Encuesta de satisfacción de padres de pacientes y equipo médico sobre el consentimiento informado en un hospital pediátrico de la Ciudad de Buenos Aires / Satisfaction survey of parents and medical staff regarding informed consent in a pediatric hospital in the city of Buenos Aires

El consentimiento informado es un proceso en el que un paciente libre y bien informado o sus representantes autorizan o no un procedimiento médico. Objetivos: El objetivo del estudio fue explorar el grado de satisfacción de padres de pacientes y profesionales con respecto al CI implementado en diferentes áreas del hospital. Métodos: Estudio observacional y descriptivo mediante encuesta anónima, a médicos y padres de pacientes atendidos en el hospital entre enero y julio de 2018. Resultados: Se obtuvieron 158 respuestas de profesionales y 139 de padres. Para el 50% de los padres el CI es un proceso para mejorar la calidad. El 81% de ellos consideró que recibió la información, la comprendieron y pudieron aclarar dudas. El 89% recibió la información del médico y el 59% en el lugar adecuado. De los profesionales, 57% consideró al CI como un proceso de información para mejorar la calidad. El 3% estimó que los padres comprenden la información siempre, el 66% consideró que el CI contiene la información suficiente y 13% le entregó una copia a la familia. Conclusiones: El grado de satisfacción de los padres en relación al CI es alto mientras que el de los profesionales es moderado. Hay que continuar trabajando en el proceso de comunicación entre ambos grupos (AU)

Informed consent is a process based on which a free and wellinformed patient or his/her representatives decide whether or not to authorize a medical procedure. Objectives: The aim of the study was to explore the degree of satisfaction of parents of patients and professionals regarding the IC implemented in different areas of the hospital. Methods: Observational and descriptive study using an anonymous survey of physicians and parents of patients treated at the hospital between January and July 2018. Results: the survey was responded by 158 physicians and 139 parents. Overall, 50% of the parents considered that the IC is part of a quality improvement process; 81% of them found they received adequate information, understood it, and were able to clarify doubts. Eighty-nine percent received the information from the physician and 59% in the appropriate area. Of the professionals, 57% considered the IC to be an information process to improve quality; 3% felt that parents always understand the information; 66% felt that the IC contains sufficient information; and 13% gave the family a copy. Conclusions: A degree of satisfaction with the IC was found in parents while it was moderate among physicians. It is necessary to continue working on the communication process between both groups (AU)

Is the universal population Hepatitis C virus screening a cost-effective strategy? A systematic review of the economic evidence.

OBJECTIVE: Efficient strategies are needed in order to achieve the objective of the WHO of eradicating Hepatitis C virus (HCV). Hepatitis C infection can be eliminated by a combination of direct acting antiviral (DAA). The problem is that many individuals remain undiagnosed. The objective is to conduct a systematic review of the evidence on economic evaluations that analyze the screening of HCV followed by treatment with DAAs. METHODS: Eleven databases were performed in a 2015-2018-systematic review. Inclusion criteria were economic evaluations that included incremental cost-effectiveness ratio (ICER) in terms of cost per life year gained or quality-adjusted life year. RESULTS: A total of 843 references were screened. Sixteen papers/posters meet the inclusion criteria. Ten of them included a general population screening. Other populations included were baby-boomer, people who inject drugs, prisoners or immigrants. Comparator was "standard of care", other high-risk populations or no-screening. Most of the studies are based on Markov model simulations and they mostly adopted a healthcare payer´s perspective. ICER for general population screening plus treatment versus high-risk populations or versus routinely performed screening showed to be below the accepted willingness to pay thresholds in most studies and therefore screening plus DAAs strategy is highly cost-effective. CONCLUSIONS: This systematic review shows that screening programmes followed by DAAs treatment is cost-effective not only for high risk population but for general population too. Because today HCV can be easily cured and its long-term consequences avoided, a universal HCV screening plus DAAs therapies should be the recommended strategy to achieve the WHO objectives for HCV eradication by 2030.

RanBP2-Mediated SUMOylation Promotes Human DNA Polymerase Lambda Nuclear Localization and DNA Repair.

Cellular DNA is under constant attack by a wide variety of agents, both endogenous and exogenous. To counteract DNA damage, human cells have a large collection of DNA repair factors. Among them, DNA polymerase lambda (Polλ) stands out for its versatility, as it participates in different DNA repair and damage tolerance pathways in which gap-filling DNA synthesis is required. In this work, we show that human Polλ is conjugated with Small Ubiquitin-like MOdifier (SUMO) proteins both in vitro and in vivo, with Lys27 being the main target of this covalent modification. Polλ SUMOylation takes place in the nuclear pore complex and is mediated by the E3 ligase RanBP2. This post-translational modification promotes Polλ entry into the nucleus, which is required for its recruitment to DNA lesions and stimulated by DNA damage induction. Our work represents an advance in the knowledge of molecular pathways that regulate cellular localization of human Polλ, which are essential to be able to perform its functions during repair of nuclear DNA, and that might constitute an important point for the modulation of its activity in human cells.

Manejo de la pancreatitis aguda grave en niños. Serie de 3 casos / Management of severe acute pancreatitis in children. A series of 3 cases

La pancreatitis aguda es una entidad poco frecuente en la población pediátrica, cuya incidencia ha aumentado en las últimas dos décadas. Sin embargo, existen pocos estudios sobre esta afección, por lo que su manejo terapéutico resulta muy variable, especialmente en los casos graves. En este trabajo describimos nuestra experiencia sobre el manejo en una unidad de cuidados intensivos pediátrica de 3 casos clínicos con esta afección en los últimos meses. En ellos se aplicaron las directrices extraídas de las guías clínicas sobre el manejo de la pancreatitis aguda en pacientes adultos basadas en la optimización de la analgesia, la administración de fluidoterapia i.v. agresiva y el reposo pancreático inicial con reintroducción precoz de la nutrición enteral, con lo que mostraron una buena evolución clínica posterior. Nuestro objetivo principal, dado el aumento en la incidencia de esta entidad, es destacar la importancia de un alto nivel de sospecha clínica ante un cuadro de dolor abdominal que permita un diagnóstico precoz y la rápida instauración de un tratamiento adecuado en estos casos, así como incidir en los puntos más importantes de su manejo

Acute pancreatitis is a rare entity among pediatric population, whose incidence has increased in the last two decades. However, there are few studies on this condition, so its therapeutic management is unsteady, especially in severe cases. In this article, we describe our experience in a pediatric intensive care unit in the management of 3 clinical cases with pancreatitis occured in the last months. We applied the guidelines extracted from the clinical guides about management of acute pancreatitis in adult patients, based on improving analgesia, administration of intensive fluid therapy and initial pancreatic rest with early reintroduction of enteral nutrition, which showed a good subsequent clinical evolution. Our main purpose, given the increase in the incidence of this entity, is to emphasize the importance of a high level of clinical suspicion when facing a case of abdominal pain that may allow an early diagnosis and a quick establishment of a proper treatment in these cases, as well as to highlight the most important facts of its management

Effect of Akt activation and experimental pharmacological inhibition on responses to neoadjuvant chemoradiotherapy in rectal cancer.

BACKGROUND: Neoadjuvant chemoradiotherapy (CRT) is one of the preferred initial treatment strategies for locally advanced rectal cancer. Responses are variable, and most patients still require surgery. The aim of this study was to identify molecular mechanisms determining poor response to CRT. METHODS: Global gene expression and pathway enrichment were assessed in pretreatment biopsies from patients with non-metastatic cT2-4 N0-2 rectal cancer within 7 cm of the anal verge. Downstream Akt activation was assessed in an independent set of pretreatment biopsies and in colorectal cancer cell lines using immunohistochemistry and western blot respectively. The radiosensitizing effects of the Akt inhibitor MK2206 were assessed using clonogenic assays and xenografts in immunodeficient mice. RESULTS: A total of 350 differentially expressed genes were identified, of which 123 were upregulated and 199 downregulated in tumours from poor responders. Mitochondrial oxidative phosphorylation (P < 0·001) and phosphatidylinositol signalling pathways (P < 0·050) were identified as significantly enriched pathways among the set of differentially expressed genes. Deregulation of both pathways is known to result in Akt activation, and high immunoexpression of phosphorylated Akt S473 was observed among patients with a poor histological response (tumour regression grade 0-2) to CRT (75 per cent versus 48 per cent in those with a good or complete response; P = 0·016). Akt activation was also confirmed in the radioresistant cell line SW480, and a 50 per cent improvement in sensitivity to CRT was observed in vitro and in vivo when SW480 cells were exposed to the Akt inhibitor MK2206 in combination with radiation and 5-fluorouracil. CONCLUSION: Akt activation is a key event in the response to CRT. Pharmacological inhibition of Akt activation may enhance the effects of CRT. Surgical relevance Organ preservation is an attractive alternative in rectal cancer management following neoadjuvant chemoradiotherapy (CRT) to avoid the morbidity of radical surgery. Molecular steps associated with tumour response to CRT may provide a useful tool for the identification of patients who are candidates for no immediate surgery. In this study, tumours resistant to CRT were more likely to have activation of specific genetic pathways that result in phosphorylated Akt (pAkt) activation. Pretreatment biopsy tissues with high immunoexpression of pAkt were more likely to exhibit a poor histological response to CRT. In addition, the introduction of a pAkt inhibitor to cancer cell lines in vitro and in vivo led to a significant improvement in sensitivity to CRT. Identification of pAkt-activated tumours may thus allow the identification of poor responders to CRT. In addition, the concomitant use of pAkt inhibitors to increase sensitivity to CRT in patients with rectal cancer may constitute an interesting strategy for increasing the chance of a complete response to treatment and organ preservation.

Divulgación de información sobre los pacientes del hospital: ¿Derecho o responsabilidad? / Dissemination of hospital patient data: A right or responsibility?

Los medios de comunicación son un importante actor en toda sociedad democrática. Su rol social en las cuestiones de salud, y en particular en lo relacionado con los derechos de la infancia, merece ser destacado. La manera en que se describen los niños, niñas y adolescentes en los medios tiene un impacto profundo en la actitud de la sociedad hacia la niñez. Un manejo adecuado de la imagen de la infancia que mostramos en los medios de comunicación es vital para contribuir a redimensionar la situación de los niños, niñas y adolescentes en la sociedad y valorar sus identidades, sus deseos y preferencias, sus miedos y sus derechos. Como hospital pediátrico nos cabe una gran responsabilidad respecto a lo que comunicamos, ya que los niños, niñas y adolescentes y sus familias son un grupo extremadamente vulnerable, más aún cuando son pacientes y en razón de todo ello depositan su confianza en recibir una especial protección, eminentemente asistencial y que debe ser inseparable de los aspectos jurídicos y éticos. Hay que considerar la diferencia del uso de la información con fines científicos y docentes, de la que puede ser utilizada como nota periodística, ya que van destinadas a grupos diferentes y persiguen objetivos distintos (AU)

The media is an important actor in the democratic society. Their role in health issues, particularly those related to children's rights, is outstanding. The way boys and girls and adolescents are described in the media has a profound impact on the attitude of society towards children. Adequate management of the image of childhood we show in the media is a vital contribution to the redimensioning of the situation of boys and girls, and adolescents in society respecting their identities, wishes, fears, and rights. As a pediatric hospital we have a great responsibility regarding what we communicate because boys and girls and adolescents as well as their families are an extremely vulnerable group, even more so when they are patients and consequently deposit their trust in us to receive special protection and care, which should be inseparable from judicial and ethical aspects. Data use for scientific and teaching aims should be distinguished from information used in the media, as target groups and aims pursued are different (AU)

Microbe associated molecular patterns from rhizosphere bacteria trigger germination and Papaver somniferum metabolism under greenhouse conditions.

Ten PGPR from different backgrounds were assayed on Papaver somniferum var. Madrigal to evaluate their potential as biotic elicitors to increase alkaloid content under the rationale that some microbe associated molecular patterns (MAMPs) are able to trigger plant metabolism. First, the 10 strains and their culture media at two different concentrations were tested for their ability to trigger seed germination. Then, the best three strains were tested for their ability to increase seedling growth and alkaloid levels under greenhouse conditions. Only three strains and their culture media enhanced germination. Then, germination enhancing capacity of these best three strains, N5.18 Stenotrophomonas maltophilia, Aur9 Chryseobacterium balustinum and N21.4 Pseudomonas fluorescens was evaluated in soil. Finally, the three strains were applied on seedlings at two time points, by soil drench or by foliar spray. Photosynthesis was measured, plant height was recorded, capsules were weighted and alkaloids analyzed by HPLC. Only N5.18 delivered by foliar spray significantly increased plant height coupled to an increase in total alkaloids and a significant increase in opium poppy straw dry weight; these increases were supported by a better photosynthetic efficiency. The relative contents of morphine, thebaine, codeine and oripavine were affected by this treatment causing a significant increase in morphine coupled to a decrease in thebaine, demonstrating the effectivity of MAMPs from N5.18 in this plant species. Considering the increase in capsule biomass and alkaloids together with the acceleration of germination, strain N5.18 appears as a good candidate to elicit plant metabolism and consequently, to increase productivity of Papaver somniferum.

In-planta detection and monitorization of endophytic colonization by a Beauveria bassiana strain using a new-developed nested and quantitative PCR-based assay and confocal laser scanning microscopy.

Beauveria bassiana strain 04/01-Tip obtained from larvae of the opium poppy stem gall Iraella luteipes endophytically colonizes opium poppy plants and protect it against this pest. Development of a specific, rapid and sensitive technique that allows accurately determining the process and factors leading to the establishment of this strain in opium poppy plants would be essential to achieve its efficient control in a large field scale. For that purpose in the present study, species-specific primers that can be used in conventional or quantitative PCR protocols were developed for specifically identification and detection of B. bassiana in plant tissues. The combination of the designed BB.fw/BB.rv primer set with the universal ITS1-F/ITS4 primer set in a two-step nested-PCR approach, has allowed the amplification of up to 10fg of B. bassiana. This represented an increase in sensitivity of 10000- and 1000-fold of detection than when using the BB.fw/BB.rv primers in a single or single-tube semi-nested PCR approaches, respectively. The BB.fw and BB.rv primer set were subsequently optimized to be used in real time quantitative PCR assays and allowed to accurately quantify B. bassiana DNA in different plant DNA backgrounds (leaves and seeds) without losing accuracy and efficiency. The qPCR protocol was used to monitor the endophytic colonization of opium poppy leaves byB. bassiana after inoculation with the strain EABb 04/01-Tip, detecting as low as 26fg of target DNA in leaves and a decrease in fungal biomass over time. PCR quantification data were supported in parallel with CLMS by the monitoring of spatial and temporal patterns of leaf and stem colonization using a GFP-tagged transformant of the B. bassiana EABb 04/01-Tip strain, which enabled to demonstrate that B. bassiana effectively colonizes aerial tissues of opium poppy plants mainly through intercellular spaces and even leaf trichomes. A decline in endophytic colonization was also observed by the last sampling times, i.e. from 10 to 15days after inoculation, although fungal structures still remained present in the leaf tissues. These newly developed molecular protocols should facilitate the detection, quantification and monitoring of endophytic B. bassiana strains in different tissues and host plants and would help to unravel the factors and process governing the specific endophytic association between opium poppy and strain EABb 04/01-Tip providing key insights to formulate a sustainable strategy for I. luteipes management in the host.

Dolor como factor predictor de depresión en el paciente oncológico: estudio de casos y controles. Estudio D-PRESS / Pain as predictor of depression in cancer patients: case-control study. Studio D-PRESS

Objetivos: Valorar la correlación entre dolor oncológico y depresión, determinar la prevalencia de depresión en los grupos de casos y controles, y conocer qué factores de la historia clínica del paciente podrían estar potencialmente asociados a la depresión. Métodos: Estudio observacional, retrospectivo, y multicéntrico. Se recogió información de la historia clínica de pacientes, de al menos 3 meses anteriores al inicio del estudio, de edad ≥ 18 años, que padecían dolor tras el diagnóstico oncológico (EVA ≥ 3) y que cumplimentaron el inventario de depresión de Beck (IDB). Los pacientes se clasificaron como casos y controles en base a la puntuación IDB (≥ 8 y ≤ 7, respectivamente). Resultados: Se incluyó un total de 248 pacientes con una media de edad de 59,0 ± 12,4 años. La media del IDB para el grupo de casos fue 13,1 ± 4,9, y para el grupo control 3,8 ± 2,1. El tiempo medio de supervivencia de los pacientes fue mayor en el grupo control (20,0 meses) en comparación con el grupo caso (12 meses; p = 0,0032). En líneas generales, la puntuación del IDB se correlacionó significativamente con la intensidad del dolor en las últimas 24 horas (0,215; p = 0,0007) y con el número de horas de dolor durante las últimas 24 horas (0,170; p = 0,0073). Presentar un estadio tumoral más avanzado fue uno de los factores que aumentó el riesgo de padecer depresión (p = 0,0113). El análisis multivariante demostró el carácter predictivo del cáncer digestivo (p = 0,0454) y del estadio tumoral T (T2 vs T4; p = 0,0039, y T3 vs T4; p = 0,0012) como factores de riesgo de padecer depresión. Conclusiones: De acuerdo a otros estudios previos, existe una clara correlación entre la intensidad de dolor y el estado psicológico del paciente. El potencial predictivo de ciertos factores clínicos (estadío tumoral y ciertos tipos tumorales) posibilita la identificación de pacientes oncológicos en riesgo de padecer depresión (AU)

Objectives: To evaluate the relationship between cancer pain and depression, to determine the prevalence of depression in both groups the cases and controls and also to evaluate which factors from the medical records can be potentially associated with depression. Methods: Observational, retrospective and multi-centre study. Patients were ≥18 years old, had medical data ≥ 3 months, experienced pain after cancer diagnosis (VAS ≥ 3) and completed the Beck Depression Inventory (BDI). Patients were classified as cases and controls based on the BDI score (≥ 8 y ≤ 7, respectively). Results: A total of 248 patients were included (mean age 59.0 ± 12.4 years). Mean BDI for the case group was 13.1 ± 4.9, and for the control group, 3.8 ± 2.1. Patients in the control group, had a longer survival time (20.0 months) in comparison with patients in the case group (12 months; p = 0.0032). For the overall population, BDI scoring was correlated with the intensity of pain during the last 24 hours (0.215; p = 0.0007) and the hours of pain during the last 24 hours (0.170; p = 0.0073). A more advanced disease stage was also among the factors that increased the risk of depression (p= 0.0113). The multivariate analysis revealed the predictive nature of digestive cancers (p = 0.0454) and T stage (T2 vs T4; p = 0.0039, and T3 vs T4; p = 0.0012) as risk factors for depression. Conclusions: According with previous studies, there is a clear relationship between pain intensity and patient's psychological status. The predictive potential of medical factors for depression (tumor stage and type of cancer) opens the possibility to target patients at risk (AU)

Pain in clinical oncology: patient satisfaction with management of cancer pain.

BACKGROUND: Despite effective analgesic therapy, inadequate pain control is frequently perceived by patients and caregivers. AIMS: To assess satisfaction with management of pain in cancer patients. METHODS: Between January and May 2007, a cross-sectional multicentre study was conducted in 64 Medical Oncology Departments throughout Spain. A total of 525 outpatients with oncological diseases completed a questionnaire with demographic data, characteristics and intensity of pain, and perceptions and attitudes towards pain management at the time of a routine clinical visit. Physicians also completed a questionnaire with tumour-related and treatment-related data. Cluster analysis was used to classify patients into three groups (satisfied, neither satisfied nor dissatisfied or neutral, dissatisfied) according to pain intensity and satisfaction with treatment. RESULTS: Patients satisfied with their analgesic treatment (33%) had lower pain intensities and, when regularly asked about their pain, considered their physicians to be more involved in their treatment. Neither satisfied nor dissatisfied patients (neutral) (44%) had higher mean pain intensities. Two-thirds of them achieved marked relief of their pain and also thought that physicians were aware of their situation. Dissatisfied patients (23%) had moderate to severe pain intensities, and said that they were asked less frequently about their pain, and thought that their physicians were less involved in their analgesic treatment. CONCLUSION: Physician-patient communication and information provided to patients are essential aspects of patient perceptions and attitudes towards control of cancer-related pain. Pain is seen as a condition that may be controlled but affects the capacity to lead a normal life.

Discrepancias clínicas: anatomopatológicas de los niños fallecidos en el Hospital Juan P. Garrahan en el año 2009 / Discrepancies between clinical and autopsy diaagnosis in children who died at the Juan P. Garrahan Hospital in 2009

La autopsia es utilizada cada vez con menos frecuencia en pediatría, pese a aportar una valiosa y, a veces insospechada información. Esto se explicaría por la mayor disponibilidad actual de medios diagnósticos no invasivos, y fundamentalmente por la dificultad de obtener el consentimiento de los padres para realizarla. Sin embargo, el clarificar el o los diagnósticos de fallecimiento es de gran impor tancia tanto para el equipo médico como para la familia del paciente. En el año 2009, en el Hospital Garrahan fueron registradas 265 defunciones y 17 autopsias (6,4%). Se utilizó la escala de Goldman y col. modificada por Battle y col. para la categorización de los hallazgos de las necropsias. Según ésta, en la muestra analizada se observaron 6 casos (35%) de concordancias anatomo-clínicas. En los 11 casos restantes (65%) hubo discordancia anátomo-clínica. De los casos que presentaron discrepancias, el 82% fueron discrepancias mayores. El hallazgo más importante encontrado fue la infección asociada, en un 65% de las autopsias (11/17). Valorizar el apor te de los hallazgos anatomopatológicos aumentaría el interés del clínico para solicitar, evaluar y analizar el informe de la necropsia.

Autopsy is being less frequently performed in pedriatrics inspite of providing valuable and at times unexpected clini-cal information. This could partly be explained by the gre-ater availability of non-invasive diagnostic techniques, butfundamentally by the difficulty of obtaining parental con-sent to perform the autopsy. However, determining thecause of death is of great importance not only to the medi-cal team but also to the family. In 2009, at the GarrahanHospital 265 deaths were recorded and 17 autopsies wereperformed (6.4%). To categorize the findings of the autop-sies, we used the criteria by Goldman et al. amended byBattle et al. According to these criteria, concordance bet-ween the clinical and autopsy diagnosis was observed in 6cases (35%). Discrepancy was found in the remaining 11cases (65%), being major discrepancies in 82%. Infection wasthe most important finding observed in 65% of autopsies(11/17). Emphasizing the importance of pathological fin-dings may increase the clinician's interest to request anautopsy and to evaluate and analyze the autopsy report.

Extranjeros no residentes y cobertura de salud. Un conflicto entre principios / Non-resident foreigners and health care coverage. A conflict of principles

La atención de extranjeros no residentes en hospitales públicos de alta complejidad es un problema de salud pública presente en la Argentina desde hace mucho tiempo, pero que se ha agravado en los últimos años. Es un tema sobre el que no se ha profundizado y sobre el cual no se encuentra bibliografía. El objetivo del presente estudio fue describir los motivos de internación y la ocupación de camas en el Hospital Garrahan, de niños extranjeros no residentes durante el año 2006, y comparar los resultados obtenidos con los mismos datos correspondientes al año 2004 para observar la tendencia. Material y Métodos: Se obtuvieron mediante registros informáticos todos los datos de los pacientes extranjeros hospitalizados en dos períodos: desde el 1 de enero al 31 de diciembre de los años 2004 y 2006 respectivamente. Se analizaron el número de camas ocupadas por extranjeros, en los diferentes sectores de internación durante los años 2004 y 2006. Resultados: Durante en año 2004 se internaron 389 niños extranjeros no residentes, con edades comprendidas entre 1 mes y 19 años. (2,1% de los egresos anuales) Durante el año 2006 se internaron un total de 1446 niños En el primer período (2004 )los días totales de internación de estos niños fueron 3.828 mientras en el año 2006 el número total de días de internación ascendió a 7.329 días, que significa un incremento del 91% con respecto al 2004, siendo el área donde se observó el aumento más importante la correspondiente a cuidados intermedios y moderados(CIM): 5.335 días (72,7%). Conclusiones: Dada la magnitud del problema, se deben pensar soluciones viables a mediano y largo plazo, pero el reconocimiento del problema es la primera etapa necesaria para su solución (AU)

Health care for non-resident foreigners at public tertiary care hospitals has been a public health problem for many years and has aggravated over the past time. However, the subject has not been the subject of debate no articles regarding this topic have been published in the literature The aim of the present study was to describe the reasons for admission and occupation of hospital beds in the Garrahan Hospital of non-resident foreign children during 2006 and to compare these results with data from 2004 to observe if there is a trend. Material and Methods: From computerized records all data of foreign patients hospitalized during two different periods were obtained: Between January 1 and December 31 of 2004 and 2006, respectively. The number of beds occupied by foreigners in different in-patient sectors during 2004 and 2006 was analyzed. Results: In 2004, 389 non-resident foreign children aged between 1 month and 19 years were admitted (2.1% of the yearly discharges). In 2006 a total of 1446 children were admitted. In the first period (2004), the total number of hospital days of these children was 3828, while in 2006 the total number of hospital days increased to 7329, a 91% increased compared to 2004. The highest increase was observed in the area of intermediate and moderate care (CIM): 5335 days (72.7%). Conclusions: Given the size of the problem, adequate medium- and long-term solutions should be developed, however, recognition of the problem is the first necessary step (AU)

Systemic protection of Papaver somniferum L. against Iraella luteipes (Hymenoptera: Cynipidae) by an endophytic strain of Beauveria bassiana (Ascomycota: Hypocreales).

The poppy stem gall wasp, Iraella luteipes (Thompson) (Hymenoptera: Cynipidae), is one of the main pests of the opium poppy, Papaver somniferum L., an economically important pharmaceutical crop cultivated worldwide. In a previous study, we obtained from I. luteipes larvae a strain of the entomopathogenic fungus Beauveria bassiana (Ascomycota: Hypocreales) that can become established endophytically in opium poppy plants. A field experiment was conducted to study the ability of this B. bassiana strain to provide systemic protection against damage by I. luteipes in opium poppy in southern Spain for three seasons. Conidial suspensions were applied as seed dressings, leaf sprays, or soil sprays. The effect of the treatment was studied by harvesting fully ripened plants and dissecting I. luteipes larvae from the stem. The effect of treatment on growth and yield was also evaluated. Emergence of I. luteipes adults was not uniform over the 3 yr, with important differences exhibited in the duration of the emergence period, although the flight peaks tended to occur in mid-late April. B. bassiana seed dressings, leaf sprays at the fourth true-leaf stage, and soil sprays were not significantly different in their ability to reduce the number of larvae per plant compared with the controls, with percentage reductions of 36.5-58.5, 64.4-73.4, and 51.9-57.2% in 2005, 2006, and 2007, respectively. Even though the population level of I. luteipes increased over the 3 yr, the efficacy of the fungal inoculation in reducing the larval population was maintained throughout the study period. No significant differences between inoculation methods were detected in the percentage of leaf pieces showing fungal growth when placed on B. bassiana selective medium, with mean values in the range of 10-15% for the three seasons. Leaf pieces from controls did not exhibit any sign of B. bassiana growth when placed on B. bassiana-selective medium. Neither adverse effects on growth and yield nor symptomatic tissues were observed in B. bassiana-treated plants compared with controls in any of the three seasons.

First Report of Pectobacterium carotovorum Causing Soft Rot of Opium Poppy in Spain.

Opium poppy (Papaver somniferum L.) is an economically important pharmaceutical crop in Spain. Approximately 8,000 ha are cultivated annually in southern and central Spain. To improve yields, opium poppy cultivation is expanding to more humid or irrigated areas of Spain. In the springs of 2005 and 2007, we observed poppy plants with wilt and stem rot symptoms in irrigated, commercial opium poppy (cv. Nigrum) at Carmona and Écija, which are in Seville Province in southern Spain. Closer observations of affected plants revealed darkening and water soaking of the leaves and stem at the soil level, wilting of the lower leaves or the entire plant, and dark brown discoloration of stem vascular tissues and pith of the plant. Severely affected plants became completely rotten and collapsed. Isolations from symptomatic tissues on nutrient agar consistently yielded bacterial colonies. Pure cultures of four representative bacterial strains (two per each of affected field and year of isolation) were used in triplicate for a comparative analysis of biochemical and physiological traits in the 'carotovora' group of Erwinia (1) with known isolates of Pectobacterium carotovorum subsp. carotovorum, P. carotovorum subsp. atrosepticum, and Dickeya chrysanthemi. The isolates from opium poppy were gram negative, facultatively anaerobic, oxidase negative, catalase positive, grew at 37°C, and did not produce gas from D-glucose. Acid was produced from D(+)-arabinose, lactose, and D(+)-trehalose, but not from α-D-methylglucoside. In addition, the opium poppy bacterial isolates caused soft rot on potato slices within 24 h at 25°C and did not induce a hypersensitive reaction on tobacco leaves. Use of the Biolog GN microplates and the OmniLog ID 1.2 system identified the four poppy isolates as P. carotovorum (showing a 66.7% similarity with the subsp. carotovorum). Pathogenicity of poppy isolates was tested on three 6-week-old opium poppy plants (cv. Nigrum) by injecting 100 µl of a bacterial suspension containing 108 CFU/ml in the basal stem. Plants that served as controls were injected with sterile water. Plants were incubated in a growth chamber adjusted to 28°C, 90% relative humidity, and a 14-h photoperiod of fluorescent light of 360 µE·m-2·s-1. Severe symptoms of soft rot and darkening developed on stems of inoculated plants within 3 to 5 days after inoculation. No symptoms developed on control plants. Bacterial strains reisolated from inoculated plants were identified as P. carotovorum on the basis of the Biolog system, as well as biochemical and physiological characters. To our knowledge, this is the first report of P. carotovorum causing soft rot of commercial opium poppy crops in Spain and elsewhere. The presence of this bacterial pathogen to irrigated crops and humid areas may pose an important constraint on the yield of opium poppy crops in Spain. References: (1) R. S. Dickey and A. Kelman. Pages 44-59 in: Laboratory Guide for Identification of Plant Pathogenic Bacteria. N. W. Schaad, ed. The American Phytopathological Society, St. Paul, MN, 1988.

Peronospora arborescens Causes Downy Mildew Disease in Commercial Opium Poppy Crops in France.

Opium poppy is a strategic crop for the pharmaceutical industry because it is the only source of morphine, codeine, and thebaine alkaloid drugs. Approximately 7,360 ha (average from 2001 through 2007) of opium poppy (Papaver somniferum) are grown annually in France, mainly in the Northern-East (Champagne-Ardenne) and Centre-West (Centre and Poitou-Charentes) regions of the country. This acreage accounts for nearly 5.6% of the legally cultivated opium poppies worldwide. Disease symptoms resembling those of downy mildew (2) have been observed frequently in those opium-poppy-growing areas, especially in the Charente-Maritime, Cher, Loiret, and Loir et Cher departments. Disease symptoms included chlorotic to light yellow lesions on the leaf blade, curling and thickening of affected tissues, and expanding necrotic lesions that coalesced, eventually giving rise to large necrotic areas or death of the entire leaf tissues and the plant. With wet weather or high relative humidity, sporangiophores with sporangia were produced frequently on the abaxial leaf surface and occasionally on the adaxial side. Peronospora arborescens and P. cristata have been demonstrated as causal agents of opium poppy downy mildew disease and both have been reported in Europe (1-3); however, the specific identity causal agent in commercial opium poppy crops in France has not yet been determined. Microscopic observations of affected leaves in symptomatic opium poppy leaves sampled from three commercial fields in Loiret Department revealed dichotomously branching sporangiophores bearing single sporangia and oospores of shape and measurements similar to those reported for P. arborescens and P. cristata (1,3). Sporangia dimensions of P. arborescens and P. cristata overlapped, making it difficult to differentiate between the two species based solely on morphological characters (3). A species-specific PCR assay protocol (2) that differentiated P. arborescens from P. cristata was used to diagnose the pathogen. Also, the sequence of the complete 5.8S ribosomal DNA gene and internal transcribed spacers (ITS) 1 and 2 were determined and maximum parsimony analysis was performed with the Peronospora spp. data set described by Landa et al. (2). Both species-specific PCR and phylogenetic analyses of ITS sequences showed that P. arborescens was the only Peronospora species associated with the three samples of downy-mildew-affected leaves analyzed. Thus, DNA fragments of 545, 594, and 456 bp were amplified using total DNA extracted from the sampled leaves and P2, P3, and P6 primer pairs (2), respectively. ITS sequences of all three samples showed 100% homology (GenBank Accession No. EU295529). Phylogenetic analyses using Neighbor Joining of those sequences placed the infecting Peronospora sp. in a clade (100% support) that included all P. arborescens sequences from the GenBank database with 99.2 to 99.9% homology among sequences (2,3). To our knowledge, this is the first report and molecular evidence that P. arborescens causes downy mildew disease in commercial opium poppy crops in France. References: (1) S. M. Francis. No. 686 in: Descriptions of Pathogenic Fungi and Bacteria. CMI, Kew, Surrey, UK, 1981. (2) B. B. Landa et al. Phytopathology 97:1380, 2007. (3) J. B. Scott et al. Phytopathology 93:752, 2003.

First Report of Downy Mildew of Opium Poppy Caused by Peronospora arborescens in Spain.

Opium poppy (Papaver somniferum) is an economically important pharmaceutical crop in Spain with approximately 7,400 ha cultivated annually. In the spring of 2004, severe attacks by a new foliar disease were observed approximately 500 km apart in commercial opium poppy fields in the Castilla-La Mancha and Andalusia regions of central and southern Spain, respectively. The incidence of affected fields ranged from 40 to 50%, and incidence of diseased plants ranged from 20 to 30%. Initial disease symptoms included irregularly shaped, chlorotic-to-light yellow leaf lesions (ranging in size from 0.5 to 4 cm). Affected tissues curled, thickened, and became deformed and necrotic as disease developed. Lesions expanded in size and often coalesced, eventually giving rise to large necrotic areas in leaves or death of entire leaves. In wet weather or conditions of high relative humidity, a dense felt of sporangiophores with sporangia was produced on the abaxial leaf surface and occasionally on the adaxial surface. Microscopic observations revealed sporangiophores branching dichotomically at least four to six times, ending with sterigmata bearing single sporangia. Sporangia were hyaline, elliptical to spherical in shape, and measured 18 to 24 × 14 to 18 µm (average 19 ± 1.2 × 15 ± 1.6 µm). Occasionally, oospores formed in necrotic leaf tissues. Oospores were dark brown (the surface was irregularly ridged) and measured 36 to 46 µm in diameter (average 39 ± 4.4 µm). The oospore wall was 3 to 11 µm thick. On the basis of the observed morphological features of six symptomatic plant samples from fields at Castilla-La Mancha and Andalusia regions, we identified the pathogen as Peronospora arborescens (1). Pathogenicity was confirmed by inoculating 4- to 6-week-old opium poppy plants (cv. nigrum) with an isolate collected from a field in Ecija, Andalusia. Seed of test plants was surface disinfested and germinated under sterile conditions. Plants were sprayed with a suspension of 1 to 5 × 105 sporangia per ml in sterile distilled water. Plants sprayed with sterile water served as controls. There were five replicate plants per treatment. Plants were enclosed in sealed plastic bags and kept in the dark for 24 h. This was followed by incubation in a growth chamber at 21°C, 60 to 90% relative humidity, and a 12-h photoperiod (fluorescent light: 360 µE·m-2·s-1). After 5 to 7 days, typical downy mildew symptoms developed in inoculated plants. All control plants remained symptomless. Sporulation by the pathogen on symptomatic leaves occurred when affected plants were sprayed with water, enclosed in sealed plastic bags, and incubated at 21°C in the dark for 24 h. To our knowledge, this is the first report of P. arborescens infecting opium poppy in Spain. Infestations of poppy weeds (Papaver rhoeas) and wild Papaver somniferum were also observed in affected opium poppy fields, which may bear importance in the epidemiology of the disease as alternative hosts for inoculum increase and survival of P. arborescens under field conditions. References: (1) S. M. Francis. No. 686 in: Descriptions of Pathogenic Fungi and Bacteria. CMI, Kew, Surrey, UK, 1981.

Evaluación de la atención hospitalaria de los pacientes fallecidos en el Hospital de Pediatría Juan.P Garrahan entre marzo y septiembre de 2001. Informe de la Comisión de Mortalidad / Evaluation of in-patient care of patients dying at the Hospital de Pediatría J. P Garrahan between March and September 2001

Objetivo:En el marco de un programa de evaluacíon de calidad de atención médica,se crea la comisión de Mortalidad con el objetivo de analizar,con una nueva propuesta metodológica,la atención de los pacientes fallecidos en el hospital.Este informe reporta los resultados de trabajo de dicha comisión.Pacientes y métodos:se realizó un análisis retrospectivo de todos los pacientes fallecidos en el hospital entre el 15 de marzo y el 30 de septiembre de 2001.Cada historia clínica tuvo dos instancias independientes de revisión:el grupo tratante y un miembro de la comisión.Se registraron;edad,lugar/res de internación,diagnostico de base,lugar de óbito,solicitud de necropsia,y concordancia entre el grupo tratante y la comisióm.La muerte se clasifico en inevitable,potencialmente evitable o evitable.Resultados:se registraron 7759 admisiones y 149 fallecimientos(1.9 por ciento)siete historias clínicas no pudieron ser evaluadas.La mediana de edad fue de 18.5 meses(r=1d-19a)El 17,6 por ciento eran menores de 1 mes y 43,4 por ciento menor de 1 año.la mediana del tiempo de internación de 9.5 días(r=3-215)Los diagnósticos más frecuentes de enfermedad de base fueron:enfermedad oncológica 36,cardiopatía congénita 15 e infección respiratoria 12.La principal causa de muerte de aquellas consideradas potencialemente evitables(n=10)fue la infección intrahospitalaria.Conclusiones:La mortalidad hospitalaria durante el período de estudio fue de 1.9 por ciento,El 80 por ciento de la muertes ocurrieron en el área de terapia intensiva(ucip,ucin y quemados)Se consideraron inevitables 97/107 muertes(90 por ciento)potencialmente evitables 10(9.3 por ciento)y una evitables(0.9 por ciento)Solo se realizó necropsia en el 14.7 por ciento de la población estudiada