El binomio causalidad-azar: ¿principio explicativo del conocimiento científico en medicina? / The causality-chance binomial: explanatory principle of scientific knowledge in medicine?

Resumen Este ensayo cuestiona las verdades matemáticas como principio explicativo del conocimiento científico médico. Se analiza, en primer término, el concepto de normalidad actual basado en una distribución de valores probabilísticos, y se destacan sus limitaciones y equívocos para captar la complejidad de la condición humana. Los sistemas cerrados (juegos de azar), origen de la teoría de las probabilidades y del binomio causalidad-azar, se comparan con los sistemas abiertos propios del proceso vital y se argumentan sus diferencias extremas. Se destaca el despropósito de depositar en el binomio causalidad-azar el significado de asociaciones entre sucesos propios de la complejidad de la vida humana en salud y enfermedad. Se confrontan las características de la causalidad mecanicista (puntual, lineal, unidireccional, homogénea y fija), que equipara al organismo con una máquina y es la única explicación científica aceptada del acontecer de la vida humana, con las de la causalidad contextual (difusa, heterogénea, jerárquica, multidireccional y cambiante), que especifica diversos órdenes causales interactuantes que dan forma a la condición humana: el histórico, el social, el político, el económico, el cultural o el biológico, que representa una mirada escrutadora y penetrante de la complejidad de los seres humanos. Se concluye la superioridad de la causalidad contextual sobre la mecanicista, que abre posibilidades explicativas de sucesos vitales que suelen arrumbarse como «efectos del azar¼. Esta aproximación integradora a la complejidad humana puede enriquecer y fortalecer el método clínico, hoy degradado y en riesgo de extinción.

Abstract This essay questions mathematical truths as an explanatory principle of the medical scientific knowledge. It analyzes, in the first place, the current concept of normality based on a distribution of probabilistic values and its limitations and mistakes to capture the complexity of the human condition are highlighted. The closed systems (gambling) origin of the theory of probabilities and the binomial causality-chance are compared with open systems typical of the complexity of the vital process, and their extreme differences are argued. The nonsense of depositing in the causality-chance binomial the meaning of associations between events typical of the complexity of human life in health and disease is highlighted. The characteristics of mechanistic causality (punctual, homogeneous, linear, unidirectional and fixed), which equates the organism with a machine and is the only accepted scientific explanation of events of human life, are confronted with those of contextual causality (diffuse, heterogeneous, hierarchical, multidirectional and changing), which specifies various interacting causal orders that shape of human condition: the historical, the social, the political, the economical, the cultural or the biological that represents a scrutinizing and penetrating look at the complexity of human beings. It concludes the superiority of contextual causality over mechanistic causality that opens up explanatory possibilities of the vital events that are usually put away as "effects of chance". This integrative approach to the human complexity can enrich and strengthen the clinical method that is now degraded and at risk of extinction.

Blood parasite load by qPCR as therapeutic monitoring in visceral leishmaniasis patients in Brazil: a case series study

ABSTRACT Background: This study aimed to describe the kinetics of Leishmania parasite load determined using kinetoplast DNA (kDNA)-based quantitative polymerase chain reaction (qPCR) in visceral leishmaniasis (VL) patients. Methods: Parasite load in blood was assessed by qPCR at five time points, up to 12 months post-diagnosis. Sixteen patients were followed up. Results: A significant reduction in the parasite load was observed after treatment (P < 0.0001). One patient had an increased parasite load 3 months post-treatment and relapsed clinically at month six. Conclusions: We have described the use of kDNA-based qPCR in the post-treatment follow-up of VL cases.

What else in times of COVID-19? The role of minimally invasive autopsy for the differential diagnosis of acute respiratory failure in a case of kala-azar

ABSTRACT Visceral leishmaniasis (VL) is a chronic vector-borne zoonotic disease caused by trypanosomatids, considered endemic in 98 countries, mainly associated with poverty. About 50,000-90,000 cases of VL occur annually worldwide, and Brazil has the second largest number of cases in the world. The clinical picture of VL is fever, hepatosplenomegaly, and pancytopenia, progressing to death in 90% of cases due to secondary infections and multi-organ failure, if left untreated. We describe the case of a 25-year-old female who lived in the metropolitan area of Sao Paulo, who had recently taken touristic trips to several rural areas in Southeastern Brazil and was diagnosed post-mortem. During the hospitalization in a hospital reference for the treatment of COVID-19, the patient developed acute respiratory failure, with chest radiographic changes, and died due to refractory shock. The ultrasound-guided minimally invasive autopsy diagnosed VL (macrophages containing amastigote forms of Leishmania in the spleen, liver and bone marrow), as well as pneumonia and bloodstream infection by gram-negative bacilli.

La venganza como rechazo de la responsabilidad. la ira de Dios / La muerte lenta de Luciana B / Revenge as rejection of responsibility

Dos novelas sucesivas del escritor y matemático argentino Guillermo Martínez, "Crímenes imperceptibles" (2004) y "La muerte lenta de Luciana B." (2007) fueron llevadas al cine. En ambas se abordan las categorías lógico-matemáticas de azar y necesidad, permitiendo abrir una brecha entre ellas para conjeturar una hipótesis clínica sobre la responsabilidad subjetiva de los personajes. Este trabajo pone el foco en la versión "La ira de Dios" (Schindel, 2022), introduciendo la cuestión de las leyes del azar, la respuesta de un sujeto a ese encuentro con el azar, para concluir con la venganza como rechazo de la responsabilidad.

Two successive novels by Argentine writer and mathematician Guillermo Martínez, "Imperceptible Crimes" (2004) and "The Slow Death of Luciana B." (2007) were made into movies. In both, the logical-mathematical categories of chance and necessity are addressed, allowing a gap to be opened between them to conjecture a clinical hypothesis about the subjective responsibility of the characters. This work focuses on the version "The Wrath of God" (Schindel, 2022), introducing the question of the laws of chance, the response of a subject to that encounter with chance, to conclude with revenge as a rejection of the responsibility

Mutagénesis inducida en plantas de Solanum betaceum Cav. mediante el uso de dietil sulfato (DES) / Induced mutagenesis in Solanum betaceum Cav. plants by the use of diethyl sulphate (DES)

RESUMEN La materia prima del fitomejoramiento es la variabilidad genética, que se presenta baja, en especies en proceso de domesticación, que no han sido sometidas a selección, como en Solanum betaceum. Una de las tecnologías para incrementar la variabilidad genética es la inducción de mutagénesis. El objetivo del estudio fue evaluar, a través de marcadores RAMs, las variaciones moleculares presentes en plántulas de S. betaceum, provenientes de semillas sometidas a diferentes concentraciones del agente mutante dietil sulfato (DES). Los loci polimórficos oscilaron entre 87,5 y 100 % y el número de alelos efectivos (Ne), entre 1,0 y 1,99. Los loci más polimórficos se observaron en TG, AG, ACA y CGA, que mostraron una heterosis media insesgada entre 0,34 y 0,51, que permite establecer que estos marcadores sean útiles para obtener mayor discriminación entre mutantes en S. betaceum. Las distancias genéticas oscilaron entre 0,30 y 1,0. El 81,28 % de estos registros se dieron entre 0,60 y 0,90; esto revela bajo nivel de cambios, debido al DES. Estos pequeños cambios contribuyeron a enriquecer la variabilidad genética de la muestra tratada con DES. Los marcadores RAMs fueron útiles para detectar cambios entre plantas provenientes de semillas tratadas con DES y plantas normales. La variabilidad genética entre tratamientos con DES fueron más altos que tratamientos sin DES. Las similitudes genéticas fueron bajas entre plantas tratadas y no tratadas y fueron altas, entre no tratadas. Los cambios producidos por DES fueron de baja magnitud; sin embargo, produjeron cambios en los niveles de variabilidad genética.

ABSTRACT The raw material for plant breeding is genetic variability, which is low in species in the process of domestication that have not been subjected to selection, as is the case with Solanum betaceum. One of the technologies to increase genetic variability is mutagenesis induction. The objective was to evaluate, through RAMs markers, the molecular variations present in S. betaceum seedlings from seeds previously subjected to different concentrations of the mutant agent diethyl sulfate (DES). The polymorphic loci ranged from 87.5 to 100%, number of effective alleles (Ne) between 1.0 and 1.99. The most polymorphic loci were observed in TG, AG, ACA, and CGA, which showed a mean unbiased heterosis between 0.34 and 0.51 with an average of 0.44, which allows establishing that these markers are useful to obtain greater discrimination between mutants in S. betaceum. Genetic distances ranged from 0.30 to 1.0. The 81.28% of these records were between 0.60 and 0.90. This reveals a low level of changes due to DES. These small changes contribute to enriching the genetic variability of the DES-treated sample. The RAMs markers were useful for detecting changes between plants from DES treated seeds and normal plants. Genetic variability between DES treatments was higher than non-DES treatments. Genetic similarities were low between treated and untreated plants and were high among untreated plants. The changes produced by DES were of low magnitude, however, they produced changes in the levels of genetic variability.

Liposomal amphotericin B is more effective in polymorphic lesions of post kala-azar dermal leishmaniasis

Background: Post kala-azar dermal leishmaniasis (PKDL) is thought to be the reservoir of infection for visceral leishmaniasis in South Asia. The development of strategies for the diagnosis and treatment of PKDL are important for the implementation of the visceral leishmaniasis elimination program. Aims: Liposomal amphotericin B (L-AMB) has been an overwhelming success in the treatment of visceral leishmaniasis. However, the empirical three-week regimen of L-AMB proposed for PKDL was shown to be inadequate, especially in the macular variant. This study aimed to delineate response of the different variants of PKDL to L-AMB. Methods: Skin biopsies were collected from PKDL cases at disease presentation and upon completion of treatment with L-AMB. Parasite DNA was detected by Internal Transcribed Spacer-1 PCR (ITS-1 PCR) and quantified by amplification of parasite kDNA. CD68 + macrophages were estimated in tissue sections by immunohistochemistry. Results: Treatment with L-AMB decreased the parasite load by 97% in polymorphic cases but only by 45% in macular cases. The median parasite load (89965 vs 5445 parasites/μg of genomic DNA) as well as infiltration by CD68+ cells before treatment was much greater in the polymorphic cases. Limitations: Although monitoring of the parasite load for 12 months post-treatment would have been ideal, this was not possible owing to logistical issues as well as the invasive nature of biopsy collection procedure. Conclusion: A dramatic decrease in the parasite burden was noted in patients with polymorphic lesions. Although patients with macular disease also had a decrease in parasite burden, this was not as marked as in the polymorphic cases. There was also a significantly greater infiltration of CD68 + macrophages in polymorphic PKDL before therapy

A rare case of pancytopenia due to leishmaniasis - A case report

Visceral Leishmaniasis (VL) or Kala Azar is a chronic protozoal infectious disease caused by the Leishmania donovani complex which causes a variety of hematologic manifestations. It is manifested by fever, hepatosplenomegaly, weight loss, pancytopenia and hypergammaglobinemia. In India it is mainly seen in the states of Bihar and West Bengal. Patients with VL can present to the hematologist for variety of hematological presentation even before the diagnosis of VL is made. Anemia is the most common hematological manifestation of VL. VL may also be associated with leucopenia, thrombocytopenia, pancytopenia, hemophagocytosis and disseminated intravascular coagulation. Hematological improvement is noted with the treatment for VL. Relapses are rare. In this case report, we present a rare case of leishmaniasis with pancytopenia, which is rare in Hyderabad, Telangana, India

Analysis on the diagnosis of 47 cases of Kala-azar in Gansu Province / 中华地方病学杂志

Objective:To learn about the diagnosis of Kala-azar in Gansu Province, and to provide a basis for formulating corresponding prevention and control measures.Methods:The data (age, gender, onset time, diagnosis time, diagnosis unit, etc.) of Kala-azar cases in Gansu Province from January to December 2018 were collected from the China Disease Prevention and Control Information System. At the same time, a case report questionnaire was designed to collect information such as the initial diagnosis unit and initial diagnosis results; a diagnosis and treatment questionnaire of medical institutions was designed to investigate the knowledge of diagnosis and treatment of Kala-azar (main epidemic areas, main symptoms, common detection methods, main therapeutic drugs and drug use methods) among doctors in county and township hospitals, and the pass rate and awareness rate were calculated.Results:A total of 47 Kala-azar cases were included, with an average age of 17 years. Among them, men accounted for 57.45% (27/47) and women accounted for 42.55% (20/47). Among the initial diagnosis hospitals, the proportions of provincial, municipal, county and township hospitals were 2.13% (1/47), 12.77% (6/47), 42.55% (20/47) and 42.55% (20/47), respectively; among the hospitals with confirmed cases, provincial, municipal, county and township hospitals accounted for 48.94% (23/47), 31.91% (15/47), 19.15% (9/47) and 0 (0/47), respectively. The shortest time from initial diagnosis to diagnosis of the 47 cases was 1 day; the longest was 124 days, with an average of 27 days. A total of 96 valid questionnaires were collected from doctors in county and township hospitals, of which 30 scored 60 points or above, and the pass rate was 31.25% (30/96). Among the five surveys on diagnosis and treatment knowledge of Kala-azar, doctors in county and township hospitals had the highest awareness rate of "main therapeutic drugs", which was 77.08% (74/96), and there was significant difference (χ 2 = 9.86, P = 0.002) between doctors in the two-level hospitals [90.00% (45/50), 63.04% (29/46)]. The awareness rate of "main symptoms" was the lowest, which was 25.00% (24/96), and there was significant difference (χ 2 = 4.51, P = 0.034) between doctors in the two-level hospitals [34.00% (17/50), 15.22% (7/46)]. Conclusions:The awareness rate of diagnosis and treatment knowledge of Kala-azar among doctors in county and township hospitals in Gansu Province is low, and their diagnostic ability is weak. It is recommended to strengthen the training of clinicians, improve the timeliness of diagnosis, and achieve early diagnosis, early report and early treatment of Kala-azar.

Liposomal amphotericin B was successfully used to treat a case of kala-azar with prominent renal damage / 中华地方病学杂志

Objective:To analyze the diagnosis and treatment process of a kala-azar case with prominent renal damage treated with liposomal amphotericin B (L-AmB), and to provide theoretical basis for clinical diagnosis and treatment.Methods:A retrospective analysis method was used to analyze the clinical data, diagnosis and treatment process and laboratory test results of a case of kala-azar with prominent renal damage who presented to the Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University on June 30, 2020.Results:A 56-year-old female patient presented with fever (the highest body temperature was 38.2 ℃) and chills. The results of clinical laboratory tests showed that hemoglobin(55 g/L), red blood cell (2.68 × 10 12/L), white blood cell (1.06 × 10 9/L) and platelet count (8.00 × 10 9/L) were decreased, renal function showed abnormal blood urea nitrogen and creatinine, spleen enlargement, etc., and the diagnosis of kala-azar combined with kidney insufficiency was confirmed by blood and bone marrow Leishmania spp. examination. With the assistance of continuous renal replacement therapy (CRRT), after a small dose of L-AmB was initially and slowly increased and maintained at a low dose, the patient's body temperature was normal, the blood routine showed that the three-lineage cells gradually increased, and the renal function showed blood urea nitrogen and creatinine decreased gradually the spleen was retracted; no recurrence was found at follow-up after 6 months, and renal function returned to normal. Conclusions:L-AmB is safe and effective in the treatment of kala-azar with renal damage as the prominent manifestation. The patient is not only cured by etiology, but is also recovered renal function.

Acute uveitis: A rare adverse effect of miltefosine in the treatment of post-kala-azar dermal leishmaniasis

Abstract Post-kala-azar dermal leishmaniasis is a skin disorder occurring in 5-10% of visceral leishmaniasis patients after treatment with miltefosine,the first-line drug for this skin disorder. We reported a case of acute anterior uveitis,a rare adverse effect, experienced by a patient treated with miltefosine for post-kala-azar dermal leishmaniasis. This adverse effect developed after 15 days of miltefosine consumption, and the patient himself discontinued the treatment. The ophthalmic complication was completely resolved with antibiotics and steroid eye drops. After recovery from the ophthalmic complication, the patient was successfully treated with liposomal amphotericin B for the skin lesions.

Nutritional status and vitamin A and zinc levels in patients with kala-azar in Piauí, Brazil

Abstract INTRODUCTION: Malnutrition and kala-azar (or visceral leishmaniasis) are significant public health problems in different parts of the world. Immunity and susceptibility to infectious and parasitic diseases are directly linked to the host's nutritional state, but little is known about the interaction between nutrition and kala-azar. This study aimed to evaluate nutritional status with kala-azar and correlate these findings with the clinical and laboratory manifestations of the disease, and zinc and retinol levels. METHODS: This was a cross-sectional study of 139 patients with kala-azar. Nutritional status classification was performed according to international recommendations. Parametric or nonparametric tests were applied whenever indicated in a two-sided test with a 5% significance level. RESULTS: Weight loss and malnutrition were more frequent in adults. Body mass index-for-age, fat area of the arm, and upper arm muscle area were significantly associated with probability of death. The presence of human immunodeficiency virus, hepatomegaly, and splenomegaly was correlated with nutritional assessment. Blood leukocyte and lymphocyte, serum creatine, and vitamin A levels were significantly higher in adult men. Vitamin A levels were highly associated with the level of hemoglobin and C-reactive protein (CRP) in multivariate analysis. All patients had reduced plasma zinc levels, but this finding had no association with the outcome variables. CONCLUSIONS: Malnutrition was correlated with severe disease and was more prevalent in older people with kala-azar. Vitamin A deficiency was associated with hemoglobin and CRP. Zinc levels were reduced in patients with kala-azar.

Cutaneous parasitism in patients with American visceral leishmaniasis in an endemic area

Abstract INTRODUCTION: Visceral leishmaniasis (VL) represents a public health concern in several areas of the world. In the American continent, VL transmission is typically zoonotic, but humans with active VL caused by Leishmania infantum are able to infect sandflies. Thus, individuals with cutaneous parasitic infections may act as reservoirs and allow interhuman transmission. Additionally, the skin may be responsible for reactivation of the disease after therapy. This study's objective was to evaluate cutaneous parasitism in humans with VL in an American endemic area. METHODS: A cross-sectional hospital-based study was conducted in northeast Brazil from October 2016 to April 2017. Biopsies of healthy skin for histopathology and immunohistochemistry were performed prior to treatment in all study patients. RESULTS: Twenty-two patients between the ages of five months to 78 years were included in the study. Seven patients (31.8%) tested positive for HIV. Only one patient had cutaneous parasitism, as confirmed by immunohistochemistry prior to treatment. Parasitism was not detected after treatment. CONCLUSIONS: Cutaneous parasitism in the healthy skin of humans with visceral leishmaniasis, although unusual, may be a source of infection for phlebotomine sandflies.

Cytological and molecular detection of Leishmania spp. in different biological tissues of dogs in areas endemic for visceral leishmaniasis / Detecção citológica e molecular de Leishmania spp. em diferentes amostras biológicas de cães em áreas endêmicas para leishmaniose visceral

Devido à ampla distribuição da leishmaniose visceral (LV) no Brasil e à importância dos cães no ciclo de transmissão dessa zoonose, o presente estudo teve como objetivo avaliar a ocorrência de Leishmania spp. e caracterizar a espécie circulante em diferentes tecidos biológicos de cães da Baixada Cuiabana, Mato Grosso, Brasil. Amostras de sangue, linfonodo e medula óssea foram coletadas de 205 cães para realização de análise parasitológica por citologia e análise molecular por meio da nested PCR (nPCR) e do sequenciamento . Dos 205 cães estudados, 34 (16,58%) animais foram positivos pela nPCR, dos quais 12 possuíam formas amastigotas de Leishmania spp. na citologia. Amostras positivas na nPCR foram sequenciadas e caracterizadas como Leishmania (Leishmania) infantum. A sensibilidade da nPCR nas amostras de medula óssea, linfonodo e sangue foi de 94,87%, 91,8% e 98%, respectivamente, enquanto a especificidade foi de 100% para todas as amostras. O presente estudo relata a ocorrência de LV canina em 16,58% dos cães analisados, caracterizando a L. infantum como agente causador. Entre as amostras avaliadas, a medula óssea foi a única a apresentar concordância substancial entre as técnicas de nPCR e citologia (k = 0,643), sendo considerada a amostra mais adequada para o diagnóstico da doença. Os resultados ampliam o conhecimento de espécies de Leishmania infectando cães no Brasil, destacando a importância da identificação etiológica em áreas com escassos dados moleculares.(AU)

The Incidence of Leishmania donovani using RK39 and Buffy Coat Concentration Technique in Blood Donors in Gadarif State

Visceral leishmaniasis is an endemic disease in Sudan which affects many populations certainly in Gadarif State. A hospital-based cross-sectional study was conducted at Gadarif Teaching Hospital, 100 healthy apparent blood donors were included in the study and their blood specimens were examined microscopically by buffy coat technique and serologically by rk39 and there was no positivity reported in the study. Further study must be conducted with large sample size and molecular diagnostic method (PCR) must be used.

Assessment of Treatment Outcome in Post-Kala-Azar Dermal Leishmaniasis (PKDL) Patients– A Record-Based Observational study in a Speciality Public Hospital, Kolkata

In the absence of effective vector control measures and vaccines against leishmaniasis, effective chemotherapy remains the mainstay of treatment. Identification of post-kala-azar dermal leishmaniasis (PKDL) is important due to the long and toxic treatment and the fact that PKDL patients may serve as a reservoir for visceral leishmaniasis (VL). This retrospective study was done to assess the outcome of pharmacotherapy in post-kala-azar dermal leishmaniasis (PKDL) patients in a specialty public hospital in Kolkata. Methods: The hospital records of all consecutive PKDL patients admitted at Calcutta School of Tropical Medicine (CSTM), Kolkata during the last five years - 2010-2014, were reviewed and the relevant information inputs as documented studied to realize the noted objectives. Clinical presentation on admission including presence of co-infections (particularly HIV), trends and patterns of treatment regimens and rationale thereof, if available; treatment (anti-leishmaniasis) outcomes in reference to efficacy, safety and tolerability, fatality like serious complications and mortality and adverse drug reactions (for anti-leishmaninal drugs primarily), if any was noted. Results: PKDL cases presented with insidious onset skin lesions of different types without much systemic illness. 2 out of 19 cases presented with fever and 2 other cases had mild anemia. PKDL cases presented with 4 types of skin lesions. Multiple macular or hyppigmented macular lesions were commonest, 8 out of 19 cases (42.10%). In PKDL cases treatment outcome was difficult to say unless parasitologically declared negative, though clinically regression of the lesions were visible in all cases. Tolerability was least with AmB followed by SSG and best with miltefosine. Conclusion: So, it can be concluded from this study that in this institute PKDL were treated with conventional and liposomal AmB as well as with SSG, miltefosine and combination therapy. Among the regimens short course L-AmB was found to be the most efficacious and tolerable in respect to ADRs and hospital stay.

A Hospital Based Retrospective Study of Post Kala-Azar Dermal Leishmaniasis (PKDL) Cases

Post Kala-azar dermal leishmaniasis (PKDL) is a cutaneous form of leishmaniasis and usually occurs one to several years after apparent cure of visceral leishmaniasis (VL). Methods: The present work was designed as a retrospective tertiary urban hospital based, observational, clinico-epidemiological study during the period from February 2018 to January 2019. Results: A total of 24 PKDL patients, 16 males (66.66%) and 8 females (33.34%) were included in the study. The age of the patients ranged from 8 years to 56 years (mean age 30.6 years). Lesions in most of our patients (n=21, 87.50%) were located on the face, including the lip and nose. Most of our patients (n=20, 83.33%) were nodular (non-ulcerative), while two (08.33%) had nodulo ulcerative lesions and one (04.16%) had macular lesions. In the present study, 91.66.47 % (n = 22) of PKDL patients reported history of VL. The median time of manifestation of PKDL after VL treatment were 32 months (range = 5–286 months). Majority (n=20) of cases with history of VL had been treated with amphotericin B while the remaining (n=4,) had been treated with sodium stibogluconate. Conclusion: The present study highlights occurrence of PKDL in endemic area.Further epidemiological studies are required for identification of vector and strain of Leishmania involved.

Predicción de muertes por lesiones de tráfico en Ibagué Colombia con caminata al azar probabilista / Prediction of deaths from road traffic injuries in Ibague Colombia with probabilistic random walk

Resumen Introducción: El análisis del comportamiento de la dinámica de epidemia como son el dengue y malaria en Colombia ha llevado al diseño de nueva metodología de carácter predictivo, las cuales establecen órdenes matemáticos subyacentes ante una aparente impredecibilidad de estos comportamientos. Objetivo: Confirmar la aplicabilidad de la metodología desarrollada para predecir la dinámica de la tasa de muertes por lesiones de tránsito en Ibagué Colombia para el año 2010, a partir de la caminata al azar probabilista. Metodología: Se realizó un análisis físico y matemático del de la dinámica de la tasa muertes por lesiones de tránsito en Ibagué, a partir del establecimiento de un espacio total de probabilidades con el cual se puede establecer el evento más probable en relación a los aumentos y disminuciones consecutivas anuales. Finalmente, el análisis geométrico y probabilista de esta dinámica permitió predecir la tasa del número de muertes por lesiones de tránsito para el año 2010 en Ibagué. Resultados: Para el año 2010 el DANE reporto que el número de muertes por lesiones causadas por el tránsito representa una tasa de 20,9 por cada 100.000 habitantes, el valor predicho fue de 23,2, presentado un porcentaje de acierto con la aplicación de la metodología del 90,2 %. Conclusiones: Se estableció un orden acausal probabilista para el comportamiento de la dinámica de muertes por lesiones causadas por el tránsito en Ibagué, con lo cual fue posible confirmar la aplicabilidad de la metodología y predecir el número de estas muertes para el año 2010.

Abstract Introduction: Behavioral analysis of the dynamics of epidemics such as dengue and malaria in Colombia has led to the design of new methodology of predictive character, which provides underlying mathematical commands to an apparent unpredictability of these behaviors. Objective: To confirm applicability of the methodology developed to predict the dynamics of death rate from road traffic injuries in Ibague Colombia for 2010, from the probabilistic random walk. Methodology: A physicist and mathematician of the dynamics of the death rate from road traffic injuries in Ibague, from the establishment of a complete probability space with which to establish the most probable event related to increases and consecutive declines analysis was performed annually. Finally, the geometric and probabilistic analysis of this dynamic allowed predicting the rate of deaths from road traffic injuries in 2010 in Ibague. Results: For 2010, the DANE reported that the number of deaths from road traffic injuries represents a rate of 20.9 per 100,000 inhabitants, the predicted value was 23.2, showing a success rate with implementing the methodology of 90,2 %. Conclusions: A probabilistic acausal order for the dynamic behavior of deaths from road traffic injuries in Ibague, which was possible to confirm the applicability of the methodology and predict the number of such deaths for 2010 was established.

Where, when, and how the diagnosis of human visceral leishmaniasis is defined: answers from the Brazilian control program

BACKGROUND Timely diagnosis is recommended by the Brazilian Visceral Leishmaniasis (VL) Surveillance and Control Program to reduce case fatality. Attempts at assessing this topic in Brazil are scarce. OBJECTIVE This study aimed to describe where, when, and how the diagnosis of VL has been performed in a Brazilian endemic setting. METHODS Data of all autochthonous cases confirmed between 2011 and 2016 (N = 81) were recorded. The care-seeking itinerary until the confirmation of VL diagnosis was assessed among 57 patients. FINDINGS The majority of VL cases (79.1%) were reported by referral hospitals. The patients mainly sought primary health care centres at the onset of symptoms. However, they had to visit seven health services on average to achieve a confirmed diagnosis. The time from the onset of symptoms to the diagnosis of VL (TD) ranged from 1-212 (median, 25) days. The TD was longer among adult patients. There was a direct correlation between the patient's age and TD (r = 0.22; p = 0.047) and a higher occurrence of deaths due to the disease among older patients (p = 0.002). Almost all the patients (98.9%) underwent laboratory investigation, and the VL diagnosis was mainly confirmed based on clinical-laboratory criteria (92.6%). Positive results for the indirect fluorescence antibody test (22.7%) and parasitological examination plus rk39-based immunochromatographic tests (21.3%) were commonly employed. MAIN CONCLUSIONS VL diagnosis was predominantly conducted in hospitals with a long TD and wide application of serology. These findings may support measures focused on early diagnosis, including a greater involvement of the primary health care system.

Visceral leishmaniasis mimicking systemic lupus erythematosus

Abstract Visceral leishmaniasis (VL), or kala-azar, a serious disease resulting from a systemic infection caused by a protozoan of the genus Leishmania, is potentially fatal to humans. According to data from Sistema de Informação de Agravos de Notificação (Brazil's Information System for Notifiable Diseases) from 2015 to 2016, 6,489 new cases were recorded in Brazil in 22 of the 27 federative units. In addition to typical clinical findings, VL may be associated with autoimmune phenomena, including simulating systemic lupus erythematosus (SLE). We present the first case of autochthonous VL mimicking SLE in Santa Catarina in southern Brazil.

Revisiting the role of the slit-skin smear in the diagnosis of Indian post-kala-azar dermal leishmaniasis

Background: Post kala azar dermal leishmaniasis (PKDL) is a neglected dermatosis that develops as a sequel to kala azar after apparent complete treatment. Being a non life threatening condition, patients often delay treatment thereby maintaining a reservoir of infection. The diagnosis of PKDL rests on the demonstration of the parasite in tissue smears, immune diagnosis by detection of parasite antigen or antibody in blood, or detection and quantitation of parasite DNA in tissue specimens. Sophisticated molecular tests are not only expensive but also need skilled hands and expensive equipment. To be useful, diagnostic methods must be accurate, simple and affordable for the population for which they are intended. Aims: This study was designed to assess functionality and operational feasibility of slit-skin smear examination. Methods: Sensitivity and specificity was evaluated by performing slit-skin smear and histo-pathological examination in 46 PKDL patients and the results were compared with the parasite load in both the slit aspirate and tissue biopsy specimens by performing quantitative Real-time PCR (Q-PCR). Results: The slit-skin smear examination was more sensitive than tissue biopsy microscopy. The parasite loads significantly differed among various types of clinical lesions (P < 0.05). The threshold of parasite load for detection by SSS microscopy was 4 parasites/μl in slit aspirate and 60 parasites/μg tissue DNA in tissue biopsy while that for tissue microscopy was 63 parasites/μl and 502 parasites/μg tissue DNA respectively. As detection of Leishmania donovani bodies may be challenging in inexperienced hands, the microscopic structure of these has been detailed along with a comprehensive discussion of pre analytical, analytical and post analytical variables affecting its identification. To facilitate the diagnosis of PKDL, some scenarios have been suggested taking into consideration the clinical, epidemiological, immunological and microscopic aspects. Conclusion: Such evidence based medicine helps minimize intuition, systematize clinical experience and provides a diagnostic rationale as sufficient grounds for a clinical decision.