Reactivación de la enfermedad de Chagas después de trasplante autólogo de progenitores hematopoyéticos. Reporte de caso y revisión de la literatura

Introduction:

Chagas disease is an endemic parasitic infection in Latin America transmitted by triatomines. It is associated with risk factors such as poverty and rurality. After acute infection, a third of patients will present target organ involvement (heart, digestive tract, central nervous system). The remaining two thirds remain asymptomatic throughout their life. Pharmacological immunosuppression breaks the balance between the immune system and the parasite, favoring its reactivation.

Clinical case:

We present the case of a 58-year-old man from a Colombian rural area with a diagnosis of multiple myeloma refractory to the first line of treatment who required a new chemotherapy scheme and consolidation with autologous stem cell transplant. During the post-transplant period, he suffered from febrile neutropenia. Initial microbiological studies were negative but the peripheral blood smear evidenced trypomastigotes in blood. With a diagnosis of acute Chagas disease in a post-transplant patient, benznidazole was started. The evolution of the patient was satisfactory.

Conclusions:

Positive serology prior to transplantation makes it necessary to rule out reactivation of the pathology in the setting of febrile neutropenia. More studies are required to determine tools for estimating the probability of reactivation of the disease and defining the best cost-risk-benefit relation for the prophylactic therapy.     

Grupos de riesgo citogenético de leucemia mieloide aguda pediátrica a partir del análisis de supervivencia en un hospital de referencia para cáncer en Perú

Introduction:

Acute myeloid leukemia is a heterogeneous disorder characterized by immature myeloid cell proliferation. Cytogenetic analysis has revealed the presence of chromosomal aberrations important to patient prognosis.

Objective:

To determine cytogenetic risk groups of pediatric patients with acute myeloid leukemia according to overall survival.

Materials and methods:

In this cross-sectional observational study, the clinical records of pediatric patients diagnosed with de novo acute myeloid leukemia admitted to the Instituto Nacional de Enfermedades Neoplásicas between 2001 and 2011 with cytogenetic analysis of bone marrow were included. Cytogenetic risk groups were established according to the criteria of the Medical Research Council. Overall survival curves were generated with the Kaplan-Meier method and compared using the Mantel-Cox test and Cox regression with the software R, version 3.3.2.

Results:

A total of 130 patients were included, 68 males (52.3%) and 62 females (47.7%), most of them with subtype M2 (33%). The average age was 7.7 years (range: 0-15 years).Chromosomal aberrations were observed in 60.8% of the patients, the most frequent of which was the translocation t(8;21). According to the overall survival analysis, two cytogenetic risk groups were established: favorable and unfavorable.

Conclusion:

Two groups of cytogenetic risk were determined: high (or unfavorable) and standard (favorable).     

Aspectos biomédicos y epidemiológicos del accidente ofídico en el departamento del Cauca,Colombia, 2009-2018

Introduction:

Snakebite is a relevant public health problem in Colombia, which is evident in epidemiological data at the Latin American level, where it ranks third place in the number of snakebites, after México and Brazil.

Objective:

To perform a retrospective analysis of snakebite accidents in the department of Cauca between 2009 and 2018 based on the data from the Public Health Surveillance System of Colombia reported to the Health Institute of Cauca.

Materials and methods:

We compiled and interpreted the information from the compulsory snakebite notification forms for the study’s 10 years period. We determined snakebite incidence and frequency according to the geographical distribution and the causal agents, and we analyzed related socioeconomic variables as well.

Results:

The records accounted for 1,653 cases and low mortality. Bothrops and Bothriechis species (77.43%) caused most of the accidents followed by Micrurus (2.9%). Most of the notifications came from the south of the department, and males and farmers were the most affected with bites mainly in the upper extremities. During poisoning, hemorrhagic manifestations predominated over necrosis and infections; serotherapy criteria were not always adequately applied, however, iatrogenic complications were not frequent.

Conclusions:

El Tambo and Piamonte municipalities, being male, and rural areas were the variables most affected by ophidism, mainly bothropic ophidism. The highest incidences occurred in the southern part of Cauca, in the Patía and Caquetá river basins.     

COVID-19 y salas de análisis del riesgo en salud pública en cuatro departamentos fronterizos de Colombia

Introduction:

Public health risk management in Colombia is led by the Instituto Nacional de Salud. In the face of the COVID-19 emergency, response actions centered on the implementation of risk analysis rooms and the strengthening of surveillance at points of entry into the country.

Objective:

To analyze the implementation and maintenance phases of the COVID-19 risk analysis rooms in four border departments of Colombia.

Materials and methods:

We conducted a qualitative study of public health risk analysis rooms for COVID-19. We reviewed the documentation and data generated from March to June, 2020, in the departments of Amazonas, Vichada, Guainía, and Putumayo. We did semi-structured interviews with key actors and analyzed the answers using the NVivo plus version 11 application in three cycles: open coding, identification of emerging categories, and modeling by analyzing the identified strengths and weaknesses.

Results:

We identified the components of the incident command structure and the relationships between the public health areas. Strengths were evidenced in the integration of the areas: the management of information in real time, the border surveillance and the capabilities of rapid response teams, while weaknesses appeared in planning, community surveillance, and risk communication processes.

Conclusions:

Risk analysis rooms constitute a joint effort at the national and local levels which has promoted the articulated participation of all actors in the analysis of information and the optimization of an organized response during the COVID-19 pandemic.     

Malformaciones esqueléticas y alteraciones del crecimiento en fetos de ratas con diabetes moderada

Introduction:

Currently, diabetes mellitus represents one of the medical conditions that more frequently complicates pregnancy affecting the fetus''s growth and development.

Objective:

To determine the skeletal malformations and growth alterations in fetuses of diabetic Wistar rats.

Materials and methods:

We used a neonatally streptozotocin-induced mild diabetes model (STZ 100 mg/kg body weight - subcutaneously) in Wistar rats. In adulthood, healthy and diabetic rats were mated with healthy males of the same age and strain. On day 20 of gestation, a cesarean was performed under anesthesia. Fetuses were removed, weighed, and classified as small (SPA), adequate (APA), and large (LPA) for the gestational age. Selected fetuses were processed for skeletal anomaly and ossification sites analysis.

Results:

In the offspring of diabetic rats, there was a higher percentage of fetuses classified as small or large and a lower percentage of fetuses with adequate weight; the fetal weight mean was lower and there were fewer sites of ossification.Alterations were observed in the ossification of the skull, sternum, spine, ribs and fore and hind limbs; and also, there was a direct correlation between fetal weight and ossification degree There were congenital malformations associated with fusion and bifurcation of the ribs, as well as changes indicative of hydrocephaly, such as the dome shape of the skull, a wide distance between parietals, and the width of the anterior and posterior fontanels.

Conclusion:

Moderate diabetes during pregnancy alters fetal growth and development with macrosomia and intrauterine growth restriction, as well as skeletal malformations.     

Manifestaciones mucocutáneas y su relación con el recuento de linfocitos T CD4 en pacientes infectados con el virus de inmunodeficiencia humana hospitalizados en Medellín,Colombia

Introduction.

About 80-95% of patients infected with the human immunodeficiency virus (HIV) develop skin manifestations, which are markers of the patients’ immune status. Objective. To describe the dermatologic manifestations and the clinical and sociodemographic factors of hospitalized patients diagnosed with HIV and their correlation with CD4 T-lymphocyte count.

Materials and methods.

We conducted an observational, cross-sectional, and retrospective study of the medical records of 227 adult patients with HIV diagnosis evaluated by dermatology in a hospital in Medellín, Colombia.

Results.

We included 227 patient records with 433 dermatologic manifestations, 64.4% of them infectious. The most frequent manifestations were oral candidiasis, condylomata acuminata, and drug reactions. Moreover, a statistically significant relationship was found between disseminated herpes zoster virus and secondary syphilis with a CD4 count between 200-499 cells/mm³ (p=0.04 and 0.028, respectively). There was also a statistically significant relationship between oral candidiasis and a CD4 count of less than 100 cells/ mm³ (p=0.008).

Conclusions.

The relationship between disseminated herpes zoster with CD4 between 200-499 cells/mm³ suggests that, despite having high CD4 counts, severe forms of the disease may occur due to possible T-cell dysfunction and depletion of the immune system. Additionally, the relationship between oral candidiasis and CD4 less than 100 cells/mm³ indicates the potential role of oral candidiasis as an essential marker of weakened immune status in HIV patients.     

Clima de aprendizaje y enganche al trabajo del residente clínico: relación con la autodeterminación humana

Introduction:

The learning climate is a factor associated with the clinical resident’s engagement in work activities and the improvement of students’ well-being in the workplace through their self-determination during clinical rotation.

Objective:

To determine the relationship between the learning climate measured with the D-RECT 35 scale and residents’ self-determination and commitment to work using the UWES 17 scale.

Materials and methods:

We conducted a cross-sectional correlational study with residents of surgical medical specialties in clinical rotation at the practice site and who completed the measurement questionnaires.

Results:

We evaluated 188 residents of clinical specialties. The median of the results in the learning climate scale was 3.9/5.0; in the self-determination scale, 4.86/7.0, and in the job engagement scale, 5.0/6.0. The learning climate was considered adequate and a positive relationship was found with self-determination and the residents’ attachment to their activities; these correlations were statistically significant.

Conclusions:

Adequate learning climates are positively related to the ability to engage in work activities and the self-determination of clinical residents as they favor collaborative work and access to supervision generating greater autonomy and more enthusiasm and dedication to assigned activities. This can drive improvements in educational programs in clinical departments and translate into safer patient care.     

Detección molecular de Toxoplasma gondii en carnes para consumo humano en Ibagué, Colombia

Introduction:

Toxoplasma gondii is a parasite with great zoonotic potential. It can infect a broad range of warm-blooded hosts (including livestock) and causes significant losses in the industry. In humans, it has been described as a pathogen in immunosuppressed people, it affects the fetus development in congenital infections, and is associated with various behavioral disorders in healthy people. Humans can acquire T. gondii by consuming undercooked, contaminated meat.

Objective:

To determine T. gondii positivity (currently unknown) in meat for human consumption (i.e., beef, chicken, and pork) in the city of Ibague, Colombia.

Materials and methods:

We used conventional nested PCR and the T. gondii B1 gene sequence as amplification target. We collected samples of meat (N=186) sold in the urban area of Ibagué (62 beef, 62 chicken, and 62 pork samples) and determined the T. gondii positivity percentage for each type of meat.

Results:

The study found an average of 18.8% positivity for all meat samples, pork having the highest percentage (22.5%; 14/62), followed by beef (19.3%; 12/62) and chicken (14.5%; 9/62). The best-amplified products were sequenced by macrogen and aligned with the B1 gene sequences in GenBank, thereby confirming their identity.

Conclusions:

This is the first study of T. gondii prevalence in meat for human consumption carried out in the city of Ibagué and the department of Tolima. All three types of meat sampled represent a risk for local human infection.     

Análisis del impacto presupuestal en Colombia de la prueba de HPV con genotipificación comparada con la citología

Introduction:

The detection of the human papillomavirus (HPV) through the combination of the HPV test and other techniques such as cytology has impacted the detection and timely treatment of lesions associated with cervical cancer.

Objective:

To estimate the budgetary impact of the strategy of early detection of HPV with DNA test genotyping with reflex cytology versus conventional cytology in women aged 30 to 65 years attending the cervical cancer screening program at a health benefit managing entity in Colombia.

Materials and methods:

Using a decision tree and a Markov model, the clinical implications and direct costs of screening, diagnosis, and treatment were estimated in a cohort of women. The analysis considered two screening cycles and their annual costs. The data on the prevalence of clinical results and the costs were taken from the health managing entity. The information on the progression, persistence, and regression of the health states were taken from the ATHENA study.

Results:

The screening scheme with the HPV test, genotyping, and reflex cytology compared to conventional cytology was cost-saving. The average cost per screening cycle with the HPV test was estimated at COP $ 129,201,363 and with cytology at COP $ 186,309,952, i.e., a saving of COP $ 57,108,589 (30.7%).

Conclusion:

The implementation of the screening strategy under evaluation suggests prospective savings derived from the early detection of health states associated with the development of cervical cancer.     

Complicaciones hospitalarias en una unidad geriátrica de agudos

Introduction:

In-hospital complications frequently occur in hospitalized people over 65 worsening their clinical outcomes. There are, however, few studies on the factors associated with in-hospital complications in elderly patient care.

Objective:

To evaluate factors associated with in-hospital complications in a geriatric acute care unit in Bogotá, Colombia

Materials and methods:

We conducted an analytical, observational, retrospective study in a cohort of 1,657 patients over 65 years of age who received care in the geriatric unit of a high complexity hospital in Bogotá, Colombia. The dependent variable was in-hospital complications and the independent variables, the degree of functional dependence on admission, dementia, nutritional status, social support, comorbidity, and polypharmacy. We used Poisson’s linear regression model to identify associated variables.

Results:

The bivariate analysis showed that functional dependence (PR=2.092, p≤0.001) and malnutrition (PR=2.850, p≤0.001) were associated with a higher rate of hospital-acquired infection. In the multivariate analysis, functional dependence (PR=1.931, p=0.003) and malnutrition (PR=2.502, p=0.002) remained independent factors for in-hospital complications.

Conclusion:

In acute care centers, integral assessment at admission to identify functional dependence and malnutrition predicts in-hospital complications.     

Factores que afectan la cobertura del programa de tuberculosis en el primer nivel de atención en Honduras

Introduction:

There is a global consensus that early diagnosis and treatment of tuberculosis (TB) can accelerate its control and mitigate its consequences. The gradual increase in the TB mortality rate from 2014 to 2018 in Honduras, the reform of the health system in 2014, and the partial implementation of the “End TB” strategy motivated this study.

Objective:

To analyze barriers to and facilitators of diagnosis and treatment affecting the national TB program coverage using data from 2015 to 2019 and provide tools for the effective implementation of the “End TB” strategy in San Pedro Sula, Honduras.

Materials and methods:

This was an explanatory sequential mixed-methods study on smear-positive pulmonary TB patients older than 18 years of age. TB notification sheets and medical records from two primary health care facilities were reviewed. Semistructured interviews were conducted with health care providers, patients, and their families.

Results:

A total of 74.6% of the cases (297/398) did not receive a timely diagnosis; 62.3% (185/297) were men, 80.8% (240/297) were adults, 53.7% (108/297) had less than high school education, 49.2% (123/297) had some occupation, and 98.2% of participants received timely treatment. Identified barriers included low socioeconomic conditions, lack of coordination between public and private health systems, and boundaries set by gangs. Identified facilitators included good care and attitude of the health care personnel and the availability of medications.

Conclusions:

The lack of opportunity to diagnose the disease affected the coverage of the national TB program due to cultural and health care barriers.     

Factores asociados con la presencia de endoparásitos y ectoparásitos en perros domiciliados de la zona metropolitana de Toluca,México

Introduction:

Endoparasites and ectoparasites in dogs are of global distribution. The close relationship between dogs and man implies a risk for the transmission of zoonotic parasites. Therefore, it is necessary to determine the parasites hosted by dogs in specific areas and the factors associated with their presence.

Objectives:

To identify and to estimate the prevalence of endoparasites and ectoparasites in domiciled dogs in the Metropolitan area of Toluca, México, and the prevalence of D. caninum in fleas of the genus Ctenocephalides spp.

Materials and methods:

We collected samples from 402 domiciled dogs in four reference hospitals in the area in Toluca. We diagnosed endoparasites using direct smear, flotation, and sedimentation techniques and we performed the taxonomic identification of ectoparasites. Finally, the molecular diagnosis of D. caninum in fleas was made using the polymerase chain reaction technique (PCR).

Results:

A total of 37.2% of dogs were positive for endoparasites; the genera or species identified were Toxocara spp., Giardia spp., Ancylostoma spp., Cystoisospora spp., D. caninum, Taenia spp., and Trichuris vulpis; the prevalence of ectoparasites was 13.13%. We identified fleas of the species Ctenocephalides felis, Ctenocephalides canis; only one animal was parasitized with Rhipicephalus sanguineus and another one with Trichodectes canis; the prevalence of D. caninum in fleas was 9.5%.

Conclusion:

The prevalence of endoparasites was 37.2% while that of ectoparasites was 13.1%; this is the first analysis of endoparasites and ectoparasites conducted in the same population of dogs in México together with the molecular diagnosis of D. caninum in fleas.     

Expresión de los componentes del inflamasoma y su relación con los marcadores de riesgo cardiovascular en personas con infección por HIV-1

Introduction:

HIV-1 infection induces a chronic inflammatory state in which inflammasomes participate. The increase in inflammatory parameters is higher in individuals with active viral replication (progressors) than in those with viral control (HIV-1 controllers). This process triggers metabolic alterations related to changes in the lipid profile, which could increase the risk of cardiovascular events, even in patients with antiretroviral therapy.

Objective:

To establish whether there was a correlation between the expression of inflammasome components and cardiovascular risk markers in HIV-1 controllers and progressors with or without antiretroviral therapy.

Materials and methods:

We studied 13 HIV-1 controllers and 40 progressors (19 without antiretroviral therapy and 31 with therapy) and evaluated in them classic markers of cardiovascular risk. Using RT-PCR we quantified the expression of inflammasome components (NLRP1, NLRP3, NLRC4, AIM2, ASC, IL-1β, IL-18, and caspase-1), TLR2, TLR4, TGF-β, and IL-10.

Results:

Progressors with antiretroviral therapy had an increased expression of TLR2, TLR4, and IL-18 compared to HIV-1 controllers. They also showed high levels of triglycerides and VLDL, which positively correlated with the expression of the inflammasome components NLRP1, NLRP3, NLRC4, AIM2, ASC, and caspase-1.

Conclusion:

Progressors receiving antiretroviral therapy exhibited an increased expression of the inflammasome components, which correlated with the levels of triglycerides and VLDL. This supports the role of inflammation in cardiovascular risk during HIV-1 infection.     

Membrana de cáscara de huevo para la curación de heridas superficiales en ratones

Introduction:

Eggshell membranes offer beneficial properties for tissue regeneration and their biomedical applications are important.

Objective:

To demonstrate the effectiveness of hen unfertilized eggshell membranes in the treatment of superficial open wounds in mice compared to the conventional procedure.

Materials and methods:

15-mm linear wounds were made on the back of 10 male CF-1 mice. The mice were divided into four groups. One group did not receive any treatment and the other three were given conventional treatment, eggshell membranes dressing, and eggshell membranes powder. The evolution of the wounds was registered by photographs.We measured wounds length and healing time and calculated the length reduction rate and the percentage of healing. The healing percentages were analyzed by ANOVA with a post hoc Dunnett test (p<0.05).

Results:

The treatments with eggshell membranes and membrane powder had a wound- length reduction rate of 1.009 and 1.020 mm/day, greater than the conventional treatment, of 0.852 mm/day, and a healing time of 12 days, i.e., less than the 16-day conventional treatment. The statistical analysis showed significant differences between eggshell membrane treatments and the conventional treatment.

Conclusions:

Eggshell membrane dressing and eggshell membrane powder applied to open superficial wounds in mice were more effective than the conventional treatment in regenerating injured tissue in mice.     

Malaria importada en población pediátrica de Alicante,España (1994-2019)

Introduction:

In recent years there has been an increase in imported malaria among children in whom it is a potentially serious and fatal disease.

Objective:

To describe the incidence and the clinical and epidemiological characteristics of malaria in children diagnosed in Alicante, Spain, over a 26-year period.

Materials and methods:

We conducted an observational retrospective study of malaria in children aged under 15 years diagnosed at the Alicante General University Hospital from 1994 to 2019.

Results:

Twenty-four cases were registered over the study period. The frequency of cases increased from 2 over the first five years to 11 in the last five years. The median age of the children was 6 years (interquartile range: 3-8); 91.6% came from sub-Saharan Africa. Over half (n=15, 62.5%) were children born in Spain to immigrant parents visiting friends and relatives (VFR); just one (6.7%) had received antimalarial chemoprophylaxis.The most frequent clinical signs were fever (86.9%), hepatosplenomegaly (70.8%), and anemia (70.8%). Plasmodium falciparum was the most frequently identified species (83.3%, n=20). The most common treatment was oral piperaquine/dihydroartemisinin (41.6%, n=10) with favorable outcomes in all cases.

Conclusions:

Imported childhood malaria shows an increasing incidence and a nonspecific clinical presentation. Professional awareness of this disease and a high degree of clinical suspicion are needed for the early initiation of treatment. Pre-travel preventive measures should be promoted when appropriate.     

Importancia de la determinación de variantes en el número de copias en neonatos con aneuploidías autosómicas

Introduction:

Aneuploidies are frequent genetic disorders in clinical practice. However, little is known about other genetic variants that may influence the final phenotype.

Objective:

To determine the variations in the number of copies and regions with homozygosity greater than 0.5% or larger than 10 Mb in newborns with autosomal aneuploidies.

Materials and methods:

We performed a chromosomal microarray analysis on newborns with autosomal aneuploidies (n=7), trisomy 21 (n=5), and trisomy 18 (n=2) evaluated at the Hospital Antonio Lorena and Hospital Regional of Cusco, Perú, during 2018.

Results:

We found pathogenic and probably pathogenic variants in the number of copies in other genomic regions different to chromosomes 21 or 18 in two neonates. Additionally, we found two variants bigger than 500 kpb of unknown pathogenicity.

Conclusions:

Although the number of analyzed individuals was small, it is important to highlight that we found other variants in the number of copies that have been described in association with neurodevelopmental disorders, congenital anomalies, deafness, and short/ tall stature, among others, in almost half of them, which will probably impact the phenotype negatively in patients with aneuploidies.