Leptospirosis in Ecuador: Current Status and Future Prospects.

The location of Ecuador-an equatorial nation-favors the multiplication and dispersal of the Leptospira genus both on the Pacific Coast and in the Amazon tropical ecoregions. Nevertheless, leptospirosis epidemiology has not been fully addressed, even though the disease has been recognized as a significant public health problem in the country. The purpose of this literature review is to update knowledge on the epidemiology and geographical distribution of Leptospira spp. and leptospirosis in Ecuador to target future research and develop a national control strategy. A retrospective literature search using five international, regional, and national databases on Leptospira and leptospirosis including humans, animals, and environmental isolations of the bacteria and the disease incidence in Ecuador published between 1919 and 2022 (103 years) with no restriction on language or publication date was performed. We found and analyzed 47 publications including 22 of humans, 19 of animals, and two of the environments; three of these covered more than one of these topics, and one covered all three (i.e., One Health). Most (60%) of the studies were conducted in the Coastal ecoregion. Twenty-four (51%) were published in international journals, and 27 (57%) were in Spanish. A total of 7342 human and 6314 other animal cases were studied. Leptospirosis was a frequent cause of acute undifferentiated febrile illness in the Coast and Amazon and was associated with rainfall. All three major clusters of Leptospira-pathogenic, intermediate, and saprophytic-were identified from both healthy and febrile humans, the environment, and animals; moreover, nine species and 29 serovars were recorded over the three Ecuadorian ecoregions. Leptospira infections were diagnosed in livestock, companion, and wild animals from the Amazon and the Coast regions along with sea lions from the Galápagos Islands. Microscopic-agglutination test was the diagnostic tool most widely used. Three reviews covering national data on outpatients and inpatients determined the varied annual incidence and mortality rate, with males being more commonly affected. No human cases have been reported in the Galápagos Islands. Genomic sequences of three pathogenic Leptospira were reported. No studies on clinical ground, antibiotic resistance, or treatment were reported, nor were control programs or clinical-practice guidelines found. The published literature demonstrated that leptospirosis was and still is an endemic disease with active transmission in the four geoclimatic regions of Ecuador including the Galápagos Islands. Animal infections, distributed in mainland and insular Ecuador, pose a significant health risk for humans. Nationwide epidemiological surveys-encouraging more research on the fauna and environment with appropriate sampling design on risk factors for human and animal leptospirosis, Leptospira genotyping, increased laboratory capability, and readily available official data-are required to improve our understanding of transmission patterns and to develop effective national intervention strategies with the intention of applying One Health approaches.

Leptospirosis: Morbidity, mortality, and spatial distribution of hospitalized cases in Ecuador. A nationwide study 2000-2020.

BACKGROUND: In Ecuador, leptospirosis surveillance involves a mandatory notification of all cases and a hospitalization for severe illness. Morbidity and mortality are, nevertheless, underestimated and contribute directly to the status of leptospirosis as a neglected disease. Leptospira spp. is zoonotic in Ecuador with established endemic transmission in the Tropics. Here, we review retrospective national data within the country to aid in control strategies. METHODOLOGY/PRINCIPAL FINDINGS: In a population-based nationwide study, we analysed morbidity, mortality, and spatial distribution on confirmed hospital-discharged leptospirosis cases from 2000-2020 from a publicly accesible National Database, including males and females of all ages. We computed data for the 24 provinces across the four-geoclimatic regions of Ecuador based on seasonal and monthly variations and calculated rates according to age and sex. The spatial distribution was estimated at the level of ecoregions, provinces, and cantons. A total of 2,584 hospitalizations were recorded over all three continental regions in 22 provinces, except Carchi province and the Galapagos Islands. The annual incidence varied from 0.27 to 2.45 cases per 100,000 inhabitants with ages ranging from 1 to 98 years-old and an overall male/female ratio of 1.92:1. Most hospitalizations and deaths occurred in males ages 25-34 years. We registered 79 fatalities (3.06%); the highest mortality rate was 0.05 per 100,000 inhabitants. More cases clustered in the tropical cantons of central and north of the Coast and in the southern Amazon when compared to the Andes. CONCLUSIONS AND SIGNIFICANCE: Our findings evidence leptospirosis endemicity and pinpoint the highest incidence within resource-poor tropical settings. The highest incidence occurred in males of adult age, with those also exhibiting the highest mortality. The national incidence rate was stable, but peaks occurred intermittently during the rainy seasons. Thus, strategies aimed at leptospirosis monitoring and control involving the application of preventive measures should consider this season and the aforementioned high-risk groups.

Chronic high-altitude exposure and the epidemiology of ischaemic stroke: a systematic review.

INTRODUCTION: About 5.7% of the world population resides above 1500 m. It has been hypothesised that acute exposure to high-altitude locations can increase stroke risk, while chronic hypoxia can reduce stroke-related mortality. OBJECTIVE: This review aims to provide an overview of the available evidence on the association between long-term high-altitude exposure and ischaemic stroke. DESIGN: A systematic review was performed from 1 January 1960 to 1 December 2021 to assess the possible link between high-altitude exposure and ischaemic stroke. The AMED, EMBASE, Cochrane Library, PubMed, MEDLINE, the Europe PubMed Central and the Latin-American bibliographic database Scielo were accessed using the University of Southampton library tool Delphis. In this review, we included population and individual-based observational studies, including cross-sectional and longitudinal studies except for those merely descriptive individual-based case reports. Studies were limited to humans living or visiting high-altitude locations for at least 28 days as a cut-off point for chronic exposure. RESULTS: We reviewed a total of 1890 abstracts retrieved during the first step of the literature review process. The authors acquired in full text as potentially relevant 204 studies. Only 17 documents met the inclusion criteria and were finally included. Ten studies clearly suggest that living at high altitudes may be associated with an increased risk of stroke; however, five studies suggest that altitude may act as a protective factor for the development of stroke, while two studies report ambiguous results. CONCLUSIONS: This review suggests that the most robust studies are more likely to find that prolonged living at higher altitudes reduces the risk of developing stroke or dying from it. Increased irrigation due to angiogenesis and increased vascular perfusion might be the reason behind improved survival profiles among those living within this altitude range. In contrast, residing above 3500 m seems to be associated with an apparent increased risk of developing stroke, probably linked to the presence of polycythaemia and other associated factors such as increased blood viscosity.

A comparative analysis of lung function and spirometry parameters in genotype-controlled natives living at low and high altitude.

BACKGROUND: The reference values for lung function are associated to anatomical and lung morphology parameters, but anthropometry it is not the only influencing factor: altitude and genetics are two important agents affecting respiratory physiology. Altitude and its influence on respiratory function has been studied independently of genetics, considering early and long-term acclimatization. OBJECTIVE: The objective of this study is to evaluate lung function through a spirometry study in autochthonous Kichwas permanently living at low and high-altitude. METHODOLOGY: A cross-sectional study of spirometry differences between genetically matched lowland Kichwas from Limoncocha (230 m) at Amazonian basin and high-altitude Kichwas from Oyacachi (3180 m) in Andean highlands. The sample size estimates permitted to recruited 118 patients (40 men and 78 women) from Limoncocha and 95 (39 men and 56 women) from Oyacachi. Chi-square method was used to analyze association or independence of categorical variables, while Student's t test was applied to comparison of means within quantitative variables. ANOVA, or in the case that the variables didn't meet the criteria of normality, Kruskal Wallis test were used to compare more than two groups. RESULTS: The FVC and the FEV1 were significantly greater among highlanders than lowlanders (p value < 0.001), with a proportion difference of 15.2% for men and 8.5% for women. The FEV1/FVC was significantly higher among lowlanders than highlanders for men and women. A restrictive pattern was found in 12.9% of the participants. CONCLUSION: Residents of Oyacachi had greater FVC and FEV1 than their peers from Limoncocha, a finding physiologically plausible according to published literature. Lung size and greater ventilatory capacities could be an adaptive mechanism developed by the highlander in response to hypoxia. Our results support the fact that this difference in FVC and FEV1 is a compensatory mechanism towards lower barometric and alveolar partial pressure of oxygen pressure.

Genotyped indigenous Kiwcha adults at high altitude are lighter and shorter than their low altitude counterparts.

BACKGROUND: Anthropometric measures have been classically used to understand the impact of environmental factors on the living conditions of individuals and populations. Most reference studies on development and growth in which anthropometric measures were used were carried out in populations that are located at sea level, but there are few studies carried out in high altitude populations. OBJECTIVE: The objective of this study was to evaluate the anthropometric and body composition in autochthonous Kiwcha permanently living at low and high altitudes. METHODOLOGY: A cross-sectional study of anthropometric and body composition between genetically matched lowland Kiwcha from Limoncocha (n = 117), 230 m in the Amazonian basin, and high-altitude Kiwcha from Oyacachi (n = 95), 3800 m in Andean highlands. Student's t-test was used to analyze the differences between continuous variables, and the chi-square test was performed to check the association or independence of categorical variables. Fisher's exact test or Spearman's test was used when the variable had evident asymmetries with histograms prior to the selection of the test. RESULTS: This study shows that high altitude men are shorter than their counterparts who live at low altitude, with p = 0.019. About body muscle percentage, women at high altitudes have less body muscle percentage (- 24.8%). In comparison, men at high altitudes have significantly more muscle body mass percentage (+ 13.5%) than their lowland counterparts. Body fat percentage was lower among low altitude women (- 15.5%), and no differences were found among men. CONCLUSIONS: This is the first study to be performed in two genotyped controlled matching populations located at different altitudes to our best knowledge. The anthropometric differences vary according to sex, demonstrating that high altitude populations are, in general, lighter and shorter than their low altitude controls. Men at high altitude have more muscled bodies compared to their lowland counterparts, but their body age was older than their actual age.

Optimism and Health Self-Perception-Related Differences in Indigenous Kiwchas of Ecuador at Low and High Altitude: A Cross-Sectional Analysis.

Ortiz-Prado, Esteban, Katherine Simbaña-Rivera, Diego Duta, Israel Ochoa, Juan S. Izquierdo-Condoy, Eduardo Vasconez, Kathia Carrasco, Manuel Calvopiña, Ginés Viscor, and Clara Paz. Optimism and health self-perception-related differences in indigenous Kiwchas of Ecuador at low and high altitude: a cross-sectional analysis. High Alt Med Biol. 23:26-36, 2022. Background: Living at high altitude causes adaptive responses at every physiological and molecular level within the human body. Emotional and psychological short- or long-term consequences, including mood changes, higher mental overload, and depression prevalence, as well as increased risk to commit suicide have been reported among highlanders. The objective of this report is to explore the differences in self-reported dispositional optimism and health perception among sex-, age-, and genotype-controlled indigenous Kiwcha natives living at two different altitudes. Methods: A cross-sectional analysis of the comparison of means of subscales and summary scores of the 36-item short-form health survey (SF-36) self-reported questionnaire and the Life Orientation Test-Revised was conducted among 219 adults Kiwchas living at low (230 m) and high altitude (3,800 m) in Ecuador. Results: High-altitude dwellers presented lower scores in all the studied dimensions of SF-36 and the total score. Differences were found for the role limitation sphere due to vitality (p = 0.005), mental health (p = 0.002), and social functioning (p = 0.005). In all the cases, participants living at low altitudes scored higher than those living at high altitudes. Lowland women were more optimistic than their high-altitude counterparts. Conclusions: We observe that populations located at high altitudes have more unfavorable self-reported health states. Although our results depict the existence of significant differences in the health status of indigenous peoples living at different altitudes, further studies are needed to explain in depth the sociodemographic and/or environmental factors that might underlie these differences.

Analysis of Excess Mortality Data at Different Altitudes During the COVID-19 Outbreak in Ecuador.

Ortiz-Prado, Esteban, Raul Patricio Fernandez Naranjo, Eduardo Vasconez, Katherine Simbaña-Rivera, Trigomar Correa-Sancho, Alex Lister, Manuel Calvopiña, and Ginés Viscor. Analysis of excess mortality data at different altitudes during the COVID-19 outbreak in Ecuador. High Alt Med Biol. 22:406-416, 2021. Background: It has been speculated that living at high altitude confers some risk reduction in terms of SARS-CoV-2 infection, reduced transmissibility, and arguable lower COVID-19-related mortality. Objective: We aim to determine the number of excess deaths reported in Ecuador during the first year of the COVID-19 pandemic in relation to different altitude categories among 221 cantons in Ecuador, ranging from sea level to 4,300 m above. Methods: A descriptive ecological country-wide analysis of the excess mortality in Ecuador was performed since March 1, 2020, to March 1, 2021. Every canton was categorized as lower (for altitudes 2,500 m or less) or higher (for altitudes >2,500 m) in a first broad classification, as well as in two different classifications: The one proposed by Imray et al. in 2011 (low altitude <1,500 m, moderate altitude 1,500-2,500 m, high altitude 2,500-3,500 m, or very high altitude 3,500-5,500 m) and the one proposed by Bärtsch et al. in 2008 (near sea level 0-500 m, low altitude 500-2,000 m, moderate altitude 2,000-3,000 m, high altitude 3,000-5,500 m, and extreme altitude 5,500 m). A Poisson fitting analysis was used to identify trends on officially recorded all-caused deaths and those attributed to COVID-19. Results: In Ecuador, at least 120,573 deaths were recorded during the first year of the pandemic, from which 42,453 were catalogued as excessive when compared with the past 3 years of averages (2017-2019). The mortality rate at the lower altitude was 301/100,000 people, in comparison to 242/100,000 inhabitants in elevated cantons. Considering the four elevation categories, the highest excess deaths came from towns located at low altitude (324/100,000), in contrast to the moderate altitude (171/100,000), high-altitude (249/100,000), and very high-altitude (153/100,000) groups. Conclusions: This is the first report on COVID-19 excess mortality in a high-altitude range from 0 to 4,300 m above sea level. We found that absolute COVID-19-related excess mortality is lower both in time and in proportion in the cantons located at high and very high altitude when compared with those cantons located at low altitude.

Hematological Parameters, Lipid Profile, and Cardiovascular Risk Analysis Among Genotype-Controlled Indigenous Kiwcha Men and Women Living at Low and High Altitudes.

Introduction: Human adaptation to high altitude is due to characteristic adjustments at every physiological level. Differences in lipid profile and cardiovascular risk factors in altitude dwellers have been previously explored. Nevertheless, there are no reports available on genotype-controlled matches among different altitude-adapted indigenous populations. Objective: To explore the possible differences in plasma lipid profile and cardiovascular risk among autochthonous Kiwcha people inhabitants of low and high-altitude locations. Methodology: A cross-sectional analysis of plasmatic lipid profiles and cardiovascular risk factors in lowland Kiwchas from Limoncocha (230 m) and high-altitude Kiwchas from Oyacachi (3,800 m). Results: In the low altitude group, 66% were women (n = 78) and 34% (n = 40) were men, whereas in the high altitude group, 59% (n = 56) were women and 41% (n = 41%) were men. We found the proportion of overweight and obese individuals to be higher among low altitude dwellers (p < 0.05). Red blood cells (RBCs), hemoglobin concentration, and SpO2% were higher among high altitude dwellers and the erythrocyte size was found to be smaller at high altitude. The group located at low altitude also showed lower levels of plasma cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL), but most of these differences are not influenced by gender or elevation. Conclusions: Living at an altitude elicits well-known adaptive physiological changes such as erythrocyte count, hemoglobin concentration, hematocrit level, and serum glucose level. We also report clinical differences in the plasma lipid profile, with higher levels of cholesterol, HDL, and LDL in inhabitants of the Andes Mountain vs. their Amazonian basin peers. Despite this, we did not find significant differences in cardiovascular risk.

High SARS-CoV-2 Infection Rates Among Special Forces Police Units During the Early Phase of the COVID-19 Pandemic in Ecuador.

Background: At the beginning of the COVID-19 pandemic, health workers and first-responders, such as police officers, were in charge of trying to contain a disease that was unknown at that time. The lack of information and the tremendous need to contain new outbreaks put police officers at higher risk. Methodology: A cross-sectional study was conducted to describe SARS-CoV-2 infection rates among Police Special Forces Officers in Quito, Ecuador. In this study, 163 community-dwelling police officers from elite divisions voluntarily participated in our SARS-CoV-2 detection program using reverse transcription quantitative real-time PCR (RT-qPCR). Results: A total of 20 out of 163 police officers tested positive for SARS-CoV-2, yielding an infection rate of 12.3%. Within this cohort, 10% (2/20) of SARS-CoV-2 positive individuals were potentially super spreaders with viral loads over 108 copies/ul. About 85% of the SARS-CoV-2 positive individuals were asymptomatic and 15% reported mild symptoms related to COVID-19. Conclusions: We found a high SARS-CoV-2 infection rate within the special forces police officers that, beyond a high health risk for themselves, their families, and coworkers. Our results point out the need for permanent SARS-CoV-2 testing among asymptomatic essential workers and first-responders to avoid local outbreaks and to prevent work-place absenteeism among police special units.

Acute respiratory distress syndrome (ARDS) caused by the novel coronavirus disease (COVID-19): a practical comprehensive literature review.

INTRODUCTION: The exponential growth of SARS-CoV-2 virus transmission during the first months of 2020 has placed substantial pressure on most health systems around the world. The complications derived from the novel coronavirus disease (COVID-19) vary due to comorbidities, sex and age, with more than 50% of the patients requiring some level of intensive care developing acute respiratory distress syndrome (ARDS). The authors carried out an extensive and comprehensive literature review on SARS-CoV-2 infection, the clinical, pathological, and radiological presentation as well as the current treatment strategies. AREAS COVERED: Various complications caused by SARS-CoV-2 infection have been identified, the most lethal being the acute respiratory distress syndrome, caused most likely by the presence of severe immune cell response and the concomitant alveolus inflammation. The new treatment strategies are updated, and the analysis of the physiopathology is included in this review. EXPERT OPINION: ARDS is one of the most frequent complications in patients with COVID-19. Information regarding the etiology and physiopathology are still unfolding and for the prevention and amelioration, good clinical management, adequate ventilatory support and the use of systemic corticoids seem to be the most efficient way to reduce mortality and to reduce hospital lengths.

Earthquake-related stressors associated with suicidality, depression, anxiety and post-traumatic stress in adolescents from Muisne after the earthquake 2016 in Ecuador.

BACKGROUND: The Ecuadorian earthquake in April 16th was the second strongest and deadliest in 2016 worldwide, with approximately one million people affected. In this paper, we analyzed the psychological impact and the relationship between mental health events and various earthquake-related stressors related to the earthquake, 9 months after the event. METHODS: We conducted an analytical cross-sectional study, applying an anonymous survey to 316 adolescents (13-19 years old) from Muisne, Ecuador. Suicidal tendency, depression, anxiety and post-traumatic stress (PTSD) were evaluated via the Child PTSD Symptom Scale (CPSS), Spence Children's Anxiety Scale, Okasha Suicidality Scale, and the Center for Epidemiologic Studies Depression Scale (CES-D) and the adapted seven-questions earthquake-related stressors survey. RESULTS: We found a high prevalence of suicidal ideations and behavior, posttraumatic stress, depression and anxiety compared to international studies. Even though adolescents currently living in shelters had higher levels of anxiety, their suicidal tendency was significantly lower than those living in their own or their relatives' home. Finally, the earthquake-related stressors were not associated with suicidality and mental health events, with the exception of economic damage suffered by the family. CONCLUSIONS: High levels of depression, post-traumatic stress and anxiety among high-school students were found, especially among those who have suffered serious economic damage. The economic impact in their families and high unemployment rates among their parents seems to be related to lack of hope and favorable perspectives for their future, situation that might lead to lead to emotional disturbances and psychological disorders. Although prolonged homelessness experience in shelters may be a stressful occurrence, might also be related with spiritual growth among adolescents, and may work as a protective factor against suicidal ideations and attempts.

Clinical, genetic and microbiological characterization of pediatric patients with cystic fibrosis in a public Hospital in Ecuador.

BACKGROUND: To carry out a complete clinical, pathological, genetic and microbiological characterization of pediatric patients with molecular confirmed cystic fibrosis (CF) attending the Carlos Andrade Marín Hospital (HCAM) within the study period. METHODS: A cross-sectional analysis of the pediatric population with a confirmed diagnosis of CF disease who attended HCAM, one of the largest tertiary-level hospitals in Ecuador, between 2017 and 2018 was performed. All demographic, clinical and genetic variables were obtained from the electronic medical records (EMR) stored by the hospital. RESULTS: Forty seven patients with CF were included in the study. Gender distribution was similar between male (48.9%, n = 23) and female patients (51.1%, n = 24). The Tiffeneau-Pinelli index (FEV1/FVC) changed significantly after nine months post-diagnosis (85.55 ± 13.26; p < 0.05). The most common pathogenic genetic variants were F508del, found in 52.78% of the cohort (n = 19); H609R, found in 36.11% (n = 13); g.204099A > C, found in 14.1% (n = 7), followed by G85E and the N1303K with 11.11% (n = 3) each. CONCLUSIONS: To our best knowledge, this is the first study exploring the clinical, genetic and bacteriological profile of CF's patients in Ecuador. Within the cohort of patients, an important and unique genetic feature was characterized by the presence of the g.204099A > C and the c.206359C > A homozygous polymorphism as well as the presence of the H609R variant, a mutation only reported among Ecuadorians.

Disfunción Mioneural Periférica Como Único Elemento Para El Diagnostico De La Distrofia Miotónica Tipo I / Myoneural Disfunction For The Diagnosis Of Myotonic Dystrophy Type I

Resumen La distrofia miotónica tipo 1, también conocida como enfermedad de Steinert, es un trastorno mulsistémico que afecta principalmente al sistema músculo esquelético y liso, así como al ojo, corazón, sistema endócrino y sistema nervioso central. Esta patología es infrecuente y se caracteriza por miotonía generalizada y daño multiorgánico. Su expresión clínica es variable, pero en la mayoría de los casos se presenta un grado variable de debilidad muscular, arritmias cardiacas y otros trastornos de la conducción, alteraciones endócrinas, trastornos del sueño, cataratas y calvicie. Esta es una enfermedad hereditaria con tres fenotipos reconocibles: leve, clásico y congénito. Dependiendo de su presentación puede tener mal pronóstico y una progresión usualmente rápida, la misma que carece de un tratamiento efectivo. Presentación del caso: Paciente femenina de 54 años que ingresa al Servicio de Traumatología del Hospital San Vicente de Paul de Ibarra, Ecuador por presentar una fractura de fémur izquierdo resultante de una caída desde su silla de ruedas. Durante la hospitalización la paciente presenta insuficiencia respiratoria tipo II sin causa aparente por lo cual es ingresada a UCI para soporte ventilatorio. La paciente presenta dificultad para lograr el destete ventilatorio debido a la debilidad muscular distal y proximal. La electromiografía revela un patrón miopático compatible con el diagnóstico de distrofia miotónica tipo I. Se realiza traqueotomía y es dada de alta para seguimiento por el servicio de Medicina Interna. Se sugiere la realización de estudio molecular diagnóstico. Conclusiones: El estudio molecular es la opción diagnóstica indicada para determinar con certeza la presencia de la distrofia miotónica tipo I, además de permitir determinar su severidad dependiendo del número de repetidos. Sin embargo, las limitaciones de recursos en el presente caso forzaron a que se busquen evidencias para el diagnóstico a través de la electromiografía. Hasta le alta, el tratamiento sigue siendo sintomático. Debido a que su modo de herencia es autosómico dominante, por expansión de trinucléotidos, se debe buscar familiares que pueden encontrarse asintomáticos y podrían tener esta patología.

Abstract Myotonic dystrophy type 1, also known as Steinert's disease, is a mulsystemic disorder that primarily affects the skeletal and smooth muscle, as well as the eye, heart, endocrine system and central nervous system. This pathology is uncommon and is characterized by generalized myotonia and multiorgan damage. Its clinical expression is variable, but in most cases, there is a variable degree of muscle weakness, cardiac arrhythmias and other conduction disorders, endocrine disorders, sleep disorders, cataracts and baldness. This is a hereditary disease with three recognizable phenotypes: mild, classic and congenital. Depending on the presentation, it may show poor prognosis and a usually rapid progression, which lacks of effective treatment. Case presentation: 54-year-old female patient who enters the Traumatology service of San Vicente de Paul Hospital in Ibarra, Ecuador for presenting a left femur fracture resulting from a fall of her own height. During hospitalization, the patient presented with type II respiratory failure without apparent cause, so she was admitted to the ICU for ventilatory support. The patient had difficulty achieving ventilatory weaning due to distal and proximal muscle weakness. Electromyography reveals a myopathic pattern compatible with the diagnosis of myotonic dystrophy type I. A tracheotomy was performed, and she was discharged for follow-up by the Internal Medicine service. The performance of a molecular diagnostic study was suggested. Conclusions: The molecular study is the diagnostic gold standard to determine with certainty the presence of myotonic dystrophy type I, besides allowing to determine its severity depending on the number of repeated. However, resource limitations in the present case forced evidence to be sought for diagnosis through electromyography. The treatment remains symptomatic. Because of its inheritance pattern being autosomal dominant, due to the expansion of trinucleotides, family members must be evaluated because they may have the diagnosis even though asymptomatic.

Drug prices and trends before and after requesting compulsory licenses: the Ecuadorian experience.

Introduction: The Ecuadorian Institute of Intellectual Property (IEPI) granted several compulsory licenses between 2011 and 2017. In 2009, the President of Ecuador signed a decree that was intended to facilitate the request of compulsory licenses (CL) in the country, not only for Enfarma EP but for any privately owned local company in order to produce more accessible medicines. Areas covered: The national and international regulatory framework of pharmaceutical patents and the local applicability of CL in Ecuador. The authors also analyzed the results of requesting unplanned and epidemiologically unnecessary CL at a national level. Finally, the authors reviewed the effects of requesting, granting or denying CL on price per unit in the last 7 years of available data. Expert opinion: The authors think that compulsory licenses are useful tools when negotiating drug prices or when the demand cannot be satisfied due to economic constrain within the local health system. However, the authors' experience suggests that Ecuador did not have an established and reliable production system neither an adequate plan before requesting CL, therefore the positive effects of this measure were not clearly established.

Attitudes and perceptions of medical doctors towards the local health system: a questionnaire survey in Ecuador.

BACKGROUND: Health systems worldwide rely on health professionals to deliver services and provide framework structures. Considering their opinions about their work environment, the public policies that regulate their work and the deficiencies of the health care system are key aspects of the governance within the system. The aim of this study was to assess the perceptions of Ecuadorian physicians about several aspects of the performance of the health delivery and monitoring systems locally. METHODS: A cross-sectional survey was performed in a group of physicians in Ecuador during 2017 using a self-selection sampling strategy. The participants were contacted by telephone, direct email or in person and asked to complete the online survey which contained 47 questions. RESULTS: A total of 607 full responses were received from physicians, where 68.6% of those had graduated within the last 17 years. 46.4% of respondents were medical specialists, 23.1% general practitioners, 10.0% rural health practitioners, 9.5% sub-specialists, 5.9% were formally enrolled in a specialty program and 5.1% were researchers or administrative physicians. Data analysis of the answers showed that approximately 62% of physician respondents in the study found their current workload at the time of the survey was unmanageable, the most common complaints about the Public Health system in the study being the amount of daily paperwork (78.4%), followed by a perceived lack of vision of the health authorities (60.1%) and the resource limitations within the public hospitals (53.5%). Additionally, 71.8% of respondents referred to limitations of the National Essential Medicines chart- especially on the availability of some drugs- and 57.5% of the respondents reported concerns about the quality of medicines available for treatment. CONCLUSIONS: The data provide basic inputs for health authorities regarding the functioning of the health system in Ecuador. Health professionals' concerns can be a valuable resource for monitoring and improving health system performance: however, there is a perceived sense of disconnection between the governance or management and the service delivery arms of the healthcare system in Ecuador. Whilst not representative of the entirety of the population of doctors, the study does give insight into where improvements to the health system might be made.

The disease burden of suicide in Ecuador, a 15 years' geodemographic cross-sectional study (2001-2015).

BACKGROUND: Suicide affects people from different backgrounds, ethnical groups, socio-economic status and geographical locations. In Latin America, suicide reports arescarce, specially in Andean countries. In Ecuador, very few reports have partially described this phenomenon, nonetheless, estimation of the burden of disease (BoD) hasnever been reported in the country. METHODS: A country-wide comparison was performed using the Ministry of Public Health's national databases of overall mortality, Hospital Discharges Database, and the Population Census of the National Institute of Census and Statistics (INEC). The study variables analyzed were age, geographical distribution to provincial level, sex, means of suicide, educational attainment, marital status and mortality. Linear Regression and relative Risk analysis were used to predict outcome and the likelihood that suicide occur among study variables. RESULTS: In the last 15 years, 13,024 suicides were officially reported. Men were 3 times more likely than women to die by suicide. The overall age-adjusted suicide ratio in Ecuador corresponds to 7.1 per 100,000 per year. The sex-specific rates were 5.3 in women and 13.2 in men. The primary mean of suicide was hanging X70 (51.1%), followed by self-poisoning X68-X69 (35.2%) and firearms X72-X74 (7.6%). Provinces located at higher altitude reported higher rates than those located at sea level (9 per 100,000 vs 4.5 per 100.000). The total economic loss due to suicide was estimated to be $852.6 million during the 15 years' analysis. CONCLUSIONS: This is the first geodemographic study exploring the complete burden of suicide in Ecuador and one of the very few in Latin-America. In the last 15 years of available data, Ecuador ranks above the regional average with an adjusted suicide rate of 7.1 per 100,000 inhabitants. An important finding is that Suicide affects rather younger populations, adding more than 10,000 years of premature years of life lost (YYL) between 2001 and 2015, becoming the first and fourth leading cause of death among adolescent women and men respectively. Suicide affects people from different backgrounds, socioeconomic status and educational attainment. The mean of suicide changed over time showing that gun and pesticides related deaths decreased significantly since 2001, while hanging and suffocation increased in more than 50%.