Prevalence of Antimicrobial Resistance in Gram-Negative Bacteria Bloodstream Infections in Peru and Associated Outcomes: VIRAPERU Study.

Surveillance of antimicrobial resistance among gram-negative bacteria (GNB) is of critical importance, but data for Peru are not available. To fill this gap, a non-interventional hospital-based surveillance study was conducted in 15 hospitals across Peru from July 2017 to October 2019. Consecutive unique blood culture isolates of key GNB (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter spp.) recovered from hospitalized patients were collected for centralized antimicrobial susceptibility testing, along with linked epidemiological and clinical data. A total of 449 isolates were included in the analysis. Resistance to third-generation cephalosporins (3GCs) was present in 266 (59.2%) GNB isolates. Among E. coli (n = 199), 68.3% showed 3GC resistance (i.e., above the median ratio for low- and middle-income countries in 2020 for this sustainable development goal indicator). Carbapenem resistance was present in 74 (16.5%) GNB isolates, with wide variation among species (0% in E. coli, 11.0% in K. pneumoniae, 37.0% in P. aeruginosa, and 60.8% in Acinetobacter spp. isolates). Co-resistance to carbapenems and colistin was found in seven (1.6%) GNB isolates. Empiric treatment covered the causative GNB in 63.3% of 215 cases. The in-hospital case fatality ratio was 33.3% (92/276). Pseudomonas aeruginosa species and carbapenem resistance were associated with higher risk of in-hospital death. In conclusion, an important proportion of bloodstream infections in Peru are caused by highly resistant GNB and are associated with high in-hospital mortality.

Underutilization and Quality Gaps in Blood Culture Processing in Public Hospitals of Peru.

Correct processing of blood cultures may impact individual patient management, antibiotic stewardship, and scaling up of antimicrobial resistance surveillance. To assess the quality of blood culture processing, we conducted four assessments at 16 public hospitals across different regions of Peru. We assessed the following standardized quality indicators: 1) positivity and contamination rates, 2) compliance with recommended number of bottles/sets and volume of blood sampled, 3) blood culture utilization, and 4) possible barriers for compliance with recommendations. Suboptimal performance was found, with a median contamination rate of 4.2% (range 0-15.1%), with only one third of the participating hospitals meeting the target value of < 3%; and a median positivity rate of 4.9% (range 1-8.1%), with only 6 out of the 15 surveilled hospitals meeting the target of 6-12%. None of the assessed hospitals met both targets. The median frequency of solitary blood cultures was 71.9% and only 8.9% (N = 59) of the surveyed adult bottles met the target blood volume of 8 - 12 mL, whereas 90.5% (N = 602) were underfilled. A high frequency of missed opportunities for ordering blood cultures was found (69.9%, 221/316) among patients with clinical indications for blood culture sampling. This multicenter study demonstrates important shortcomings in the quality of blood culture processing in public hospitals of Peru. It provides a national benchmark of blood culture utilization and quality indicators that can be used to monitor future quality improvement studies and diagnostic stewardship policies.

Human exposure to fluoride from tea (Camellia sinensis) in a volcanic region-Canary Islands, Spain.

Fluoride is highly present in the environment, especially in water and its derivatives. Excessive fluoride contribution to diet poses a health risk. Tea leaves accumulate fluoride and the consumption of tea (Camellia sinensis) could pose a risk to human by the excessive fluoride intake. Ninety tea samples were analyzed by potentiometry using a selective fluoride ion electrode. Mixed tea samples (2.82 ± 1.11 mg/L) and black tea samples (2.28 ± 0.79 mg/L) recorded the highest fluoride levels. The contribution of drinking water is important for increasing fluoride levels in teas. The daily consumption of two cups (250 mL per cup) of mixed and black teas prepared with La Laguna tap water does pose a health risk for children (4-8 years old) because of the high contribution percentages (74.4% and 63.6%, respectively) of the Tolerable Upper Intake Level set in 2.5 mg/day by the EFSA (European Food Safety Authority). A minor consumption in children (4-8 years old) and adults during pregnancy is advisable.

Fluoride levels in supply water from a volcanic area in the Macaronesia region.

Fluoride is a widely distributed ion in the environment and, consequently, in water as well. High levels of fluoride in waters can be found in the Canary Islands because of their volcanic origin. Due to the risk and detrimental effects associated with a high fluoride intake, the content of this ion has been potentiometrically determined in 256 supply water samples from the islands of Tenerife, El Hierro, and La Palma, using a fluoride selective ion electrode. Fluoride mean concentration found on Tenerife is 4.22 mg/L, exceeding the parametric value of 1.5 mg/L set out in Spanish legislation. The consumption of 2 L of water from the studied municipalities of Tenerife would mean there is an excessive fluoride intake. The consumption of this water poses a serious risk to health. It is necessary to take action aimed at reducing the level of fluoride in the north of the island of Tenerife.

Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador.

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further.

Trace element and toxic metal intake from the consumption of canned mushrooms marketed in Spain.

Mushrooms are a valuable foodstuff because they are an important source of fiber and essential amino acids, but they have a great capacity to capture metals from substrate. Due to this reason, the content of 14 metals (B, Ba, Cr, Cu, Fe, Li, Mo, Ni, Sr, V, Zn, Al, Cd, Pb) of 100 samples of canned mushrooms grown in Spain were analyzed by inductively coupled plasma atomic emission spectroscopy. Fe (9.55 mg/kg) was the most notable trace element, followed by Zn (2.39 mg/kg). The most abundant toxic metal was Al (17.80 mg/kg). Significant statistical differences between the absorption of metals have been observed when comparing species. Lentinula edodes and Lactarius deliciosus are the species which had the highest metal contents. Taking the average consumption 300 g per day for adults into account, the exposure to trace toxic metals from the consumption of the studied mushrooms does not pose a health risk. However, contribution percentages of Pb (87.6%) and Al (59.2%) found in Lentinula edodes and Pholiota nameko samples, respectively, are near the maximum intake.

Potentiometric Determination of Fluoride Concentration in Beers.

Beer is a widely consumed drink throughout the world, and because its manufacture involves the use of water, beer can be, in some cases, a source of fluorides. For this reason, the objective of this study was to determine the concentration of fluorides in 50 samples of beers from different sources sold in two different types of container (aluminum can and glass bottle). The possible significant differences between the different types of packaging and the intake of fluoride from the consumption of these beers were evaluated. The concentration of fluoride in beers has been determined using the potentiometric method of fluoride determination by standard addition. The concentration of fluoride ranged between 0.06 and 1.77 mg/L. In general, the concentration was below 1 mg/L, except for three beer samples from Ireland and the USA, whose concentration was over 1.5 mg/L. No significant differences were found between the types of packaging. The contribution of fluoride to the diet from beer consumption is not high (<27%); however, it is necessary to warn consumers whenever they are in areas of high concentrations of fluoride in the water supply.

Correction to: Potentiometric Determination of Fluoride Concentration in Beers.

The original version of the article unfortunately contained a mistake. The first author Inmaculada Gutiérrez was omitted.

History of foreign embryonic isoantigens.

After defining the term 'foreign embryonic isoantigens', the author describes the experimental sequence which has allowed this new fetoprotein class to be identified. Experiments have followed three different directions, namely (i) passive immunization, by which conceptus antibodies raised in another animal species are transferred to the female animal, the effects on the offspring becoming apparent after pregnancy; (ii) laboratory techniques, where the presence of conceptus antibodies in serum from aborting women has been demonstrated by use of analytical techniques or by testing the serum on cultured embryos; and (iii) active isoimmunization, by which the female animal is immunized against a conceptus extract from the same species, and the effects on the offspring are observed after pregnancy. The immunologic basis for autoantigenicity in these fetoproteins, and its significance to materno-fetal medicine, are explained. Finally, some fetoproteins not yet unambiguously classed as foreign embryonic isoantigens are presented.

Feasibility of community-based health insurance in rural tropical Ecuador.

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50% of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3%. With affiliation, 92.2% of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

Feasibility of community-based health insurance in rural tropical Ecuador / Factibilidad de un seguro de enfermedad comunitario en una zona rural tropical de Ecuador

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50 percent of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3 percent. With affiliation, 92.2 percent of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

OBJETIVO: El objetivo principal de este estudio fue evaluar la voluntad de los habitantes de El Páramo, una zona rural en el Ecuador, de participar en un seguro de salud comunitario y determinar los factores que influían en dicha voluntad. Otro objetivo fue identificar la comprensión y las actitudes de la población hacia el modelo presentado. MÉTODOS: Se llevó a cabo una encuesta transversal usando un cuestionario estructurado. De unos 829 hogares, 210 se escogieron aleatoriamente mediante un muestreo por conglomerados en dos etapas. Se analizaron las actitudes hacia un esquema de seguro de enfermedad, se recopiló información sobre los factores que posiblemente influían en la voluntad de participar y se correlacionaron con esta última. Para comprender la posible capacidad de pago de un entrevistado, se evaluó el gasto en atención de la salud en el último episodio de enfermedad. Se definió "factibilidad" como la existencia de voluntad de participar en el esquema de seguro de enfermedad en al menos 50 por ciento de los jefes de hogar. RESULTADOS: La voluntad de participar en un modelo de seguro de enfermedad por un costo de US$ 30 por año fue de 69,3 por ciento. El 92,2 por ciento de los entrevistados declararon que, en el caso de adherirse al programa, concurrirían al establecimiento de salud local más a menudo. El nivel educativo presentó una correlación negativa con la voluntad de participar, pero otras variables no mostraron ninguna asociación significativa con ella. El estudio reveló una actitud positiva hacia el esquema del seguro de enfermedad. Se documentaron gastos de atención de salud importantes en el último episodio de enfermedad. CONCLUSIONES: La puesta en marcha de un seguro de enfermedad en la zona de estudio es factible. Sin embargo, es probable que la participación real sea inferior a la voluntad de participar declarada. Aun así, un esquema de seguro de enfermedad podría representar una opción financiera interesante en las zonas rurales donde los servicios son escasos y difíciles de mantener.

Resección laparoscópica de angiomixoma pélvico agresivo / Laparoscopic resection of an aggressive pelvic angiomyxoma

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Daily dietary intake of iron, copper, zinc and manganese in a Spanish population.

To evaluate the daily dietary intake of essential metals in the Canary Islands, the iron, copper, zinc and manganese contents in 420 food and drink samples collected in local markets were analysed by inductively coupled plasma-atomic emission spectrometry (ICP-AES). The estimated daily dietary intakes of iron, copper, zinc and manganese are 13.161 mg/day, 2.098 mg/day, 8.954 mg/day and 2.372 mg/day, respectively. The iron dietary intake was found to be below the recommendations fixed for adult women, while the copper and manganese dietary intakes fulfilled the Recommended Dietary Allowances. The mean daily intake of zinc was below the Recommended Dietary Allowance. Cereals were found to be the food group that contributed most to the intake of these metals. While the island of El-Hierro presented iron, copper, zinc and manganese mean intakes over the estimated intakes for the whole archipelago, Fuerteventura island showed the lowest intakes. Tenerife and Fuerteventura showed the lowest iron intakes, being below the recommendations.

Utilidad de 2 modelos bioquímicos predictivos del grado de fibrosis hepática en la población penitenciaria con hepatitis C / Utility of biochemical models predictive of liver fibrosis grade in inmates with hepatitis C

Objetivo.Evaluar la utilidad de 2 modelos bioquímicos (APRI y FIB-4) para la predicción del grado de fibrosis hepática (FH) en la población penitenciaria con hepatitis C crónica (HCC). Método: Estudio observacional para evaluación de pruebas diagnósticas. Se incluyeron 165 internos de 2 centros penitenciarios españoles con HCC y biopsia hepática. Los grados de FH se definieron según el Índice Metavir y posteriormente clasificados como FH ausente o leve (FH } 1), fibrosis significativa (FH ~ 2) y fibrosis grave (FH ~ 3). Se calculó el índice APRI y FIB-4 en todos los casos. La capacidad predictiva de FH se calculó mediante el área bajo la curva y se obtuvo el punto de corte óptimo en base al mejor valor de la especificidad para el diagnóstico del grado de FH. Posteriormente se calculó la sensibilidad (S), el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN). Resultados: Ciento dieciséis pacientes (80,3%) presentaban una FH inferior o igual a 1, 49 pacientes (29,3%) presentaban FH significativa y 24 pacientes (14,5%) presentaban FH grave. Un valor de APRI superior o igual a 0,55 o de FIB-4 superior o igual a 1,0 mostraba un VPP del 91% y del 92% para diagnosticar la presencia de FH (~1), aunque con una S diagnóstica baja (el 61,8 y el 61,1%, respectivamente). Un valor de APRI superior o igual a 0,86 o de FIB-4 superior o igual a 1,3 presentaba un VPN para el diagnóstico de FH avanzada del 92,5 y del 88,4%, respectivamente. Conclusiones: Ambos índices muestran una elevada capacidad predictiva para detectar la presencia de FH en reclusos con HCC, aunque su validez para identificar los grados intermedios de FH es baja. Además, un número importante de reclusos con FH no se identificaron (AU)

Objective: To evaluate the utility of two biochemical tests (APRI and FIB-4) to predict liver fibrosis (LF) in prison inmates with chronic hepatitis C. Method:We performed a cross-sectional study in 165 inmates with chronic hepatitis C and liver biopsy from two Spanish prisons. LF was staged according to the Metavir Index and was subsequently reclassified as mild or absent (LF}1), significant (LF~2) or serious (LF~3). APRI and FIB-4 were calculated in all patients. The predictive value was calculated by the area under the curve and the optimal cut-off was obtained based on the best specificity value for each LF stage. Then, we analyzed the sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for each cut-off point. Results: LF}1 was found in 116 inmates (80.3%), significant LF in 49 (29.3%) and serious LF in 24 (14.5%). An APRI value ~0.55 or FIB-4 ~1.0 showed a PPV of 91% and 92%, respectively, for the presence of any grade of LF (~1), but both tests had low diagnostic sensitivity: 61.8% and 61.1%, respectively. An APRI value ~0.86 or FIB-4 ~1.3 showed a high NPV for serious LF (92.5% and 88.4% respectively). Conclusions: Both tests have a high predictive capacity to detect the presence of LF in inmates with chronic hepatitis C, but their predictive value in detecting intermediate stages of LF is low. Moreover, a significant number of inmates with LF are not identified (AU)