Establishment of Age-Specific Whole Blood Biochemistry and Gas Reference Intervals in Broiler Chickens using the i-STAT and the Vetscan VS2 Portable Analyzers.

Whole blood biochemistry and blood gas analysis are uncommonly used in poultry, but their use could improve the diagnosis of certain diseases or aid in monitoring flock health. To create preliminary reference intervals for selected blood analytes in broilers using the i-STAT and Vetscan VS2 (VS2) portable analyzers, we tested broilers at 7, 21, and 35 days of age. A total of 134 venous blood samples from healthy chickens of two different flocks were analyzed. There were significant age-related increases in concentration for glucose, hematocrit, ionized calcium, sodium, and carbon dioxide partial pressure on the i-STAT and for aspartate aminotransferase, creatine kinase, total calcium, phosphorus, and total protein on the VS2. Conversely, significant decreases in concentration were observed for pH, oxygen partial pressure, oxygen saturation on the i-STAT and for uric acid and albumin on the VS2. Additionally, significant differences were found on some blood parameters among the two flocks. Extremely high CK values were found on broilers after 21 days of age, indicating a possible degree of muscle injury during the grow-out. Preliminary reference intervals for all the analytes at each of the age groups were obtained. This study's data provide a starting point for the interpretation of blood analysis in broiler chickens at different ages and offer a new approach to investigate certain metabolic diseases that affect commercial poultry.

Nota de investigación- Establecimiento de intervalos de referencia de gases y bioquímica de sangre completa específicos por edad en pollos de engorde utilizando los analizadores portátiles i-STAT y Vetscan VS2. La bioquímica de sangre completa y el análisis de gases sanguíneos se usan con poca frecuencia en avicultura, pero su uso podría mejorar el diagnóstico de ciertas enfermedades o ayudar a monitorear la salud de las parvadas. Para crear intervalos de referencia preliminares para componentes sanguíneos selectos en pollos de engorde utilizando los analizadores portátiles i-STAT y Vetscan VS2 (VS2), se analizaron muestras de pollos de engorde a los 7, 21 y 35 días de edad. Se analizaron un total de 134 muestras de sangre venosa de pollos sanos de dos parvadas diferentes. Hubo aumentos significativos relacionados con la edad en la concentración de glucosa, hematocrito, calcio ionizado, sodio y presión parcial de dióxido de carbono en el i-STAT, y para aspartato aminotransferasa, creatina quinasa (CK), calcio total, fósforo y proteína total en el VS2. Por otro lado, se observaron disminuciones significativas en la concentración para el pH, la presión parcial de oxígeno, la saturación de oxígeno en el i-STAT y para el ácido úrico y la albúmina en el VS2. Además, se encontraron diferencias significativas para los parámetros sanguíneos entre las dos parvadas. Se encontraron valores de creatina quinasa extremadamente altos en pollos de engorde después de los 21 días de edad, lo que indica un posible grado de lesión muscular durante el engorde. Se obtuvieron los intervalos de referencia preliminares para todos los componentes en cada uno de los grupos de edad. Los datos de este estudio proporcionan un punto de partida para la interpretación del análisis de sangre en pollos de engorde a diferentes edades y ofrecen un nuevo enfoque para investigar ciertas enfermedades metabólicas que afectan a las aves comerciales.

Osteotomía Le Fort III modificada en un paciente no sindrómico / Modified Le Fort III osteotomy in a non-syndromic patient

Las discrepancias dento-esqueletales severas presentan un reto para el cirujano maxilofacial, existe una versatilidad de osteotomías para las diferentes anomalías del crecimiento y desarrollo, sin embargo, son pocas las que permiten mejorar la proyección malar. La osteotomía Le Fort III modificada fue utilizada en un principio en pacientes con algún síndrome craneofacial, pero actualmente es una alternativa útil para discrepancias severas en pacientes no sindrómicos, ya que permite un avance cigomático-maxilar, favorece la proyección malar y disminuye la exposición escleral con un número limitado de complicaciones. Se presenta el caso de un paciente masculino de 33 años con antecedente de fractura orbitocigomática y piso orbitario izquierda con una discrepancia dento-esqueletal severa, la que fue tratada mediante osteotomía Le Fort III modificada, osteotomías sagitales mandibulares para un avance máxilo-malar y retroceso mandibular respectivamente y una genioplastia de avance; logrando un resultado funcional y estético adecuado.

The dento-skeletal severe discrepancies present a challenge for the maxillofacial surgeon, there is a versatility of osteotomies for the different growth and development anomalies, however, a few of them make possible to improve malar projection. The modified Le Fort III osteotomy was originally used in patients with some craniofacial syndrome, but now it is a useful alternative for severe discrepancies in non-syndromic patients, since it allows a zygomatic-maxillary advance, favors malar projection and reduces scleral exposure with a limited number of complications. The case of a 33-year-old male patient with a history of orbitozygomatic fracture and left orbital floor with a severe dento-skeletal discrepancy is presented, who was treated by modified Le Fort III osteotomy, mandibular sagittal osteotomies for maxillo-malar advancement and retrogression mandibular respectively and geniplasty for advance; achieving a suitable functional and aesthetic result.

Pyloric atresia and Down's syndrome: prenatal double bubble false sign. / Atresia pilórica y síndrome de Down: falso signo de la doble burbuja prenatal.

Pyloric atresia is a rare malformation, with an incidence of 1:100,000 live newborns. Male to female ratio is 1/1. Typically, it is an isolated malformation, with a good prognosis, but 20-40% of cases present epidermolysis bullosa, and to a lesser extent, multiple intestinal atresias. We present the case of a pre-term newborn prenatally diagnosed with polyhydramnios, duodenal atresia with "double bubble" sign, and suspected Down's syndrome, who eventually had pyloric atresia.

La atresia pilórica es una malformación rara, presenta una incidencia de 1:100.000 recién nacidos vivos y la ratio hombre/mujer es de 1/1. Generalmente es una malformación aislada, con buen pronóstico, pero entre el 20-40% de los casos se asocia a epidermólisis bullosa y en menor frecuencia a otras atresias intestinales múltiples. Presentamos un caso de recién nacido pretérmino con atresia pilórica con el diagnóstico prenatal de polihidramnios, atresia duodenal con signo de 'doble burbuja' y sospecha de síndrome de Down.

Atresia pilórica y síndrome de Down: falso signo de la doble burbuja prenatal / Pyloric atresia and Down’s syndrome: prenatal double bubble false sign

La atresia pilórica es una malformación rara, presenta una incidenciade 1:100.000 recién nacidos vivos y la ratio hombre/mujer es de 1/1.Generalmente es una malformación aislada, con buen pronóstico, peroentre el 20-40% de los casos se asocia a epidermólisis bullosa y enmenor frecuencia a otras atresias intestinales múltiples.Presentamos un caso de recién nacido pretérmino con atresia piló-rica con el diagnóstico prenatal de polihidramnios, atresia duodenal consigno de ‘doble burbuja’ y sospecha de síndrome de Down.(AU)

Objective. Pyloric atresia is a rare malformation, with an incidenceof 1:100,000 live newborns. Male to female ratio is 1/1. Typically, itis an isolated malformation, with a good prognosis, but 20-40% ofcases present epidermolysis bullosa, and to a lesser extent, multipleintestinal atresias.We present the case of a pre-term newborn prenatally diagnosedwith polyhydramnios, duodenal atresia with “double bubble” sign, andsuspected Down’s syndrome, who eventually had pyloric atresia.(AU)

Factores de riesgo de fracaso de ventilación no invasiva en neumonía primaria por influenza A en pacientes críticos / Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting

Objetivo Analizar factores de riesgo de fracaso de la ventilación no invasiva (VNI) en pacientes que ingresan en una unidad de cuidados intensivos (UCI) por neumonía primaria por virus influenza A (H1N1)pdm09. Demostrar que los pacientes que fracasan con la VNI tienen mayor mortalidad y estancias más largas. Diseño Estudio de cohorte. Ámbito UCI polivalente de un hospital universitario de 16 camas. Pacientes Pacientes adultos que ingresaron en la UCI en los que se confirmó el diagnóstico de neumonía por influenza A (H1N1)pdm09 y que recibieron ventilación mecánica. Variables Edad, sexo, puntuaciones de gravedad, administración de corticoides, oseltamivir dentro de las 72h de la sintomatología, días de sintomatología previos al ingreso, cuadrantes afectados, fracaso hemodinámico, renal y datos analíticos al ingreso, mortalidad y estancia en UCI y hospitalaria. Resultados Ingresaron 54 pacientes y 49 fueron ventilados. Sexo femenino, 29 (59,2%) y una edad media±desviación estándar de 66,77±14,77 años. Fueron ventilados con VNI 43 (87,75%), de los que fracasaron 18 (41,9%). Los pacientes que fracasaron presentaron menor edad (63 vs. 74 años; p=0,04), mayor puntuación SOFA (7 vs. 4; p=0,01) y mayor fracaso hemodinámico (61,1 vs. 8%; p=0,01). Además, presentaron estancias más largas tanto en UCI (26,28 vs. 6,88 días; p=0,01) como hospitalarias (32,78 vs. 18,8 días; p=0,01), y mayor mortalidad en UCI (38,9 vs. 0%; p=0,02). Se identificaron como factores de riesgo de fracaso a VNI recibir corticoides (OR 7,08; IC 95% 1,23-40,50) y el fallo hemodinámico precoz (OR 14,77; IC 95% 2,34-92,97). Conclusiones El tratamiento con corticoides y el fracaso hemodinámico precoz se asociaron con el fracaso de la VNI en pacientes con neumonía primaria por virus influenza A (H1N1)pdm09. Estos tienen una mortalidad superior. (AU)

Objective To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. Design A cohort study was carried out. Scope A mixed ICU (16 beds) in a teaching hospital. Patients Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. Measurements Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. Results A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; P=.04), with a higher SOFA score (7 vs. 4; P=.01) and greater early hemodynamic failure (61.1 vs. 8%; P=.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; P=.01) and hospital stay (32.78 vs. 18.8 days; P=.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; P=.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. Conclusions Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality. (AU)

Risk factors associated to noninvasive ventilation failure in primary influenza A pneumonia in the critical care setting.

OBJECTIVE: To evaluate the risk factors associated to noninvasive mechanical ventilation (NIV) failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus admitted to the intensive care unit (ICU), and to demonstrate the association of NIV failure to increased mortality and longer stays. DESIGN: A cohort study was carried out. SCOPE: A mixed ICU (16 beds) in a teaching hospital. PATIENTS: Adult patients admitted to the ICU with a diagnosis of pneumonia due to influenza A (H1N1)pdm09 virus requiring mechanical ventilation. MEASUREMENTS: Age, sex, severity scores, administration of corticosteroids, oseltamivir within 72h of symptoms onset, days of symptoms prior to admission, affected quadrants, hemodynamic parameters, renal failure, laboratory test data on admission, mortality and stay in ICU and in hospital. RESULTS: A total of 54 patients were admitted to the ICU and 49 were ventilated; 29 were females (59.2%), and the mean age±standard deviation was 66.77±14.77 years. Forty-three patients (87.75%) were ventilated with NIV, and 18 (41.9%) of them failed. Patients with NIV failure were younger (63 vs. 74 years; p=0.04), with a higher SOFA score (7 vs. 4; p=0.01) and greater early hemodynamic failure (61.1 vs. 8%; p=0.01). In addition, they presented longer ICU (26.28 vs. 6.88 days; p=0.01) and hospital stay (32.78 vs. 18.8 days; p=0.01). The ICU mortality rate was also higher in the NIV failure group (38.9 vs. 0%; p=0.02). In the multivariate analysis, corticosteroid therapy (OR 7.08; 95% CI 1.23-40.50) and early hemodynamic failure (OR 14.77; 95% CI 2.34-92.97) were identified as independent risk factors for NIV failure. CONCLUSIONS: Treatment with corticosteroids and early hemodynamic failure were associated to NIV failure in patients with primary pneumonia due to influenza A (H1N1)pdm09 virus infection admitted to the ICU. The failure of NIV was associated to increased mortality.

Sindemia de COVID-19 e influenza a H1N1: reporte de caso / Syndemic of COVID-19 and influenza a H1N1: case report

Se presenta el caso de un paciente masculino de 64 años con cuadro progresivo de fiebre, tos seca, fatiga, eventos diarreicos y disnea agudizada; que en primera instancia es atendido en el área de urgencias y después es admitido en la Unidad de Cuidados Intensivos por su estado grave de salud. Durante el abordaje inicial se realiza tomografía computada de tórax, la cual muestra infiltrados pulmonares con patrón en vidrio esmerilado, cuya presencia hace sospechar de una infección causada por el virus SARS-CoV-2; misma que posteriormente se demuestra estar agudizada debido a una coinfección con el virus de la Influenza A H1N1. Este reporte de caso presenta la evolución clínica, imagenológica y analítica, de un miembro de una población de pacientes quienes cursan simultáneamente cuadros clínicos de dos epidemias: la COVID-19 y la Influenza A H1N1, principalmente durante el invierno, y en el marco de un fenómeno conocido como sindemia.

A case of a 64-year-old male patient is presented with progressive symptoms of fever, dry cough, fatigue, diarrheal events, and exacerbated dyspnea. In the first instance, he is treated in the emergency room, and then he is admitted to the Intensive Care Unit due to his serious health condition. During the initial approach, computed tomography of the chest is performed, which shows pulmonary infiltrates with a ground-glass pattern, whose presence suggests an infection caused by the SARS-CoV-2 virus, which is later shown to be exacerbated due to coinfection with the Influenza A H1N1 virus. This case report presents the clinical, imaging, and laboratory evolution of a member of a population of patients who simultaneously present clinical symptoms of two epidemics: COVID-19 and Influenza A H1N1, mainly during the winter, and within the framework of a phenomenon known as a syndemic

Ventilacion mecanica no invasiva y covid-19. Minimizando la dispersion / Non invasive mechanical ventilation and covid-19. minimizing dispersión

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Effect of coccidial challenge and vaccination on the performance, veterinary postmortem scores, and blood biochemistry of broiler chickens.

A total of 960 male Cobb 500 broilers were used in a growth performance study to explore the effect of coccidial vaccination and/or coccidial challenge on blood biochemistry and veterinary postmortem metrics. Day-old chicks were randomly divided into one of the 4 experimental treatments. Treatments were arranged in a 2 × 2 factorial arrangement, with the factors being without or with vaccination (administered on day 1) or coccidial challenge (oral gavage on day 7). Growth performance was monitored on a weekly basis. Blood sample collection, as well as full veterinary necropsies, were carried out on days 6, 8, 13, 20, 27, and 34. Birds that did not receive the vaccination but were challenged with coccidiosis had higher feed conversion ratio, lower body weights, and higher mortality than the other experimental groups, and this effect was particularly evident from day 13 to day 20. Birds challenged with coccidiosis had lower plasma sodium and total carotenoid concentrations and higher potassium and globulin concentrations than nonchallenged birds. Significant interactions between age and experimental treatment for these blood parameters were observed, particularly on day 13. The necropsy results confirmed the effectiveness of the challenge and vaccination treatments, wherein birds that were challenged had higher coccidiosis scores on day 13 and day 27 than birds that were not challenged. These results demonstrate the potential for plasma sodium, potassium, total protein, total carbon dioxide, globulin, and carotenoid analysis for early diagnosis of coccidiosis in growing broiler chickens. Further work is necessary to establish whether the changes in blood biochemistry observed in the present study are transferable to alternative flocks of chicken and whether early diagnosis and intervention may mitigate performance losses associated with this disease.

Pandemia COVID-19, la nueva emergencia sanitaria de preocupación internacional: una revisión / Pandemic COVID-19, the new health emergency of international concern: a review

A finales de diciembre del 2019 se reportaron una serie de casos de neumonía atípica, en ese momento de origen desconocido, en Wuhan, China. Días más tarde se identificó al agente etiológico como un nuevo coronavirus. A este nuevo coronavirus se le llamó SARS-CoV-2, y a la enfermedad que produce se la denominó COVID-19. El origen de este nuevo virus se presume zoonótico, siendo los murciélagos su probable vector. Debido al acelerado número de contagios y muertes que se produjeron primero en China y posteriormente alrededor del mundo, la infección de este virus pasó rápidamente de ser un brote aislado en una región china a convertirse en una emergencia sanitaria de preocupación internacional, y posteriormente en una pandemia. El propósito de esta revisión es estudiar la información más relevante y actual del patógeno, así como la epidemiología, la patología, las características clínicas, la transmisión, la prevención y el tratamiento de la enfermedad

In late December 2019, some cases of atypical pneumonia, at that time of unknown origin, were reported in Wuhan, China. Days later, the etiologic agent was identified as a new coronavirus. This new coronavirus was called SARS-CoV-2 and the disease it produces was named COVID-19. The origin of this new virus is presumed zoonotic, with bats being its probable vector. Due to the rapid number of infections and deaths that occurred first in China and later around the world, the infection of this virus quickly went from being an isolated outbreak in a Chinese region to becoming a health emergency of international concern and later, a pandemic. The purpose of this review is to study the most relevant and current information on the pathogen, as well as epidemiology, pathology, clinical features, transmission, prevention, and treatment of the disease

Effect of broiler genetics, age, and gender on performance and blood chemistry.

A total of 640 broilers were used to determine the effects of strain, sex, and age on hematology and blood chemistry using rapid detection devices. Day old chicks from two genetic lines of common fast-growing and high-yield broiler strains were sexed and allocated to 40 pens (16 birds per pen) containing either male or female and Ross or Cobb strains (n = 10). Venous blood was analyzed weekly using 2 broilers from each pen (n = 20) using the i-STAT® Alinity Handheld Clinical Analyzer, Zoetis Vetscan VS2, and iCheck™ Carotene devices at 14, 21, 28, 35, and 42 d, as well as growth performance. Post-mortem health tracking metrics were also recorded on 42 d. Broilers were deemed healthy based on posting data results and performed in accordance with industry standards with males presenting greater BW and reduced FCR than female broilers. Ross broilers displayed greater BW to 14 d with similar FCR compared with Cobb birds. Day of age had a highly significant impact on blood calcium, phosphorus, potassium, sodium, chloride, carotene, aspartate aminotransferase, creatine kinase, bile acids, uric acid, total protein, albumin, globulin, total carbon dioxide, hematocrit, and malondialdehyde. Male broilers had reduced blood sodium, chloride, carotene, uric acid, albumin, and increased total protein, glucose, and total carbon dioxide. Ross broilers had greater blood potassium, and sodium, as well as reduced uric acid, total protein, globulin, and malondialdehyde, compared with Cobb birds. These results demonstrated the effectiveness of point-of-care devices in measuring blood chemistry and hematology in modern broilers. These data can be utilized to determine normal healthy blood ranges in these types of broilers when accounting for strain, sex, and age.

[Pandemic COVID-19, the new health emergency of international concern: A review]. / Pandemia COVID-19, la nueva emergencia sanitaria de preocupación internacional: una revisión.

In late December 2019, some cases of atypical pneumonia, at that time of unknown origin, were reported in Wuhan, China. Days later, the etiologic agent was identified as a new coronavirus. This new coronavirus was called SARS-CoV-2 and the disease it produces was named COVID-19. The origin of this new virus is presumed zoonotic, with bats being its probable vector. Due to the rapid number of infections and deaths that occurred first in China and later around the world, the infection of this virus quickly went from being an isolated outbreak in a Chinese region to becoming a health emergency of international concern and later, a pandemic. The purpose of this review is to study the most relevant and current information on the pathogen, as well as epidemiology, pathology, clinical features, transmission, prevention, and treatment of the disease.

Flood protection ecosystem services in the coast of Puerto Rico: Associations between extreme weather, flood hazard mitigation and gastrointestinal illness.

Floods are becoming increasingly influential in coastal cities due to the intensification of extreme weather events. The impacts of flooding go beyond damages to infrastructure, it also affects human health. During floods, discharge of sewage into streets increases exposure to pathogens causing gastrointestinal (GI) illnesses. A potential strategy for coastal protection during weather hazards is the use of flood protection ecosystem services, but their effectiveness at ameliorating the impact of floods on GI illnesses remain understudied. Here we explore the relationship between extreme rainfall, flood protection ecosystem services, and the occurrence of Medicare claims for gastrointestinal (GI) illnesses in Puerto Rico. We first conducted model averaging to detect variables explaining flood impact for the years (1999-2014), and then used these variables as predictors in a spatio-temporal analysis of GI illness in the same period (1999-2013). Our results show that flood impact varies proportionally with extreme rainfall, and inversely with flood protection ecosystem services, particularly due to the presence of karst soils. The protective effect of karst soils is lost when there is a high percentage of people living in flood prone areas, as suggested by a significant interaction effect between these two variables. In support of our hypotheses, cases of GI illness also spike after extreme rainfall events and are affected by the interaction effect of karst soils and people living in flood prone areas. Our results support the linkage between extreme weather events, flood damages and GI illnesses, and suggests a buffering role of ecosystem services that promote rainfall infiltration. The relevance of these ecosystem services, however, is affected by planning decisions such as residential development in flood prone areas. Our results help inform planning strategies for future weather hazards, accounting for the role of natural and built infrastructure on minimizing flood impacts and human health effects.

DNA and chromosomal damage in Senegalese sole (Solea senegalensis) as side effects of ozone-based water treatment - Contribution to optimization of fish-farming practices.

The progressive growth of aquaculture implicates a dependence on large water amounts, which are submitted to disinfection processes, namely ozonation. Considering the importance of genomic integrity, it is critical to improve the knowledge on ozone-related genotoxic hazard to organisms reared in recirculating aquaculture systems (RAS) applying ozonation. Therefore, genetic damage induced by ozone exposure in the Senegalese sole (Solea senegalensis) was assessed, combining the comet and the erythrocytic nuclear abnormalities (ENA) assays, reflecting different damage levels, i.e. DNA and chromosomal damage, respectively. Fish were subjected to a daily 6-h ozone (0.15 mg L-1) exposure, repeated for 3 consecutive days, simulating a short-term event of overozonation. To assess the temporal impact of the previous event, the progression of damage was evaluated 7 days later, following transference to ozone-free water or to 0.07 mg L-1 ozone, a routinely adopted level in RAS. Both endpoints pointed to the ozone genotoxic potential, displaying DNA oxidation as a possible mechanism of damage. Overall, the present findings pointed out the genotoxic hazard of ozone to fish, highlighting the importance of these types of studies and contributing to improve aquaculture practices, namely in RAS systems. These early genotoxic signals may be a prelude to negative repercussions on fish health, which may affect the aquaculture productivity. The present findings recommend precautions in relation to accidental or intentional overozonation in fish-farming, even when short-term events are considered. The strategies to mitigate the impact of ozonation in S. senegalensis may include a dietary extra supplementation of antioxidants (regularly, or punctually in cases of overozonation).

Antimicrobial stewardship program in critical care medicine: What is going on? Who gives more? / Programas de optimización antibiótica en medicina crítica. ¿Qué está ocurriendo? ¿Quién da más?

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Strong Neutron Pairing in core+4n Nuclei.

The emission of neutron pairs from the neutron-rich N=12 isotones ^{18}C and ^{20}O has been studied by high-energy nucleon knockout from ^{19}N and ^{21}O secondary beams, populating unbound states of the two isotones up to 15 MeV above their two-neutron emission thresholds. The analysis of triple fragment-n-n correlations shows that the decay ^{19}N(-1p)^{18}C^{*}→^{16}C+n+n is clearly dominated by direct pair emission. The two-neutron correlation strength, the largest ever observed, suggests the predominance of a ^{14}C core surrounded by four valence neutrons arranged in strongly correlated pairs. On the other hand, a significant competition of a sequential branch is found in the decay ^{21}O(-1n)^{20}O^{*}→^{18}O+n+n, attributed to its formation through the knockout of a deeply bound neutron that breaks the ^{16}O core and reduces the number of pairs.

Global programmatic use of bedaquiline and delamanid for the treatment of multidrug-resistant tuberculosis.

SETTING: The World Health Organization recommended two new drugs, bedaquiline (BDQ) and delamanid (DLM), for the treatment of multidrug-resistant tuberculosis (MDR-TB) in 2013 and 2014, respectively. An estimated one third of patients with MDR-TB would benefit from the inclusion of these drugs in their treatment regimens. DESIGN: A convenience sample of 36 countries voluntarily reported monthly data on cumulative programmatic use of new drugs to the Drug-Resistant TB Scale-Up Treatment Action Team between 1 July 2015 and 31 June 2017. Programmatic use was defined as treatment for MDR-TB with newer drugs outside of clinical trials or compassionate use. RESULTS: A total of 10 164 persons were started on BDQ and 688 started on DLM during the reporting period. Only 15.7% of the 69 213 persons estimated to need newer drugs over the study period were reported to have received them. CONCLUSION: While there has been significant progress in some countries, uptake of the newer drugs has not kept pace with a conservative estimate of need; fewer than 20% of persons likely to benefit from either BDQ or DLM have received them. Concerted efforts are needed to ensure that the newer drugs are made available more widely for persons with MDR-TB in need of these therapeutic options.