[Recommendations on organization, design, characteristics and operation of neonatology services]. / Recomendaciones de organización, diseño, características y funcionamiento de servicios o unidades de neonatología.

Neonatal care has undergone important advances involving the technology for treatment and mo nitoring, the design of care spaces, the incorporation of support professionals, and, especially, the strengthening of an organizational model in networks with centers of different levels of care. Neona tal units should be located in centers with maternity services and, ideally, with pediatric ones of an equivalent level of care. This document defines the admission and transfer criteria according to the level of care and among the different levels, respectively. The evidence recommends an individual room design due to the associated benefits such as decreased occurrence and better control of health care-associated infections, improved breastfeeding, and better interaction with parents. The sugges ted room sizes favor the implementation of the family-centered care model. These recommendations establish the possibility of performing emergency surgical procedures in the neonatal unit and define the safety criteria of the physical plant. In addition, they define the human resources according to the level of care, recognizing the time dedicated to non-direct patient care activities, , and the re quirements of non-medical professionals such as psychologists, physical and respiratory therapists, occupational therapists, speech therapists, pharmacists, dietitians, and social workers. Neonatal care should be led by the neonatologist allowing the participation of general pediatricians with training and demonstrated experience in neonatal care. Midwives and neonatal nurses should have accredited formation in such area. The purpose of this document is to update the "Recommendations on the Organization, Characteristics and Operation of Neonatology Services or Units" to serve as an orien tation and guide for the design and management of neonatal care in public and private health care centers in the country.

Liver stiffness change with HCV cure in HIV-infected patients on non-nucleoside analogues.

BACKGROUND: Liver stiffness (LS) at sustained viral response (SVR) is strongly associated with a lower incidence of subsequent hepatic events. HIV NNRTIs may have a beneficial impact on fibrogenesis. OBJECTIVES: Our aim was to analyse the influence of NNRTI-based therapy on the change in LS from starting direct-acting antiviral (DAA) therapy to achieving SVR in HIV/HCV-coinfected patients. METHODS: Three hundred and thirteen HIV/HCV-coinfected patients who fulfilled the following criteria were included: (i) had achieved SVR with an IFN-free, DAA-including regimen; (ii) LS ≥9.5 kPa before therapy; (iii) LS measurement available at SVR; (iv) seronegative for HBsAg; and (v) ART containing 2 NRTIs plus either 1 NNRTI or 1 integrase inhibitor (INI) or 1-2 NRTIs plus 1 PI. LS changes were assessed. RESULTS: Seventy-four patients received NNRTI-based combinations [53 (71.6%) rilpivirine and 16 (21.6%) efavirenz] and 239 patients received other regimens. At baseline, the median (IQR) LS was 16.7 kPa (11.8-25.6) in the NNRTI group and 17.3 kPa (11.9-27.4) in the non-NNRTI group (P = 0.278). The median (IQR) percentage of LS decrease from baseline to SVR was 35.2% (18.2%-52.3%) for NNRTI-based therapy and 29.5% (10%-45.9%) for PI- or INI-based therapy (P = 0.018). In multivariate analysis, adjusted for sex, age, HCV genotype, NRTI backbone and propensity score for HIV therapy, NNRTI-based regimen use was associated with a higher LS decrease [ß = 11.088 (95% CI = 1.67-20.51); P = 0.021]. CONCLUSIONS: Treatment with NNRTI plus 2 NRTI combinations is associated with a higher LS decline than other ART combinations in HIV/HCV-coinfected patients receiving DAA-based therapy.

Projecting Climate Dependent Coastal Flood Risk With a Hybrid Statistical Dynamical Model.

Numerical models for tides, storm surge, and wave runup have demonstrated ability to accurately define spatially varying flood surfaces. However these models are typically too computationally expensive to dynamically simulate the full parameter space of future oceanographic, atmospheric, and hydrologic conditions that will constructively compound in the nearshore to cause both extreme event and nuisance flooding during the 21st century. A surrogate modeling framework of waves, winds, and tides is developed in this study to efficiently predict spatially varying nearshore and estuarine water levels contingent on any combination of offshore forcing conditions. The surrogate models are coupled with a time-dependent stochastic climate emulator that provides efficient downscaling for hypothetical iterations of offshore conditions. Together, the hybrid statistical-dynamical framework can assess present day and future coastal flood risk, including the chronological characteristics of individual flood and wave-induced dune overtopping events and their changes into the future. The framework is demonstrated at Naval Base Coronado in San Diego, CA, utilizing the regional Coastal Storm Modeling System (CoSMoS; composed of Delft3D and XBeach) as the dynamic simulator and Gaussian process regression as the surrogate modeling tool. Validation of the framework uses both in-situ tide gauge observations within San Diego Bay, and a nearshore cross-shore array deployment of pressure sensors in the open beach surf zone. The framework reveals the relative influence of large-scale climate variability on future coastal flood resilience metrics relevant to the management of an open coast artificial berm, as well as the stochastic nature of future total water levels.

Climate-induced variability in South Atlantic wave direction over the past three millennia.

Through alteration of wave-generating atmospheric systems, global climate changes play a fundamental role in regional wave climate. However, long-term wave-climate cycles and their associated forcing mechanisms remain poorly constrained, in part due to a relative dearth of highly resolved archives. Here we use the morphology of former shorelines preserved in beach-foredune ridges (BFR) within a protected embayment to reconstruct changes in predominant wave directions in the Subtropical South Atlantic during the last ~ 3000 years. These analyses reveal multi-centennial cycles of oscillation in predominant wave direction in accordance with stronger (weaker) South Atlantic mid- to high-latitudes mean sea-level pressure gradient and zonal westerly winds, favouring wave generation zones in higher (lower) latitudes and consequent southerly (easterly) wave components. We identify the Southern Annular Mode as the primary climate driver responsible for these changes. Long-term variations in interhemispheric surface temperature anomalies coexist with oscillations in wave direction, which indicates the influence of temperature-driven atmospheric teleconnections on wave-generation cycles. These results provide a novel geomorphic proxy for paleoenvironmental reconstructions and present new insights into the role of global multi-decadal to multi-centennial climate variability in controlling coastal-ocean wave climate.

Frequency response curves for a Mooney-Rivlin hyperelastic microbubble oscillating as a contrast agent in an acoustic pressure field.

In this work, we have developed numerical simulations and weakly nonlinear analysis based on the multiple-scales perturbation technique for a coated microbubble that performs radial pulsations subject to an acoustic pressure disturbance in the far-field and whose encapsulated hyperelastic material obeys the Mooney-Rivlin equation. Departing from an elastic coating as a hyperelastic shell of finite thickness, we assume eventually that the shell is of very small thickness in comparison with the microbubble radius. Under this condition, we then perform weakly nonlinear analysis, to identify resonance conditions for small pressure disturbances of the acoustic field. In parallel and also for the limit of small thickness, we have carried out numerical simulations of the radial motion of the microbubble, identifying the onset of limit cycles via the construction of Poincare maps. Under both schemes, we have recognized the importance of two dimensionless hyperelastic parameters that dictate the main behavior of the oscillations: α∗ and ß∗. Decreasing the values of these parameters, the resonance conditions are drastically amplified, which is an expected result because of the weak rigidity of the hyperelastic solid, prevails. In this manner, we suggest that moderate values for these previous parameters can be widely advisable when, in medical diagnostic applications, we are applying microbubbles as contrast agents. Therefore, we recommend widely the use of shell softens, because in this case the amplitude of radial pulsation is always amplified.

Evaluación sobre la técnica de compresiones torácicas usando APP. ¿Ayudan o entorpecen la reanimación cardiopulmonar? / Evaluation of the thoracic compression technique using APPs. Do they help or hinder cardiopulmonary resuscitation?

Objetivo: Evaluar la calidad de la reanimación cardiopulmonar (RCP) de personas no expertas guiada por una aplicación móvil con retroalimentación en tiempo real. Diseño: Estudio cuasi-experimental de corte transversal. Participantes: Una muestra de 113 estudiantes de enfermería sin experiencia ni formación en RCP participaron en el estudio. Intervenciones: Se realizaron tres test de RCP solo manos con compresiones continuas: 1)RCP sin dispositivo; 2)RCP con el teléfono apagado, y 3)RCP guiada por APP. Se aleatorizaron tres aplicaciones diferentes (Pocket CPR(R), CPR Pro(R) y Massage cardiaque et DSA(R)). Los tres test se realizaron de forma consecutiva, aleatorizados y separados 30min entre cada uno. Se utilizó el maniquí Laerdal Resusci Anne QCPR (Stavanger, Noruega) software 2.0.0.14. Variables de interés principales: Aplicaciones utilizadas. Variables demográficas para caracterizar a la muestra. Variables independientes: media de profundidad, ritmo medio, porcentaje de posición correcta de mano, porcentaje de compresiones con reexpansión correcta, porcentaje de compresiones con profundidad correcta, porcentaje de compresiones al ritmo correcto, calidad global de la RCP. Resultados: La calidad global de la RCP fue del 33,3%±32,7 para Pocket CPR, del 10,9%±22,72 para CPR Pro y del 7,8%±9,2 para Massage cardiaque et DSA. Con ninguna de las APP se consiguen mejorías estadísticamente significativas. El porcentaje de tiempo que el reanimador consiguió mantener el ritmo correcto mejoró con el uso de las tres APP. Conclusiones: La RCP guiada por APP no mejoró la calidad global de las compresiones durante la reanimación, si bien mejoró el porcentaje de compresiones realizadas a un ritmo correcto

Objective: To evaluate the quality of cardiopulmonary resuscitation (CPR) by lay people when guided by a mobile phone application with real-time feedback, with the comparison of three different mobile phone applications (APPs). Design: A cross-sectional quasi-experimental study was carried out. Participants: A sample of 113 nursing students participated in the study. Interventions: Three hands-only CPR tests with continuous compressions were performed: (i)without external help; (ii)with the mobile phone turned off; and (iii)guided by APP. Three different APPs were randomly assigned (Pocket CPR(R), CPR Pro(R)> and Massage cardiaque et DSA(R)). The mannequin Laerdal Resusci Anne QCPR (Stavanger, Norway) 2.0.0.14 software was used. Variables of primary interest: APPs used. Demographic variables characterizing the study sample. Independent variables: mean depth, mean rate, percentage of correct hand positioning, percentage of compressions with correct re-expansion, percentage of compressions with correct depth, percentage of compressions at the correct rate, and overall quality of CPR. Results: Overall CPR quality was 33.3% ± 32.7 using Pocket CPR, 10.9% ± 22.72% using CPR Pro and 7.8% ± 9.2 using Massage cardiaque et DSA. None of the APPs produced a statistically significant improvement. The percentage of time that the resuscitator managed to maintain a correct compression rate improved when using all three APPs. Conclusions: Cardiopulmonary resuscitation guided by phone APPs did not improve the overall quality of compressions during resuscitation, though it improved the percentage of compressions performed at the correct rate

Evaluation of the thoracic compression technique using APPs. Do they help or hinder cardiopulmonary resuscitation? / Evaluación sobre la técnica de compresiones torácicas usando APP. ¿Ayudan o entorpecen la reanimación cardiopulmonar?

OBJECTIVE: To evaluate the quality of cardiopulmonary resuscitation (CPR) by lay people when guided by a mobile phone application with real-time feedback, with the comparison of three different mobile phone applications (APPs). DESIGN: A cross-sectional quasi-experimental study was carried out. PARTICIPANTS: A sample of 113 nursing students participated in the study. INTERVENTIONS: Three hands-only CPR tests with continuous compressions were performed: (i)without external help; (ii)with the mobile phone turned off; and (iii)guided by APP. Three different APPs were randomly assigned (Pocket CPR®, CPR Pro®> and Massage cardiaque et DSA®). The mannequin Laerdal Resusci Anne QCPR (Stavanger, Norway) 2.0.0.14 software was used. VARIABLES OF PRIMARY INTEREST: APPs used. Demographic variables characterizing the study sample. INDEPENDENT VARIABLES: mean depth, mean rate, percentage of correct hand positioning, percentage of compressions with correct re-expansion, percentage of compressions with correct depth, percentage of compressions at the correct rate, and overall quality of CPR. RESULTS: Overall CPR quality was 33.3% ± 32.7 using Pocket CPR, 10.9% ± 22.72% using CPR Pro and 7.8% ± 9.2 using Massage cardiaque et DSA. None of the APPs produced a statistically significant improvement. The percentage of time that the resuscitator managed to maintain a correct compression rate improved when using all three APPs. CONCLUSIONS: Cardiopulmonary resuscitation guided by phone APPs did not improve the overall quality of compressions during resuscitation, though it improved the percentage of compressions performed at the correct rate.

Liver Stiffness at the Time of Sustained Virological Response Predicts the Clinical Outcome in People Living With Human Immunodeficiency Virus and Hepatitis C Virus With Advanced Fibrosis Treated With Direct-acting Antivirals.

BACKGROUND: Some people living with hepatitis C virus (HCV) with sustained virological response (SVR) develop hepatic complications. Liver stiffness (LS) predicts clinical outcome in people living with human immunodeficiency virus (HIV) with active HCV coinfection, but information after SVR is lacking. We aimed to analyze the predictive ability of LS at SVR for liver complications in people living with HIV/HCV with advanced fibrosis treated with direct-acting antivirals (DAA). METHODS: In sum, 640 people living with HIV/HCV fulfilling the following criteria were included: (i) Achieved SVR with DAA-including regimen; (ii) LS ≥ 9.5 kPa before therapy; and (iii) LS measurement available at SVR. The primary endpoint was the occurrence of a liver complication-hepatic decompensation or hepatocellular carcinoma (HCC)-or requiring liver transplant after SVR. RESULTS: During a median (Q1-Q3) follow-up of 31.6 (22.7-36.6) months, 19 (3%) patients reached the primary endpoint. In the multivariate analysis, variables (subhazard ratio [SHR] [95% confidence interval]) associated with developing clinical outcomes were: prior hepatic decompensations (3.42 [1.28-9.12]), pretreatment CPT class B or C (62.5 [3.08-1246.42]) and MELD scores (1.37 [1.03-1.82]), CPT class B or C at SVR (10.71 [1.32-87.01]), CD4 cell counts <200/µL at SVR time-point (4.42 [1.49-13.15]), FIB-4 index at SVR (1.39 [1.13-1.70]), and LS at SVR (1.05 [1.02-1.08] for 1 kPa increase). None of the 374 patients with LS <14kPa at SVR time-point developed a liver complication or required hepatic transplant. CONCLUSIONS: LS at the time of SVR after DAA therapy predicts the clinical outcome of people living with HIV/HCV with advanced fibrosis. These results suggest that LS measurement may be helpful to select candidates to be withdrawn from surveillance programs.

Perfil de incidencia de VIH en embarazadas atendidas en el Instituto Nacional Materno Perinatal de Lima, Perú / Incidence rate of HIV in pregnant women attended at the Instituto Nacional Materno Perinatal of Lima, Perú

Resumen OBJETIVO Determinar la incidencia de la infección por VIH en mujeres embarazadas atendidas en el Instituto Nacional Materno Perinatal de Lima, Perú (2007-2016). MATERIAL Y MÉTODOS Estudio observacional, descriptivo y retrospectivo. Revisión de los resultados de los exámenes diagnósticos de VIH de mujeres embarazadas efectuados según la normativa nacional vigente que incluye las pruebas de tamizaje (inmunocromatografía o ELISA). Los reportes positivos se corroboran con exámenes confirmatorios (inmunofluorescencia indirecta y western blot). Determinación de la incidencia de VIH de acuerdo con la tendencia anual; aplicación de la correlación de Pearson y prueba de χ2 para comparar las características del perfil de incidencia. RESULTADOS Se tamizaron 113,258 mujeres embarazadas y la incidencia obtenida fue de 2.9 por cada mil. La tendencia anual fue errática, excepto entre 2014 y 2016 años en los que se advirtió una tendencia a disminuir. Solo se tamizó a 22.7% de las parejas masculinas en quienes la seroconcordancia fue 10.3%, y la serodiscordancia 12.4%. La frecuencia de seroconcordancia se correlacionó directamente con el porcentaje de parejas tamizadas e inversamente con la frecuencia de VIH (p<0.05). La condición de convivencia o madre soltera se asoció con mayor frecuencia a la falta de tamizaje de la pareja (p<0.001). CONCLUSIONES La incidencia de VIH confirmado fue errática (2007-2016). Deben proponerse estrategias para incrementar el tamizaje en las parejas de las embarazadas infectadas, teniendo en cuenta la alta frecuencia de inestabilidad de ese tipo de unión.

Abstract OBJECTIVE To determine the incidence of HIV infection in pregnant women treated at the National Maternal and Perinatal Institute (Lima, Peru), between 2007-2016. MATERIAL AND METHODS Observational, descriptive and retrospective study. The results of the diagnostic tests of HIV in pregnant women were reviewed, carried out according to current national regulations, which includes the screening tests (immunochromatography and / or ELISA), which in case of being reactive were corroborated by confirmatory tests (indirect immunofluorescence and Western Blot). The incidence of HIV was measured according to the annual trend, and the Pearson correlation and χ2 test were applied to compare the characteristics of the incidence profile. RESULTS 113,258 pregnant women were screened, obtaining an incidence of 2.91 per thousand pregnant women, the annual trend was erratic, except between 2014 and 2016 where there was a tendency to decrease. Only 22.73% of the couples of the pregnant women were screened, the seroconcordance was 10.3%, and the serodiscordance was 12.42%. The frequency of seroconcordance correlated directly with the percentage of sifted couples and inversely with the frequency of HIV (p <0.05). The condition of coexistence or single mother was associated more frequently with the lack of screening of the couple (p <0.001). CONCLUSIONS The confirmed incidence of HIV was erratic (2007-2016). Strategies should be elaborated to increase the screening in the pairs of the infected pregnant women, taking into account the high frequency of the instability of said union.

[Professional satisfaction for doctors of the Mobile Emergency Team and the Emergency Coordinator Office 061. Region of Murcia]. / Satisfacción laboral de los médicos de Unidades Móviles de Emergencia y del Centro Coordinador de la Gerencia de Urgencias y Emergencias 061. Región de Murcia.

OBJECTIVE: The objective was to analyze the phenomenon of work satisfaction of doctors of the Mobile Emergency Team and the Emergency Coordinator Office 061 of the Region of Murcia. MATERIAL AND METHOD: A observational, analytical and cross-sectional study of development carried out with the medical staff of the Casualty and Emergency Operations Department 061 of the Region of Murcia. Data collection was carried out in December 2013 and January 2014. NTP 394 was used. Work satisfaction: general satisfaction scale. DATA ANALYSIS: nonparametric tests for 2 samples or k samples depending on type of comparison. RESULTS: A participation rate of 88.2% was obtained, in relation to the general job satisfaction, the average of the participants was 69.55 (SD = 14.4). Of the 15 items that make up the questionnaire, « work colleagues ¼ is the factor with which doctors are more satisfied with, indicating that up to an 87%, show a positive assessment on this point. Being the second aspect most respondents valued their « job stability ¼ with a percentage of positive ratings of 76.7%. CONCLUSIONS: The main findings clearly demonstrate the importance of inter-professional relations and human potential as the cornerstone in the exercise of the activity of healthcare professionals.

Satisfacción laboral de los médicos de Unidades Móviles de Emergencia y del Centro Coordinador de la Gerencia de Urgencias y Emergencias 061. Región de Murcia / Professional satisfaction for doctors of the Mobile Emergency Team and the Emergency Coordinator Office 061. Region of Murcia

Objetivo: Analizar el fenómeno de la satisfacción de la vida laboral de los profesionales médicos de las Unidades Móviles de Emergencia y del Centro Coordinador de Urgencias del 061 de la Región de Murcia. Material y método: Estudio observacional, analítico y transversal realizado al personal médico de la Gerencia de Urgencias y Emergencias 061 de la Región de Murcia. La recogida de datos se realizó en diciembre de 2013 y enero de 2014. Se utilizó como instrumento la NTP 394: Satisfacción laboral: escala general de satisfacción. Análisis de datos: pruebas no paramétricas para 2 muestras o k muestras según la comparación. Resultados: Se obtuvo una tasa de participación del 88,2%. En relación con la satisfacción laboral general, la media de los participantes se sitúa en 69,5 (DT = 14,4). De los 15 ítems que componen el cuestionario, los «compañeros de trabajo» constituyen el factor en el que los médicos se encuentran más satisfechos, señalando que hasta un 87% muestran valoraciones positivas en este punto. El segundo aspecto más valorado por los encuestados es su «estabilidad en el empleo» con un porcentaje de valoraciones positivas del 76,7%. Conclusiones: Los principales hallazgos dejan patente la importancia de las relaciones interpersonales y el potencial humano como pilar básico en el ejercicio de la actividad laboral de los profesionales sanitarios (AU)

Objective: The objective was to analyze the phenomenon of work satisfaction of doctors of the Mobile Emergency Team and the Emergency Coordinator Office 061 of the Region of Murcia. Material and method: An observational, analytical and cross-sectional study of development carried out with the medical staff of the Casualty and Emergency Operations Department 061 of the Region of Murcia. Data collection was carried out in December 2013 and January 2014. NTP 394 was used. Work satisfaction: general satisfaction scale. Data analysis: nonparametric tests for 2 samples or k samples depending on type of comparison. Results: A participation rate of 88.2% was obtained, in relation to the general job satisfaction, the average of the participants was 69.55 (SD = 14.4). Of the 15 items that make up the questionnaire, «work colleagues» is the factor with which doctors are more satisfied with, indicating that up to an 87%, show a positive assessment on this point. Being the second aspect most respondents valued their «job stability» with a percentage of positive ratings of 76.7%. Conclusions: The main findings clearly demonstrate the importance of inter-professional relations and human potential as the cornerstone in the exercise of the activity of healthcare professionals (AU)

Prevalence of metabolic syndrome in urban Colombian adolescents aged 10-16 years using three different pediatric definitions.

The aim of this study was to evaluate the metabolic syndrome (MetS) prevalence in adolescents using three different definitions for this age group. The evaluated sample consisted of 718 male and 743 female adolescents. Definitions by Cook et al., de Ferranti et al. and International Diabetes Federation (IDF) for adolescents were used to estimate the prevalence of MetS. The prevalence of MetS was 8.5, 2.5 and 1.2% by de Ferranti et al., Cook et al. and IDF definitions, respectively. High fasting glucose component had the lower prevalence whereas high triglycerides levels component was the most prevalent. In obese adolescents, the prevalence of MetS was higher. MetS classification in adolescents strongly depends on the definition chosen. Further research is required for the evaluation of the current definitions (multicentric studies), and for addition or design of new and useful criteria.

C-reactive protein, waist circumference, and family history of heart attack are independent predictors of body iron stores in apparently healthy premenopausal women.

Ferritin levels have been associated with metabolic syndrome and insulin resistance. The aim of the present study was to evaluate the prediction of ferritin levels by variables related to cardiometabolic disease risk in a multivariate analysis. For this aim, 123 healthy women (72 premenopausal and 51 posmenopausal) were recruited. Data were collected through procedures of anthropometric measurements, questionnaires for personal/familial antecedents, and dietary intake (24-h recall), and biochemical determinations (ferritin, C reactive protein (CRP), glucose, insulin, and lipid profile) in blood serum samples obtained. Multiple linear regression analysis was used and variables with no normal distribution were log-transformed for this analysis. In premenopausal women, a model to explain log-ferritin levels was found with log-CRP levels, heart attack familial history, and waist circumference as independent predictors. Ferritin behaves as other cardiovascular markers in terms of prediction of its levels by documented predictors of cardiometabolic disease and related disorders. This is the first report of a relationship between heart attack familial history and ferritin levels. Further research is required to evaluate the mechanism to explain the relationship of central body fat and heart attack familial history with body iron stores values.

Identificación de las competencias del gastroenterólogo chileno: técnica delphi modificada / Competencies of a chilean gastroeneterologist: modified delphi technique

Introduction: The importance of identifying the final competences of pre and postgraduate students is a growing a concern at national and international level due to the need of developing curricula aimed at educating competent professionals that respond to the society´s needs. Objetive: To identify the competencies of a general gastroenterologist (GG). Methods: Modified Delphi technique with a 3-round survey to a group of experts at national level. Sixty-eigth experts were surveyed including gastroenterologists, professionals of related specialties, representatives of scientific societies, and organizations that provide accreditation of both medical study programs and specialties certification. The first survey proposed a list of 224 competencies. Then, in the second and third rounds, the experts must prioritize the competencies according to the importance, usin a 0-4 Likert-type scale. Results: In the first round, 41 experts (60.3 percent) prioritized the 332 identified competencies. Og those, 255 were considered important or very important. In the third round, 252 competencies were confirmed as relevant by 38 experts (55.9 percent). Of the 49 practical procedures identified, only 15 were finally considered as part of the competencies of the GG.A significant percentage of procedures were considered of a higher level of training, particularly, complex endoscopic procedures. Conclusion: Identified competencies will be highly useful in the desing of competencies based curricula and in the implementation of evaluation systems appropriate for each competency. Specialty programs and their graduates might be evaluated according to these competencies.

Introducción: Identificar las competencias terminales de los egresados de pre y postgrado es de creciente interés nacional e internacional debido a la necesidad de desarrollar currículos enfocados en la formación de profesionales competentes, que respondan a las necesidades de la sociedad. El Gastroenterólogo General (GG), debe adquirir competencias cognitivas, destrezas psicomotrices y actitudes. Objetivo: Identificar las competencias del GG. Método: Encuesta de 3 rondas con técnica Delphi modificada a un grupo de expertos a nivel nacional para priorizar las competencias del GG según importancia utilizando una escala Likert de 0 a 4. Se encuestó a 68 expertos incluyendo gastroenterólogos, profesionales de especialidades relacionadas, representantes de Sociedades Científicas, organismos acreditadores de programas y certificadores de especialidades médicas. Resultado: En la primera ronda, se ofreció una lista de 224 competencias a 37 profesionales (54,4 por ciento del total de expertos) quienes agregaron 108 competencias adicionales. En la segunda ronda, 41 expertos (60,3 por ciento) priorizaron las 332 competencias identificadas. De ellas, 255 fueron consideradas importantes o muy importantes. En la tercera ronda, 252 competencias fueron confirmadas como relevantes por 38 expertos (55,9 por ciento). De los 49 procedimientos prácticos identificados, sólo 15 fueron finalmente considerados como parte de las competencias del GG. Un alto porcentaje de los procedimientos fueron considerados en un nivel de entrenamiento superior, en particular los procedimientos endoscópicos complejos. Conclusión: Las competencias identificadas serán de gran utilidad en el diseño de currículos basados en competencias e implementación de sistemas de evaluación apropiados para cada competencia. Los programas de especialidad así como sus egresados podrán ser evaluados de acuerdo a estas competencias.

Clonal complexes and diversity of exotoxin gene profiles in methicillin-resistant and methicillin-susceptible Staphylococcus aureus isolates from patients in a Spanish hospital.

Molecular epidemiology studies have allowed the identification of the methicillin (meticillin)-resistant (MRSA) and methicillin-susceptible (MSSA) clonal complexes (CCs) and clones of Staphylococcus aureus circulating in a Spanish hospital recently. Of 81 isolates tested, 32.1% were MRSA. Most of them carried staphylococcal cassette chromosome mec (SCCmec) IVc (88.5%) and belonged to CC5 (88.5%; multilocus sequence typing types ST125 [mainly associated with spa type t067], ST5, and ST228). A higher diversity was found among MSSA isolates (67.9%). Eighty percent shared the genetic background of major MRSA lineages (CC5 [38.2%; ST125 and ST5], CC30 [25.5%; ST30], CC45 [14.5%; ST45 and ST47], and CC8 [1.8%; ST8]), but CC12, CC15, CC51, and CC59 were also detected. Many exotoxin genes were present in each of the 81 isolates, independent of whether they were involved in sepsis (11 to 22) or other types of infections (13 to 21), and they appeared in 73 combinations. The relevant data are that (i) all isolates were positive for hemolysin and leukotoxin genes (98.8% for lukED and 25.9% for lukPV); (ii) all contained an enterotoxin gene cluster (egc with or without seu), frequently with one or more genes encoding classical enterotoxins; (iii) about half were positive for tst and 95% were positive for exfoliatin-encoding genes (eta, etb, and/or etd); and (iv) the four agr groups were detected, with agrII (55.6%) and agrIII (23.5%) being the most frequent. Taken together, results of the present study suggest a frequent acquisition and/or loss of exotoxin genes, which may be mediated by efficient intralineage transfer of mobile genetic elements and exotoxin genes therein and by eventual breakage of interlineage barriers.

Diagnostic detection of Streptococcus pneumoniae PpmA in urine.

Streptococcus pneumoniae infections are often difficult to diagnose accurately, as it is not uncommon for clinical samples to be culture-negative, particularly after antibiotic administration. The rapid Binax NOW S. pneumoniae urinary antigen test lacks specificity in children, owing to pneumococcal antigen reactions in children who are nasopharyngeal carriers of S. pneumoniae. A western blot assay with a specific polyclonal antibody was developed for direct detection of the putative proteinase maturation protein A (PpmA) in urine samples from children with pneumococcal infections. The sensitivity and specificity of the assay were 66.7% and 100%, respectively. Previous antibiotic treatment or S. pneumoniae nasopharyngeal colonization did not affect PpmA antigenuria. Results also demonstrated the presence of PpmA cross-reactive epitopes in commensal bacteria that co-colonize the nasopharyngeal niche, although the non-pneumococcal cross-reactive protein(s) did not interfere with the detection assay. S. pneumoniae PpmA in the urine of children with pneumococcal infections may be a marker that has the potential to be used in the clinical diagnosis of pneumococcal infection.

Persistence of HPV infection and risk of high-grade cervical intraepithelial neoplasia in a cohort of Colombian women.

Little is known about the dynamics of human papillomavirus (HPV) infection and subsequent development of high-grade cervical intraepithelial neoplasia (CIN2/3), particularly in women >30 years of age. This information is needed to assess the impact of HPV vaccines and consider new screening strategies. A cohort of 1728 women 15-85 years old with normal cytology at baseline was followed every 6 months for an average of 9 years. Women with squamous intraepithelial lesions were referred for biopsy and treatment. The Kaplan-Meier method was used to estimate the median duration of infection and Cox regression analysis was undertaken to assess determinants of clearance and risk of CIN2/3 associated with HPV persistence. No difference in the likelihood of clearance was observed by HPV type or woman's age, with the exception of lower clearance for HPV16 infection in women under 30 years of age. Viral load was inversely associated with clearance. In conclusion, viral load is the main determinant of persistence, and persistence of HPV16 infections carry a higher risk of CIN2/3.