.58/0.58 in white females, 0.47/0.59 in black males and 0.58/0.54 in black females. The distribution of ACE genotypes differed significantly between cases and controls only in black women according to the additive model (chi2p=0.04) but the adjusted OR did not show significant association (OR 1.14 95% CI 0.62 to 2.10). CONCLUSION: The ACE I/D polymorphism was not associated with hypertension in our multiethnic sample. While the chi2 test for additive model in black women suggested a marginal significance, the adjusted OR did not show any significant association.

Epizootics of yellow fever in Venezuela (2004-2005): an emerging zoonotic disease.

Epidemics and epizootics of yellow fever (YF) have been occurring in the border area of eastern Colombia and western Venezuela since 2003; for this reason many epidemiological control measures were adopted by the Ministry of Health (MOH) trying to prevent their spreading. These activities included monkey deaths surveillance as well as immunization of susceptible individuals with YF vaccine. In this setting, we analyzed epidemiological and epizootical issues related to YF in Venezuela during 2004-2005. In this period, YF epizootics occurred initially without geographical links to the 2003 outbreaks (which occurred at the Southern Maracaibo lake epizootic wave), but in relation with the Guayana epizootic wave; beginning in Monagas state and then affecting Anzoátegui, Guárico, and Sucre states. Just months later, Apure was also affected. Mérida and Táchira also report epizootics for the end of 2004. This year concluded with 15 human deaths due to YF and more than 100 howler monkey deaths. In the same year, 715 suspected cases were investigated confirming YF in 0.7% of them. For these reasons, between 2002 and 2004, Venezuela's MOH has vaccinated approximately 1.9 million people in areas considered to be enzootic. The country's goal for 2006 is to have 7 million people residing in high-risk cities and towns vaccinated, and in this way, preventing and controlling this emerging zoonotic disease.

Intestinal parasitic infections among pregnant women in Venezuela.

INTRODUCTION: Intestinal parasitic infections, especially due to helminths, increase anemia in pregnant women. The results of this are low pregnancy weight gain and IUGR, followed by LBW, with its associated greater risks of infection and higher perinatal mortality rates. For these reasons, in the setting of no large previous studies in Venezuela about this problem, a national multicentric study was conducted. METHODS: Pregnant women from nine states were studied, a prenatal evaluation with a coproparasitological study. Univariated and multivariated analyses were made to determine risk factors for intestinal parasitosis and related anemia. RESULTS: During 19 months, 1038 pregnant women were included and evaluated. Intestinal parasitosis was evidenced in 73.9%: A lumbricoides 57.0%, T trichiura 36.0%, G lamblia 14.1%, E hystolitica 12.0%, N americanus 8.1%, E vermicularis 6.3%, S stercoralis 3.3%. Relative risk for anemia in those women with intestinal parasitosis was 2.56 (P < .01). DISCUSSION: Intestinal parasitoses could be associated with conditions for development of anemia at pregnancy. These features reflect the need of routine coproparasitological study among pregnant women in rural and endemic zones for intestinal parasites. Further therapeutic and prophylactic protocols are needed. Additional research on pregnant intestinal parasitic infection impact on newborn health is also considered.

HLA DQA1*0501 and DQB1*02 in Cuban celiac patients.

Celiac disease (CD) susceptibility has been strongly associated with HLA-DQ2 and HLA-DQ8. The main objective of this study was to assess the distribution of HLA DQA1*0501 and DQB1*02 alleles (DQ2) for the first time in a group of Cuban celiac patients. We evaluated 22 patients, 54 first-degree relatives, and 60 controls for detection of antitissue transglutaminase (tTG)-specific antibodies in serum. We found that 100% of the probands and 19% of the first-degree relatives were positive for the antibodies in serum. We did not detect any specific response for the healthy control individuals. We observed a significant over-representation of DQ2 heterodimer, both in patients and relatives. In the group of patients, 86.3% were positive for DQA1*0501, 90.2% were positive for DQB1*02, and 86.3% were positive for both alleles. The frequencies in relatives and controls were as follows: 70%, 90%, and 70%; and 56.6%, 45%, and 20%, respectively. In conclusion, we found that the proportion of our celiac patients carrying DQ2 was similar to the proportion of CD patients reported in populations with different genetic backgrounds. These results underline the primary importance of HLA-DQ alleles in susceptibility to celiac disease.

Ecoepidemiological and Social Factors Related to Rabies Incidence in Venezuela during 2002-2004.

Rabies in Venezuela has been important in last years, affecting dogs, cats, and human, among other animals, being a reportable disease. In Zulia state, it is considered a major public health concern. Recently, a considerable increase in the incidence of rabies has been occurring, involving many epidemiological but also ecoepidemiological and social factors. These factors are analyzed in this report. During 2002-2004, 416 rabies cases were recorded. Incidence has been increasingly significantly, affecting mainly dogs (88.94%). Given this epidemiology we associated ecoepidemiological and social factors with rabies incidence in the most affected state, Zulia. In this period 411 rabies cases were recorded. Zulia has varied environmental conditions. It is composed mostly of lowlands bordered in the west by mountain system and in the south by the Andes. The mean is temperature 27.8°C, and mean yearly rainfall is 750 mm. Climatologically, 2002 corresponded with El Niño (drought), middle 2003 evolved to a Neutral period, and 2004 corresponded to La Niña (rainy); this change may have affected many diseases, including rabies. Ecological analysis showed that most cases occurred in lowland area of the state and during rainy season (p<0.05). Additionally, there is an important social problem due to educational deficiencies in the native population. Many ethnic groups live un Zulia, many myths about rabies are in circulation, and the importance of the disease is not widely realized. The full scale of the rabies burden is unknown, owing to inadequate disease surveillance. Although there have been important advances in our knowledge and ability to diagnose and prevent it, enormous challenges remain in animal rabies control and provision of accessible-appropriate human prophylaxis worldwide. Human and animal surveillance including ecological and social factors is needed.

Extracción de amblyomma cajennense (fabricius, 1787) de un caso de otoacariasis humana en el Estado Sucre-Venezuela / Extraction of amblyomma cajennense (fabricius, 1787) a case of human otoacariasis in the State Sucre-Venezuela

El ingreso accidental de insectos y otros artrópodos en el canal auditivo es una etiología común de los cuerpos extraños en otorrinolaringología. La infestación humana con especies del genero Amblyomma es infrecuentemente reportada. Se reporta el caso de un paciente masculino de 7 años de edad, natural y procedente de Tunapuy, Municipio Libertador, Estado Sucre, cuya madre refiere la introducción de un "insecto" en el oído derecho en horas de la madrugada. El paciente presentó dolor de moderada a fuerte intensidad en el oído derecho. Al evaluarse el canal auditivo por otoscopia se evidenció la presencia de una garrapata de <5 mm de largo, la cual fue extraída con pinzas, posterior a la colocación directa de xilocaína al 2 por ciento en el canal auditivo. No se observaron signos de lesión significativa, inflamación o supuración. Se le indicó profilaxis antimicrobiana con cefadroxilo 30 mg/Kg/d bid vo, así como nimesulide 5 mg/kg/d bid vo, ambos por 5 días. El paciente fue reevaluado a los 14 días, no presentando sintomatología alguna, ni signos de enfermedad local o sistémica. Posteriormente la garrapata aislada del oído fue identificada taxonómicamente según las claves de Hoogstraal y Jones, como Amblyomma cajennense. Esta garrapata se ha descrito aislada de diversos hospedadores mamíferos, incluyendo al humano; reportándose en los Estados Amazonas, Anzoátegui, Apure, Bolívar, Carabobo, Falcón, Guárico, Lara, Miranda, Yaracuy y Zulia. De acuerdo a la revisión realizada, éste es el primer reporte de su descripción en el Estado Sucre.

Lepidopterism due to exposure to the moth Hylesia metabus in northeastern Venezuela.

Lepidopterism refers to a spectrum of medical conditions in humans that usually involves the skin and results from contact with the adult or larval forms of certain butterflies and moths. We analyzed the epidemiologic and clinical features associated with exposure to the moth Hylesia metabus between 1970 and 2002 in the Cajigal district, Sucre, Venezuela. Fifty cases of lepidopterism mostly affecting individuals under 18 years of age were identified during this period and manifested as pruritic dermatitis with or without associated respiratory symptoms. With increased travel to endemic areas of lepidopterism, travel and tropical medicine practitioners should be aware of the clinical spectrum of this condition.