Neurobrucellosis in a common bottlenose dolphin (Tursiops truncatus) stranded in the Canary Islands.

BACKGROUND: Brucella spp. isolation is increasingly reported in cetaceans, although associated pathologies, including lesions of the musculoskeletal and nervous systems, are less frequently described. Concerning the nervous system, Brucella sp. infection causing meningitis, meningoencephalitis or meningoencephalomyelitis have been extensively reported in striped dolphins (Stenella coeruleoalba), and less frequently in other cetacean species. CASE PRESENTATION: A juvenile female common bottlenose dolphin (Tursiops truncatus) was found stranded alive in Lanzarote (Canary Islands, Spain) in 2005, but died shortly after. On physical examination, the dolphin showed a moderate body condition and was classified as code 2 (fresh dead) at the time of necropsy. The main gross findings were severe multiorgan parasitism, thickened and congested leptomeninges, and (sero)fibrino-suppurative and proliferative arthritis of the shoulder joint. Histopathological examination revealed the distinct features of a sub-acute systemic disease associated with Cetacean Morbillivirus (CeMV) infection. However, brain lesions diverged from those reported in systemic CeMV infection. This led to suspect that there was a coinfecting pathogen, based on the characteristics of the inflammatory response and the lesion distribution pattern in the central nervous system. Brucella sp. was detected in the brain tissue by PCR and Brucella antigen was demonstrated by immunohistochemistry in the brain and shoulder joint lesions. CONCLUSIONS: The zoonotic potential of marine mammal strains of Brucella has been demonstrated both in natural and laboratory conditions. In this study, PCR detected Brucella sp. in the brain of a common bottlenose dolphin stranded in the Canary Islands; the dolphin was also co-infected with CeMV. This is the first detection of Brucella sp. infection in a stranded cetacean in this archipelago. Therefore, we stress the importance of taking adequate measures during the handling of these species to prevent the transmissions of the infection to humans.

Boron Toxicity Reduces Water Transport from Root to Shoot in Arabidopsis Plants. Evidence for a Reduced Transpiration Rate and Expression of Major PIP Aquaporin Genes.

Toxic boron (B) concentrations cause impairments in several plant metabolic and physiological processes. Recently we reported that B toxicity led to a decrease in the transpiration rate of Arabidopsis plants in an ABA-dependent process within 24 h, which could indicate the occurrence of an adjustment of whole-plant water relations in response to this stress. Since plasma membrane intrinsic protein (PIP) aquaporins are key components influencing the water balance of plants because of their involvement in root water uptake and tissue hydraulic conductance, the aim of the present work was to study the effects of B toxicity on these important parameters affecting plant water status over a longer period of time. For this purpose, transpiration rate, water transport to the shoot and transcript levels of genes encoding four major PIP aquaporins were measured in Arabidopsis plants treated or not with a toxic B concentration. Our results indicate that, during the first 24 h of B toxicity, increased shoot ABA content would play a key role in reducing stomatal conductance, transpiration rate and, consequently, the water transport to the shoot. These physiological responses to B toxicity were maintained for up to 48 h of B toxicity despite shoot ABA content returning to control levels. In addition, B toxicity also caused the down-regulation of several genes encoding root and shoot aquaporins, which could reduce the cell to cell movement of water in plant tissues and, consequently, the water flux to shoot. All these changes in the water balance of plants under B toxicity could be a mechanism to prevent excess B accumulation in plant tissues.

Prostatic Lesions in Odontocete Cetaceans.

The prostate is the only accessory male genital gland described in cetaceans. Although few studies describe the gross and histologic anatomy of the prostate in cetaceans, there is no information on pathological findings involving this organ. The prostate glands of 45 cetaceans, including 8 different odontocete species ( n = 44) and 1 mysticete, were evaluated. The main pathologic diagnoses were verminous prostatitis, septic prostatitis, viral prostatitis, benign prostatic hyperplasia, and prostatitis of unknown etiology. Verminous prostatitis ( n = 12) was caused by nematodes of the genus Crassicauda, and different presentations were observed. Septic prostatitis, identified in 2 cases, both involved nematode infestation and Clostridium spp coinfection. One case of viral prostatitis was identified and was associated with morbillivirus infection. In prostatitis of unknown cause ( n = 7), varying degrees of prostatic lesions, mostly chronic inflammation, were identified. Impacts at individual levels (eg, localized disease, loss of reproductive capacity) and population levels (eg, decreased reproductive success) are plausible. Our results indicate a high occurrence of prostatic lesions in free-ranging odontocetes. For this reason, the prostate should be routinely inspected and sampled during necropsy of odontocete cetaceans.

Abscisic acid and transpiration rate are involved in the response to boron toxicity in Arabidopsis plants.

Boron (B) is an essential microelement for vascular plant development, but its toxicity is a major problem affecting crop yields in arid and semi-arid areas of the world. In the literature, several genes involved in abscisic acid (ABA) signalling and responses are upregulated in Arabidopsis roots after treatment with excess B. It is known that the AtNCED3 gene, which encodes a crucial enzyme for ABA biosynthesis, plays a key role in the plant response to drought stress. In this study, root AtNCED3 expression and shoot ABA content were rapidly increased in wild-type plants upon B-toxicity treatment. The Arabidopsis ABA-deficient nced3-2 mutant had higher transpiration rate, stomatal conductance and accumulated more B in their shoots than wild-type plants, facts that were associated with the lower levels of ABA in this mutant. However, in wild-type plants, B toxicity caused a significant reduction in stomatal conductance, resulting in a decreased transpiration rate. This response could be a mechanism to limit the transport of excess B from the roots to the leaves under B toxicity. In agreement with the higher transpiration rate of the nced3-2 mutant, this genotype showed an increased leaf B concentration and damage upon exposure to 5 mM B. Under B toxicity, ABA application decreased B accumulation in wild-type and nced3-2 plants. In summary, this work shows that excess B applied to the roots leads to rapid changes in AtNCED3 expression and gas exchange parameters that would contribute to restrain the B entry into the leaves, this effect being mediated by ABA.

Effectiveness and Safety of Entecavir or Tenofovir in a Spanish Cohort of Chronic Hepatitis B Patients: Validation of the Page-B Score to Predict Hepatocellular Carcinoma.

BACKGROUND: Long-term antiviral therapy has resulted in viral suppression and biochemical response in chronic hepatitis B, although the risk of hepatocellular carcinoma has not been abolished. The Page-B score could be useful to estimate the probability of HCC. AIMS: To analyze the effectiveness and safety of entecavir or tenofovir for more than 4 years and the usefulness of Page-B score in the real-world setting. METHODS: Analysis of Caucasian chronic hepatitis B subjects treated with entecavir or tenofovir from the prospective, multicenter database CIBERHEP. RESULTS: A total of 611 patients were enrolled: 187 received entecavir and 424 tenofovir. Most were men, mean age 50 years, 32% cirrhotic and 16.5% HBeAg-positive. Mean follow-up was 55 (entecavir) and 49 (tenofovir) months. >90% achieved HBV DNA <69 IU/mL and biochemical normalization by months 12 and 36, respectively. Cumulative HBeAg loss and anti-HBe seroconversion were achieved by 33.7 and 23.8%. Four patients lost HBsAg; three HBeAg-positive. Renal function remained stable on long-term follow-up. Fourteen (2.29%) developed HCC during follow-up all of them with baseline Page-B ≥10. Nine were diagnosed within the first 5 years of therapy. This contrasts with the 27 estimated by Page-B, a difference that highlights the importance of regular HCC surveillance even in patients with virological suppression. CONCLUSIONS: Entecavir and tenofovir achieved high biochemical and virological response. Renal function remained stable with both drugs. A Page-B cut-off ≥10 selected all patients at risk of HCC development.

Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine.

UNLABELLED: We investigated left ventricular diastolic dysfunction (LVDD) and its relationship with circulatory function and prognosis in cirrhosis with portal hypertension and normal creatinine. Conventional and tissue Doppler (TDI) echocardiography, systemic and hepatic hemodynamics, and the activity of endogenous vasoactive systems (AEVS) were measured prospectively in 80 patients. Plasma renin activity (PRA; >4 ng/mL/hour) was used as a surrogate of effective arterial blood volume. Patients were followed up for 12 months. Thirty-seven patients had LVDD (19 with grade 1 and 18 with grade 2). Left ventricular hypertrophy, left atrial volume, AEVS, and natriuretic peptide levels were significantly greater in patients with LVDD than without LVDD. Patients with grade 2 LVDD, compared to grade 1 LVDD and without LVDD, had significantly lower mean arterial pressure and higher Model for End-Stage Liver Disease (MELD) score, E-wave transmitral/early diastolic mitral annular velocity (E/e' ratio), cardiopulmonary pressures, PRA, and natriuretic peptide levels. Systolic and cardiac chronotropic function were significantly lower in patients with grade 2 LVDD than without LVDD. LVDD was more frequent in patients with ascites and increased PRA than patients without ascites or with ascites but normal PRA. Fourteen patients with LVDD developed hepatorenal syndrome (HRS) type 1 on follow-up. Survival was different according to degree of LVDD (without LVDD: 95%; grade 1 LVDD: 79%; grade 2 LVDD: 39%; P < 0.001). Independent predictive factors of mortality were MELD score and E/e' ratio. CONCLUSION: LVDD occurs simultaneously with other changes in cardiac structure and function and is associated with an impairment of effective arterial blood volume. LVDD is a sensitive marker of advanced cirrhosis, type 1 HRS development, and mortality.

A qualitative study of the relationships between residents and nursing homes nurses.

AIMS AND OBJECTIVES: To explore the relationships between residents and nurses in Spanish nursing homes. BACKGROUND: The nurses are one of the elements conditioning the life of the nursing home resident, influencing sense of security and mediating the relationships among residents. DESIGN: A qualitative phenomenological approach was applied. METHODS: An initial purposeful sampling of Spanish residents from nursing homes in the southern area of Madrid was conducted. The study included nursing home residents, aged 60 and over, with no cognitive impairment and who were able to communicate verbally in Spanish. Data were collected using unstructured and semi-structured interviews, researcher field notes, and personal diaries and letters from the residents. Data collection was concluded once theoretical saturation was reached, and data were analysed using the Giorgi proposal. RESULTS: Two main themes emerged: (1) 'meeting the nursing home nurses,' residents interact with nurses and establish relationships with them. The relationship is perceived as positive yet distant, and at times it is difficult to establish a closer relationship; and (2) 'managing relationships with the nursing home nurses,' residents learn to manage their relationships with the nurses, acquiring new behaviours to get closer to them, avoiding confrontations and helping each other. CONCLUSIONS: Residents manage their relationships with nurses using multiple behavioural strategies. They perceive these adjustments as necessary to facilitate daily life or avoid problems and/or confrontations. Deepening the relationships between residents and nurses could improve the management of nursing homes. RELEVANCE TO CLINICAL PRACTICE: Dialogue and active listening with residents must be incorporated into the daily nursing care. It should be given the same attention to all residents, with special attention to residents with cognitive and functional difficulties.

Combined intervention strategy for reversing iron-deficiency anaemia and deficiency in psychomotor development in chronic malnutrition.

Introduction: Background: chronic iron-deficiency anaemia in children has a negative impact on neuronal and cognitive development. Despite current knowledge on this subject, in Bolivia iron intake along the psychomotor development stimulation as part of a comprehensive rehabilitation process for children with severe chronic malnutrition is not yet used. Objective: to evaluate the effect of a neurorestorative diet, consisting of iron supplements and other micronutrients, along with psychomotor stimulation in preschool children with chronic malnutrition, iron-deficiency anaemia and severe psychomotor delay. Patients and methods: twenty-four children between 1 and 56 months of age admitted to the integral nutritional recovery centre (INRC), Paediatric Hospital of Cochabamba, Bolivia were included. A strategy of intervention was applied consisting of nutritional replenishment through the administration of elaborated meals prepared from local foods with high heme and non-heme iron concentration, added with vegetables plus the administration of micronutrient´s supplementation and the psychomotor stimulation. Anthropometric indices, psychomotor and biochemical parameters were measured at four times points, during the hospitalisation period. Results: at the beginning, the anthropometric and psychomotor parameters were decreased (between -2 and -3 z score and below 50 % respectively). Combined strategy intervention with iron and other micronutrients together photons produced significant changes between the evaluated time points, both in anthropometric and psychomotor parameters, although these changes were less than expected. Conclusions: the combined strategy used in this study allowed recovery from the anaemia and minimal growth due to the low birth weight or chronic malnutrition. However, the intervention was insufficient to achieve a complete recovery.

Introducción: Antecedentes: la anemia ferropénica crónica en niños tiene un gran impacto negativo en el desarrollo neuronal y cognitivo. A pesar del conocimiento actual sobre el tema, en Bolivia aún no se utiliza la ingesta de hierro más estimulación del desarrollo psicomotor como parte de un proceso de rehabilitación integral de niños con desnutrición crónica severa. Objetivo: evaluar el efecto de una dieta neuro reparadora, consistente en suplementos de hierro y otros micronutrientes, junto con estimulación psicomotora en niños preescolares con desnutrición crónica, anemia por deficiencia de hierro y retraso psicomotor severo. Pacientes y métodos: se incluyeron veinticuatro niños entre 1 y 56 meses de edad ingresados en el centro de recuperación nutricional integral (CRIN), Hospital Pediátrico de Cochabamba, Bolivia. Se aplicó una estrategia de intervención consistente en la reposición nutricional mediante la administración de comidas elaboradas a partir de alimentos locales con alta concentración de hierro hemo y no hemo, adicionados con vegetales más la administración de suplementación con micronutrientes y la estimulación psicomotora. Se midieron índices antropométricos, parámetros psicomotores y bioquímicos en cuatro momentos del tiempo de hospitalización. Resultados: al principio, los parámetros antropométricos y psicomotores estaban disminuidos (entre -2 y-3 puntuación z; y menor a 50 % respectivamente). La estrategia combinada de intervención con hierro y otros micronutrientes junto con fotones produjo cambios significativos entre los momentos evaluados, tanto en los parámetros antropométricos como psicomotores, aunque estos cambios fueron menores a lo esperado. Conclusiones: la estrategia combinada utilizada en este estudio permitió la recuperación de la anemia y un crecimiento mínimo debido al bajo peso al nacer o la desnutrición crónica. Sin embargo, la intervención fue insuficiente para lograr una recuperación completa.

Is the influence of nurse care practices and nursing home organization understood? A qualitative study.

AIM: To describe residents' experience of nursing home organization and nursing care practices in a region of Spain. BACKGROUND: Nursing home organization, nursing practices and rules within the institution may all influence residents' daily living and their perception on the quality of care provided. DESIGN: A qualitative approach was conducted, using purposeful and theoretical sampling. Data were collected from nursing home residents, following unstructured and semi-structured interviews, researcher field notes and residents' personal diaries and letters. Giorgi analysis was conducted. RESULTS: Two main themes emerged. (1) 'Following nursing home rules'. Norms may be seen as boundaries, especially for those residents who were independent before admission. (2) 'Prioritizing nursing care in residents'. Prioritizing the nursing care may limit the autonomy of residents because it does not meet their preferences and needs. CONCLUSION: Understanding the meaning of nursing home organization and nursing care practices with nursing home residents might provide deeper insight into their expectations. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing staff should have greater involvement in the nursing home organization, as well as in prioritizing the care provision based on resident's needs and preferences.

Risk factors for COVID-19 mortality in hospitalized patients in Bolivia.

Objectives: This study aimed to ascertain which factors are associated with higher risk of mortality among hospitalized COVID-19 Bolivian patients. Methods: This retrospective observational study assessed risk factors associated with mortality in patients (n = 549) hospitalized for SARS-CoV-2 infection in a Bolivian hospital between April 6, 2020, and August 18, 2022. Results: The results provide evidence of association between male sex (odds ratio [OR] = 1.6, 95% confidence interval [CI] 1.06-2.6), older age, 51-61 years-old (OR = 5.2, 95% CI 2.2-12.6), 62-70 years-old (OR = 8.7, 95% CI 3.7-20.5), >70 years-old (OR = 16.9, 95% CI 7.1-39.9), and blood group A (OR = 1.9, 95% CI: 1.1-3.4) with higher mortality risk. The strong association between mortality and relatively young age, may be due to high frequency of undiagnosed comorbidities. Vaccination was associated with a reduction in mortality only when time period of hospitalization was not adjusted for. Conclusion: Among hospitalized patients in Bolivia male sex, older age, and blood group A are associated with higher mortality risk. Mortality risk increased markedly from a relatively young age and decreased in parallel to the uptake of the vaccination program. However, the gradual reduction in mortality can also be due to improved patient management and changes in natural immunity and virulence of circulating strains as the pandemic progressed.

Morphological Assessment of Concomitant Lesions Detected in Goat Herds Naturally Infected with Paratuberculosis (Johne's Disease).

Paratuberculosis (PTB), caused by Mycobacterium avium subspecies paratuberculosis (MAP), causes significant financial losses in the ruminant industry. The aim of this study is to describe the concomitant pathological findings as well as PTB-induced lesions in 39 naturally infected goats (15 vaccinated and 24 non-vaccinated). All animals exhibited MAP-induced microscopic lesions affecting target organs, although only 62% of those were detected grossly. Mainly concomitant inflammatory pathologies were recognized affecting the hemolymphatic, respiratory and gastrointestinal systems. Non-vaccinated animals exhibited both moderate and marked granulomatous enteritis in contrast with vaccinated ones which presented mild intestinal affection. Our results demonstrate that non-vaccinated animals presented pneumonia in all age groups studied (from 12 up to >48 months old). A significantly higher prevalence of ileocecal valve PTB lesions was detected in non-vaccinated animals with pneumonic lesions (p = 0.027). Furthermore, a reduction of gastrointestinal non-PTB processes was described in vaccinated goats. In conclusion, a PTB infected goat herd can be affected by a wide range of concomitant pathologies, mostly inflammatory in origin. Anatomic pathology is of crucial importance for correct herd diagnosis and histopathology is an indispensable tool for lesion detection. Additionally, anti-MAP vaccination could have a beneficial effect on the reduction of respiratory and gastrointestinal non-PTB diseases.

Herpes virus infection associated with interstitial nephritis in a beaked whale (Mesoplodon densirostris).

BACKGROUND: The capacity for herpesvirus to cause disease in cetaceans is unclear and may be varied depending on the different conditions of individuals and between different species. Kidney pathology and intralesional virus-associated infection have been rarely reported in cetaceans. RESULT: On April 2004, an old adult male Blainville's beaked whale (Mesoplodon densirostris) 420 cm long with a poor body condition was stranded on Tenerife Island. During necropsy, no gross lesions were observed in the kidneys. However, membranous glomerulonephritis, multifocal interstitial lymphoplasmacytic nephritis and acute multifocal necrotizing tubulointerstitial nephritis with intranuclear inclusion bodies was diagnosed by histological analysis. Tissue samples were submitted for bacteriological analysis and molecular viral screening. CONCLUSION: A novel alpha herpesvirus associated with interstitial nephritis was identified in an old adult male Blainville's beaked whale (M. densirostris) with a poor body condition stranded in the Canary Islands. This report suggests that identification of herpesvirus infection could be used as a differential diagnosis for interstitial nephritis in cetaceans.

Cetaceans Humerus Radiodensity by CT: A Useful Technique Differentiating between Species, Ecophysiology, and Age.

Cetaceans are mammals that underwent a series of evolutionary adaptations to live in the aquatic environment, including morphological modifications of various anatomical structures of the skeleton and their bone mineral density (BMD); there are few studies on the latter. BMD is related to the radiodensity measured through computed tomography (CT) in Hounsfield units (HU). This work aimed to test and validate the usefulness of studying humeral bone radiodensity by CT of two cetacean species (the Atlantic spotted dolphin and the pygmy sperm whale) with different swimming and diving habits. The radiodensity was analysed at certain levels following a new protocol based on a review of previous studies. Humeral radiodensity values were related to four aspects: species, diving behaviour, swimming activity level, and age. We observed that the consistent differences in the radiodensity of the cortical bone of the distal epiphysis between animals of different life-history categories suggest that this bone portion could be particularly useful for future ontogenetic studies. Hence, this technique may be helpful in studying and comparing species with different ecophysiologies, particularly distinguishing between swimming and diving habits.

Morphological Structure of the Aortic Wall in Deep Diving Cetacean Species: Evidence for Diving Adaptation.

This study analyses the aortic wall structure in nine cetacean species with deep diving habits belonging to four Odontoceti families: Ziphiidae, Kogiidae, Physteridae, and Delphinidae. Samples of ascending, thoracic and abdominal aorta were processed for histological and morphometric studies. The elastic component was higher in the proximal aortic segments, and the muscular elements increased distally in all cases. Morphometric analyses showed that all families presented a decrease in the thickness of the arterial wall and the tunica media along the aorta. The reduction was dramatic between ascending and thoracic aorta in the Physeteridae specimens; meanwhile, the other three families showed a more uniform decrease between the ascending, thoracic and abdominal aorta. The decline was not correlated with a reduced elastic or lamellar unit thickness but with a loss of lamellar units. The organization of the elements in the aortic wall did not show essential modifications between the four families, resembling the structure described previously in the shallow and intermediate diving dolphins. Our findings support that the difference in the morphometric characteristics of the different segments in the aortic wall is likely related to the diving habit more than the absolutes values of any other parameter.

Pulmonary and Systemic Skeletal Muscle Embolism in a Beaked Whale with a Massive Trauma of Unknown Aetiology.

An adult female Sowerby's beaked whale was found floating dead in Hermigua (La Gomera, Canary Islands, Spain) on 7 December 2016. Severe traumas of unknown aetiology were attributed, and the gross and microscopic findings are consistent with catastrophic trauma as a cause of death. Rib fractures affected the intercostals, transverse thoracis skeletal muscles, and thoracic rete mirabile. Degenerated muscle fibres were extruded to flow into vascular and lymphatic vessels travelling to several anatomic locations into the thoracic cavity, including the lungs, where they occluded the small lumen of pulmonary microvasculature. A pulmonary and systemic skeletal muscle embolism was diagnosed, constituting the first description of this kind of embolism in an animal. The only previous description has been reported in a woman after peritoneal dialysis. Skeletal pulmonary embolism should be considered a valuable diagnostic for different types of trauma in vivo in wild animals. This is especially valuable when working with decomposed carcasses, as in those cases, it is not always feasible to assess other traumatic evidence.

Methodology and Neuromarkers for Cetaceans' Brains.

Cetacean brain sampling may be an arduous task due to the difficulty of collecting and histologically preparing such rare and large specimens. Thus, one of the main challenges of working with cetaceans' brains is to establish a valid methodology for an optimal manipulation and fixation of the brain tissue, which allows the samples to be viable for neuroanatomical and neuropathological studies. With this in view, we validated a methodology in order to preserve the quality of such large brains (neuroanatomy/neuropathology) and at the same time to obtain fresh brain samples for toxicological, virological, and microbiological analysis (neuropathology). A fixation protocol adapted to brains, of equal or even three times the size of human brains, was studied and tested. Finally, we investigated the usefulness of a panel of 20 antibodies (neuromarkers) associated with the normal structure and function of the brain, pathogens, age-related, and/or functional variations. The sampling protocol and some of the 20 neuromarkers have been thought to explore neurodegenerative diseases in these long-lived animals. To conclude, many of the typical measures used to evaluate neuropathological changes do not tell us if meaningful cellular changes have occurred. Having a wide panel of antibodies and histochemical techniques available allows for delving into the specific behavior of the neuronal population of the brain nuclei and to get a "fingerprint" of their real status.

Budd-Chiari-like pathology in dolphins.

Nearly two decades ago, pathologic examination results suggested that acoustic factors, such as mid-frequency active naval military sonar (MFAS) could be the cause of acute decompression-like sickness in stranded beaked whales. Acute systemic gas embolism in these whales was reported together with enigmatic cystic liver lesions (CLL), characterized by intrahepatic encapsulated gas-filled cysts, tentatively interpreted as "gas-bubble" lesions in various other cetacean species. Here we provide a pathologic reinterpretation of CLL in odontocetes. Among 1,200 cetaceans necropsied, CLL were only observed in four striped dolphins (Stenella coeruleoalba), with a low prevalence (2%, N = 179). Together, our data strongly suggest that CLL are the result of the combination of a pre-existing or concomitant hepatic vascular disorder superimposed and exacerbated by gas bubbles, and clearly differ from acute systemic gas embolism in stranded beaked whales that is linked to MFAS. Budd-Chiari-like syndrome in dolphins is hypothesized based on the present pathologic findings. Nonetheless, further researched is warranted to determine precise etiopathogenesis(es) and contributing factors for CLL in cetaceans.

Intralesional Meglumine Antimoniate: Safe, Feasible and Effective Therapy for Cutaneous Leishmaniasis in Bolivia.

The standard of care for cutaneous leishmaniasis includes the intramuscular/intravenous administration of pentavalent antimonials that are toxic and poorly tolerated. Primary health care usually lacks trained health staff for the diagnosis and treatment of leishmaniasis in Cochabamba Bolivia. Taking these aspects into account, a Bolivian consortium set out to explore the intralesional administration of meglumine antimoniate to treat cutaneous leishmaniasis during primary care under programmatic conditions. A four-step strategy consisting of clinical training for intralesional treatment and the promotion and periodic follow-up of health staff was carried out. The training process was applied in situ to personnel of nine primary health care centres. The intralesional treatment was applied five times every other day. Clinical follow-up after six-months of treatment showed a 77% healing proportion and 5% of therapeutic failure among 152 enrolled patients. The drug volume used in the intralesional procedure was on average 1.7 mL/ulcer treated. In conclusion, the strategy used was successful and effective, accomplishing a healing proportion similar to the long standardized treatment with a reduced time of administration, no severe side effects, and it is feasible to conduct by trained health staff. Our study supports the current PAHO/WHO recommendation for the intralesional administration of pentavalent antimonials for the treatment of cutaneous leishmaniasis.