Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study / Fatores de risco associados à ruptura uterina e deiscência: Um estudo transversal canadense

Abstract Objective To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. Methods Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. Results There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p=0.02), elevated maternal body mass index (BMI; OR: 3.4; p=0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p=0.05) and 5-minute low Apgar score (OR: 5.9; p<0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p=0.006), postpartum hemorrhage (OR: 13.9; p<0.001), hysterectomy (OR: 23.0; p=0.002), and stillbirth (OR: 8.2; p<0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight. Conclusion This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

Resumo Objetivo Comparar os fatores de risco maternos e perinatais associados à ruptura uterina completa e deiscência uterina. Métodos Estudo transversal de pacientes com ruptura/deiscência uterina no período de janeiro de 1998 a dezembro de 2017 (30 anos) internadas na Unidade de Parto de um hospital universitário terciário no Canadá. Resultados Ocorreram 174 (0,1%) casos de transtorno uterino (29 rupturas e 145 deiscências) em 169.356 partos. Houve associações entre deiscência e multiparidade (razão de chances [RC]: 3,2; p=0,02), índice demassa corporal (IMC)materno elevado (RC: 3,4; p=0,02), tentativa de parto vaginal após cesariana (RC: 2,9; p=0,05) e baixa pontuação Apgar em 5minutos (RC: 5,9; p<0,001). A ruptura uterina foi associada a partos prematuros (36,5 ± 4,9 versus 38,2 ± 2,9; p=0,006), hemorragia pós-parto (RC: 13,9; p<0,001), histerectomia (RC: 23,0; p=0,002) e natimorto (RC: 8,2; p<0,001). Não houve associação entre ruptura uterina e idade materna, idade gestacional, início do trabalho de parto, ruptura espontânea ou artificial de membranas, uso de ocitocina, tipo de incisão uterina e peso ao nascer. Conclusão Esta grande coorte demonstrou que existem diferentes fatores de risco associados à ruptura ou à deiscência uterina. A ruptura uterina ainda representa uma grande ameaça à saúde materno-fetal e, diferentemente da crença comum, a deiscência uterina também pode comprometer os desfechos perinatais.

Alternative HPV vaccination schedules in Latin America / Los esquemas alternativos de vacunación contra VPH en América Latina

Abstract: In 2008, the first HPV vaccination program in Latin America started in Panama, targeting girls aged 10-11 years with a 3-dose vaccine schedule, an initiative that was to be followed by other Latin American countries after local feasibility and population acceptability evaluations were completed. A 3-dose vaccine regimen over six months was originally chosen for HPV vaccines, copying the Hepatitis B vaccine schedule (0, 1-2, 6 months). Alternative vaccine schedules have been proposed afterwards based on: i) noninferior immunogenicity or immune response levels compared to those at which clinical efficacy has been proven (i.e., those observed in a 3-dose HPV vaccine schedule in women aged 15-26), and, ii) proven efficacy in clinical trials and/or effectiveness among women who were provided less than three doses due to a lack of adherence to a 3-dose vaccine schedule. In 2014, based on the available evidence and the potential increase in coverage by expansion of vaccination target groups, particularly in low and middle income countries (LMIC), the World Health Organization recommended a 2-dose schedule with at least a 6-month interval between doses for females up to 15 years of age and a 3-dose schedule for older women. More recently, it has been suggested that 1-dose HPV vaccination schemes may provide enough protection against HPV infection and may speed up the introduction of HPV vaccination in LMIC, where most needed.

Resumen: En 2008, se inició en Panamá el primer programa de vacunación contra el virus del papiloma humano (VPH), dirigido a niñas de 10 a 11 años, utilizando un esquema de tres dosis en seis meses, iniciativa que fue adoptada por otros países de la región tras evaluar la aceptabilidad en la población y la viabilidad de llevar a cabo el programa. Inicialmente, el esquema de tres dosis para las vacunas contra el VPH se basó en el utilizado en la vacunación contra la hepatitis B (0, 1-2, 6 meses). Posteriormente, se han propuesto esquemas de vacunación alternativos, utilizando evidencia sobre: i) la inmunogenicidad o niveles de respuesta inmune no inferiores a aquéllos con los cuales la eficacia clínica de la vacuna fue probada (es decir, aquéllos observados con tres dosis en mujeres de 15 a 26 años); y ii) la eficacia demostrada en ensayos clínicos y efectividad demostrada en mujeres a quienes se vacunó con menos de tres dosis debido a falta de adherencia al esquema completo de tres dosis. En 2014, la Organización Mundial de la Salud recomendó un esquema de dos dosis con al menos seis meses de intervalo entre dosis para mujeres de hasta 15 años de edad y uno de tres dosis para mujeres mayores. La recomendación se basó en la evidencia disponible hasta entonces y a un posible aumento en cobertura mediante la ampliación de los grupos etarios a vacunarse, particularmente en países de ingresos bajos y medios (PIBMs). Más recientemente, se ha sugerido un esquema de vacunación contra el VPH de una sola dosis, el cual podría proporcionar suficiente protección contra la infección por VPH y así acelerar la introducción de la vacunación contra el VPH en PIBMs donde más se necesita.

Unilateral absence of vas deferens: prevalence among 23, 013 men seeking vasectomy

ABSTRACT Purpose: To determine the prevalence of unilateral absence of vas deferens (UAVD) in men with both testes seeking vasectomy. Materials and Methods: Computerized charts of 23,013 patients encountered between January 1994 and December 2013 in one university hospital and two community clinics of Quebec City, Canada, were searched. Pre-vasectomy consultation, operative reports and semen analysis results were reviewed to identify cases of UAVD. Cases were categorized as confirmed (unilateral vasectomy and success confirmed by semen analysis) or possible congenital UAVD further sub-categorized according to whether or not a scrotal anomaly was present. Results: Among 159 men identified as potentially having UAVD, chart review revealed that 47 had only one testicle, 26 had bilateral vasa, and four were misdiagnosed (post-vasectomy semen analysis [PVSA] showing motile sperm after unilateral vasectomy) leaving 82 men deemed cases of UAVD (0.36%, 95% confidence interval 0.28% to 0.43%). These were classified as confirmed (n=48, 0.21%) and possible (n=34, 0.15%; 22 without and 12 with scrotal anomalies) congenital UAVD. The misdiagnosis ratio of UAVD was low when scrotal content was otherwise normal (1:48), but higher if anomalies were present (3:12). Conclusions: Most surgeons who perform vasectomy will encounter cases of UAVD. In most suspected cases, it is safe and effective to proceed with unilateral vasectomy under local anesthesia while stressing the need for PVSA. Further studies or scrotal exploration may be considered in patient with prior scrotal surgery.

Perfil de estrés y estrés crónico en migrantes mexicanos en Canadá / Stress profile and chronic stress in Mexican immigrants in Canada

Objetivo Establecer la asociación existente entre el nivel alto de estrés crónico y las variables consideradas como negativas del perfil de estrés en los migrantes mexicanos radicados en Edmonton Canadá. Métodos La selección de la población fue por medio de la técnica aleatoria simple. El tamaño de la muestra fue: 58 migrantes, durante el año de 2010-20011, se aplicó el Inventario de Síntomas de Estrés y el Perfil de Nowack. Resultados Los niveles de estrés crónico fueron: 34 % alto, 45 % medios y 21 % bajo, El análisis de regresión estadístico se determinó que la situación de estrés y la minimización de la amenaza son predictoras para desarrollar niveles altos de estrés crónico. Conclusión La situación de estrés y la minimización de la amenaza son predictoras para desarrollar niveles altos de estrés crónico y las mujeres migrantes a diferencia del sexo masculino, tienden a no utilizar la minimización de la amenaza como afrontamiento al estrés.

Objective Establishing an association between high chronic stress levels and variables considered to be negative regarding the stress profile for Mexican migrants living in Edmonton, Canada. Methods A simple random technique was used for choosing the target population; the sample size involved 58 migrants. The Nowack Stress Profile and Maslach Burnout Inventory were used to identify immigrants' stress symptoms during 2010-2011. Results Chronic stress levels were classified as being 24 % high, 45 % medium and 21 % low. Statistical regression analysis determined that a stressful situation and threat minimisation were predictors for developing high levels of chronic stress. Conclusions Stress situation and threat minimisation were predictors for developing high levels of chronic stress; migrant women (unlike males) tended not to use threat minimisation to deal with stress.

Collaborative multicenter trials in Latin America: challenges and opportunities in orthopedic and trauma surgery / Estudos colaborativos na America Latina: desafios e oportunidades em cirurgia ortopedica e traumatologica

CONTEXT AND OBJECTIVE Orthopedic research agendas should be considered from a worldwide perspective. Efforts should be planned as the means for obtaining evidence that is valid for health promotion with global outreach. DESIGN AND SETTING Exploratory study conducted at Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil, and McMaster University, Hamilton, Canada. METHODS We identified and analyzed collaborative and multicenter research in Latin America, taking into account American and Canadian efforts as the reference points. We explored aspects of the data available from official sources and used data from traffic accidents as a model for discussing collaborative research in these countries. RESULTS The evaluation showed that the proportion of collaborative and multicenter studies in our setting is small. A brief analysis showed that the death rate due to traffic accidents is very high. Thus, it seems clear to us that initiatives involving collaborative studies are important for defining and better understanding the patterns of injuries resulting from orthopedic trauma and the forms of treatment. Orthopedic research may be an important tool for bringing together orthopedic surgeons, researchers and medical societies for joint action. CONCLUSIONS We have indicated some practical guidelines for initiatives in collaborative research and have proposed some solutions with a summarized plan of action for conducting evidence-based research involving orthopedic trauma. .

CONTEXTO E OBJETIVOS A programação de pesquisa em ortopedia deve ser considerada do ponto de vista global. Esforços devem ser planejados como forma de se obter evidência que seja válida para promoção da saúde de alcance mundial. TIPO DE ESTUDO E LOCAL Estudo exploratório conduzido na Universidade Federal de São Paulo (Unifesp), São Paulo, Brasil e na McMaster University, Hamilton, Canadá. MÉTODOS Identificamos e analisamos pesquisas multicênticas/colaborativas realizadas na América Latina, considerando os esforços nos Estados Unidos e Canadá como referência. Para tal, exploramos os aspectos dos dados disponíveis em fontes oficiais e utilizamos os dados provenientes de acidentes de trânsito como modelo de discussão de pesquisas colaborativas nestes países. RESULTADOS A avaliação demonstra uma pequena proporção de estudos colaborativos/multicêntricos em nosso meio. Análise breve demonstrou que existe enorme proporção de mortes devidas a traumas provenientes dos acidentes de trânsito. Dessa forma, parece-nos claro que iniciativas envolvendo estudos colaborativos são importantes para a definição e melhor entendimento do padrão das lesões provenientes de trauma ortopédico e as formas de tratamento. A pesquisa ortopédica pode ser importante ferramenta para aglutinar cirurgiões ortopédicos, pesquisadores e sociedades médicas para uma ação em conjunto. CONCLUSÕES Apontamos algumas diretrizes práticas para iniciativas em pequisas colaborativas e propusemos algumas soluções com um plano de ação resumido para a realização de pesquisa baseada em evidências envolvendo trauma ortopédico. .

Mortality associated with periodic limb movements during sleep in amyotrophic lateral sclerosis patients / Mortalidade associada aos movimentos periódicos de membros durante o sono em pacientes com esclerose lateral amiotrófica

OBJECTIVE: To describe the prevalence and severity of periodic limb movements during sleep in amyotrophic lateral sclerosis patients and to explore this fact as a predictor of severity of the condition with respect to mortality. METHODS: In this case-control study, questionnaire and polysomnographic data were analyzed from 35 amyotrophic lateral sclerosis patients. Controls were matched by age, genre, and body mass index. A Kaplan-Meier curve was used to compare the survival time of patients with periodic limb movements of sleep index below or above 5. RESULTS: The number of amyotrophic lateral sclerosis patients with an index greater than five was higher than controls (19 (53%) versus 4 (11%); p<0.0001), and the mean index was higher (23.55±40.07 versus 3.28±8.96; p=0.0009). Earlier mortality was more common in patients with more than five periodic limb movements per hour of sleep than patients with less than five periodic limb movements per hour of sleep (7/19 (37%) versus 1/16 (6%); p=0.04) in this group of patients that had a mean survival of 33 months. CONCLUSIONS: There were more periodic limb movements of sleep in amyotrophic lateral sclerosis patients than in the control population. The higher number of these movements in amyotrophic lateral sclerosis patients correlates with disease severity and may suggest poor survival.

OBJETIVO:Descrever a prevalência e a severidade dos movimentos periódicos de membros durante o sono nos pacientes com esclerose lateral amiotrófica e explorar isso como um preditor de severidade da doença e mortalidade. MÉTODOS: Estudo caso controle em que foram analisados 35 pacientes por questionários e polissonografia. Os controles foram pareados por idade, gênero, e índice de massa corporal. Uma curva de Kaplan-Meier foi usada para comparar o tempo de sobrevida em pacientes com índice de movimento periódico de membros durante o sono acima e abaixo de 5. RESULTADOS: O número de pacientes com esclerose lateral amiotrófica com índice de movimentos periódicos de membros durante o sono acima de cinco foi maior do que os controles (19 (53%) versus 4 (11%); p<0,0001) e a média do índice de movimentos periódicos de membros durante o sono também foi maior no grupo dos pacientes (23,55±40,07 versus 3,28±8,96; p=0,0009). A mortalidade precoce foi mais comum em pacientes com mais que cinco movimentos durante o sono por hora do que pacientes com menos do que cinco movimentos durante o sono por hora (7/19 (37%) versus 1/16 (6%); p=0,04). Nesse grupo, os pacientes tiveram sobrevida média de 33 meses. CONCLUSÃO:Houve um maior número de movimentos periódicos de membros durante o sono em pacientes com esclerose lateral amiotrófica do que na população controle. O maior número de movimentos periódicos de membros durante o sono em pacientes com esclerose lateral amiotrófica foi correlacionado com severidade da doença e pode sugerir menor sobrevida.

Corneal stromal dystrophies: a clinical pathologic study / Distrofia corneana estromal: um estudo clínicopatológico

INTRODUCTION: Corneal dystrophy is defined as bilateral and symmetric primary corneal disease, without previous associated ocular inflammation. Corneal dystrophies are classified according to the involved corneal layer in superficial, stromal, and posterior dystrophy. Incidence of each dystrophy varies according to the geographic region studied. PURPOSE: To evaluate the prevalence of stromal corneal dystrophies among corneal buttons specimens obtained by penetrating keratoplasty (PK) in an ocular pathology laboratory and to correlate the diagnosis with patient age and gender. METHODS: Corneal button cases of penetrating keratoplasty from January-1996 to May-2009 were retrieved from the archives of The Henry C. Witelson Ophthalmic Pathology Laboratory and Registry, Montreal, Canada. The cases with histopathological diagnosis of stromal corneal dystrophies were stained with special stains (Peroxid acid Schiff, Masson trichrome, Congo red analyzed under polarized light, and alcian blue) for classification and correlated with epidemiological information (age at time of PK and gender) from patients' file. RESULTS: 1,300 corneal buttons cases with clinical diagnose of corneal dystrophy were retrieved. Stromal corneal dystrophy was found in 40 (3.1%) cases. Lattice corneal dystrophy was the most prevalent with 26 cases (65%). Nineteen were female (73.07%) and the PK was performed at average age of 59.3 years old. Combined corneal dystrophy was found in 8 (20%) cases, 5 (62.5%) of them were female and the average age of the penetrating keratoplasty was 54.8 years old. Granular corneal dystrophy was represented by 5 (12.5%) cases, and 2 (40%) of them were female. Penetrating keratoplasty was performed at average age of 39.5 years old in granular corneal dystrophy cases. Macular corneal dystrophy was present in only 1 (2.5%) case, in a 36 years old female. CONCLUSION: Systematic histopathological approach and evaluation, including special stains in all stromal corneal dystrophies is critical to establish the correct diagnosis.

INTRODUÇÃO: A distrofia corneana é definida como doença primária da córnea, bilateral e simétrica, sem associação com inflamação ocular prévia. Distrofias corneanas são classificados de acordo com a camada corneana envolvida em distrofia superficial, estromal e posterior. A incidência de cada distrofia varia de acordo com a região geográfica estudada. OBJETIVO: Avaliar a prevalência de distrofias corneanas estromal em botões corneanos de espécimes obtidos por ceratoplastia penetrante (CP), oriundos do arquivo de um laboratório de patologia ocular e correlacionar o diagnóstico com a idade e o sexo dos pacientes. MÉTODOS: Os botões corneanos oriundos de ceratoplastia penetrante recebidos entre janeiro de 1996 e maio de 2009 foram selecionados dos arquivos do Henry C. Witelson Ocular Pathology and Registry Laboratory, em Montreal, Canadá. Os casos com diagnóstico histopatológico de distrofias corneanas estromal foram corados com colorações especiais ("Peroxid acid Schiff", tricrômico de Masson, vermelho Congo analisadas sob luz polarizada, e "alcian blue") para a classificação e foram correlacionados com dados epidemiológicos (idade na época da ceratoplastia penetrante e sexo) dos pacientes. RESULTADOS: 1.300 casos de botões corneanos com diagnóstico clínico de distrofia corneana foram recuperados. Distrofia corneana estromal foi encontrada em 40 (3,1%) dos casos. Distrofia corneana lattice foi a mais prevalente com 26 casos (65%). Dezenove eram do sexo feminino (73,07%) e CP foi realizada em média com 59,3 anos de idade. Distrofia corneana combinada foi encontrada em 8 (20%) casos, 5 (62,5%) eram do sexo feminino e a idade média da CP foi de 54,8 anos. Distrofia corneana granular foi encontrada em 5 (12,5%) casos, e 2 (40%) deles eram do sexo feminino. A ceratoplastia penetrante foi realizada na média de idade de 39,5 anos, em casos de distrofia corneana granular. A distrofia corneana macular esteve presente em apenas um caso (2,5%), 36 anos de idade do sexo feminino. CONCLUSÃO: A abordagem histopatológica e avaliação sistemáticas, incluindo colorações especiais em todas as distrofias corneanas é essencial para estabelecer o correto diagnóstico.

El riesgo emergente que constituyen las agresiones y violencia que sufren los médicos en el ejercicio de su profesión: el caso de España / O The emerging risk that constitute aggressions and violence that the sufferphysicians in their profession: the case of Spain

O artigo analisa dados sobres as agressões na área da saúde, considerando esse fato como um fenômeno internacional que se manifesta tanto em países europeus (Espanha, França, Grã-Bretanha) quanto em outras latitudes (América Latina, Estados Unidos, Canadá, Austrália e Nova Zelândia). A discussão se reporta a estudos realizados na Espanha com pessoal médico, os quais demonstram que a taxa de agressão é de 0,2/100.000 atos médicos, aproximadamente. O objetivo do artigo é ressaltar essas agressões e violência, que os profissionais de saúde vêm sofrendo com frequência cada vez maior, no exercício de sua profissão. Por tratar-se de fenômeno relativamente novo não há muitos dados sobre o tema. Por esse motivo, é importante aprofundar as pesquisas e análises sobre as possíveis causas deste gravíssimo problema que, segundo denuncia a Organização Mundial da Saúde (OMS), corresponde a quase 25 por cento de todos os incidentes de trabalho no setor sanitário.

Análise comparativa da condição bucal, sistêmica e sociodemográfica de idosos brasileiros e canadenses, relacionados à qualidade de vida / A comparative analysis of oral health condition, general health and sociodemographic factors in Brazilian and Canadian elderly people related to the quality of life

Este estudo investigou a relação entre as condições de saúde oral, a saúde sistêmica e os fatores sociodemográficos em idosos brasileiros, canadenses e imigrantes canadenses, relacionados à qualidade de vida. Um total de 602 pessoas, com idade entre 60 e 85 anos, participaram voluntariamente deste estudo: 202 brasileiros, 189 canadenses e 211 imigrantes canadenses (78 chineses, 125 indianos e 8 vietnamitas). Os fatores sociodemográficos analisados foram: gênero, idade, nível educacional, estado civil, moradia e renda. A condição de saúde oral avaliou o número de dentes presentes, dentes perdidos, cariados, restaurados, hígidos, além de possuir próteses dentárias, os tipos de prótese dentária, além da condição periodontal, como profundidade de sondagem, recessão gengival, nível de inserção periodontal, mobilidade dental, índice de placa e gengival. A condição sistêmica foi baseada no auto-relato, dados sobre doenças diagnosticadas e os medicamentos que estavam em uso. A qualidade de vida foi mensurada usando o Geriatric Oral Health Assessment Índex (GOHAI), o Oral Health Impact Profile-14 (OHIP-14) e o World Health Organization Quality of Life (WHOQOL-bref), que foi administrado através de entrevista pessoal. Os resultados mostraram que 65 idosos brasileiros eram edêntulos e que os brasileiros dentados tinham perdido mais dentes, 20,10 ± 10,38 dentes. Os idosos canadenses permaneciam com mais dentes, 25,51 ±15,08 dentes, e tinham mais dentes restaurados (11,13 ± 5,72 dentes). Os idosos imigrantes canadenses tinham mais dentes hígidos,15,45 ±7,71 dentes, e mais dentes cariados, 2,96 ±3,03. A prótese dentária mais facilmente encontrada eram as Próteses Totais e as Próteses Parciais Fixas, mas mais de 50% era insatisfatórias. Em relação à condição periodontal, os idosos imigrantes canadenses tinham as maiores profundidades de sondagem, os idosos brasileiros tinham as maiores recessões gengivais (1,81 ± 1,26mm) e a maior perda de inserção periodontal (3,49 ±0,96mm...

This study investigated the relationship between oral health condition, general health and sociodemographic factors in Brazilian, Canadian and Canadian immigrant elderly people related to the quality of life. A total of 602 subjects aged 60 to 85 years volunteered, being 202 Brazilian, 189 Canadian and 211 Canadian immigrant elderly individuals (among the latter, 78 Chinese, 125 Indian and 8 Vietnamese). The sociodemographic factors analyzed included gender, age, educational level, marital status, having an own house and income. Analysis of the oral condition comprised the number of present teeth, sound teeth, decayed teeth, filled teeth, missing teeth, the use of dental prosthesis, as well as the periodontal status (probing depth at six sites per tooth, gingival recession, attachment loss, plaque index, gingival index, and tooth mobility). Systemic diseases were recorded based on subjects self-reports of the diseases with which they were currently diagnosed, as well as the medications they were using. The quality of life was measured using the Geriatric Oral Health Assessment Index (GOHAI), the Oral Health Impact Profile-14 (OHIP-14) and the World Health Organization Quality of Life (WHOQOL-bref), which were administered by a personal interview. The results showed that 65 Brazilian elderly adults were edentulous and that Brazilian dentate subjects had more missing teeth (20.10 ± 10.38); the Canadian elderly adults retained more teeth (25.51 ±15.08) and had more filled teeth (11.13 ± 5.72); the Canadian immigrant elderly adults had more sound teeth (15.45 ± 7.71) and more decayed teeth (2.96 ± 3.03). The dental prosthesis most commonly found was complete dentures and fixed partial prosthesis, but more than 50% were unsatisfactory. Concerning the periodontal condition, the Canadian immigrant elderly men had the deepest probing depth values, the Brazilian elderly adults had the largest gingival recession 1.81±1.26mm) and the greatest attachment loss...

Breast cancer screening program in canada: successes and challenges / Programas de detección temprana de cáncer de mama en canadá: avances y obstáculos

This paper describes breast screening program development in Canada and the current status of screening in Canada. Programs have been implemented in most of Canada, beginning in the late 1980's. Certain components are common to all the programs, but others, such as personal invitation letters for recruitment and clinical breast examination vary across the country. Key successes in organized breast screening in Canada include the development of a comprehensive set of screening performance indicators, which are reported on regularly, and the downward trend in mortality rates observed over the past 20 years. Challenges include the continued prevalence of opportunistic screening; the need to better manage follow-up; dealing with changing evidence; and supporting informed decision-making about screening. Approaches to breast screening are dependent on the health care services available in countries, but regardless of the approach, good evaluation is necessary.

Este artículo describe el desarrollo de la detección temprana de cáncer de mama en Canadá así como la situación actual de los programas de detección de cáncer en el mismo país. En su gran mayoría, estos programas de detección han sido implementados desde comienzos de los años ochenta. Algunos elementos de estos programas representan denominadores comunes en todos ellos. Sin embargo existen otros elementos -tales como invitaciones personales para reclutamiento y exámenes clínicos de mama, que difieren dependiendo de cada jurisdicción. Algunos de los avances en los programas organizados de detección temprana de cáncer de mama en Canadá incluyen la existencia de indicadores de evaluación de desempeño, sobre los cuales se reporta de forma regular. En base a estos indicadores se puede observar una tendencia descendente en los índices de mortalidad en los últimos 20 años. Algunas de las dificultades incluyen la persistencia de detección oportunística, la necesidad de gerenciar el efectivo seguimiento de pacientes, gerenciar el constante cambio de evidencia, así como el proveer asistencia en la toma de decisiones relacionadas a la detección temprana de cáncer. Las prácticas focalizadas en mejorar la detección temprana de cáncer dependen de los servicios de salud existentes en cada país. Sin embargo e independientemente de la orientación utilizada, la necesidad de evaluar el desempeño de los programas es un elemento vital.

Epidemiology of Chagas disease in non endemic countries: the role of international migration

Human infection with the protozoa Trypanosoma cruzi extends through North, Central, and South America, affecting 21 countries. Most human infections in the Western Hemisphere occur through contact with infected bloodsucking insects of the triatomine species. As T. cruzi can be detected in the blood of untreated infected individuals, decades after infection took place; the infection can be also transmitted through blood transfusion and organ transplant, which is considered the second most common mode of transmission for T. cruzi. The third mode of transmission is congenital infection. Economic hardship, political problems, or both, have spurred migration from Chagas endemic countries to developed countries. The main destination of this immigration is Australia, Canada, Spain, and the United States. In fact, human infection through blood or organ transplantation, as well as confirmed or potential cases of congenital infections has been described in Spain and in the United States. Estimates reported here indicates that in Australia in 2005-2006, 1067 of the 65,255 Latin American immigrants (16 per 1000) may be infected with T. cruzi, and in Canada, in 2001, 1218 of the 131,135 immigrants (9 per 1000) whose country of origin was identified may have been also infected. In Spain, a magnet for Latin American immigrants since the 2000, 5125 of 241,866 legal immigrants in 2003 (25 per 1000), could be infected. In the United States, 56,028 to 357,205 of the 7,20 million, legal immigrants (8 to 50 per 1000), depending on the scenario, from the period 1981-2005 may be infected with T. cruzi. On the other hand, 33,193 to 336,097 of the estimated 5,6 million undocumented immigrants in 2000 (6 to 59 per 1000) could be infected. Non endemic countries receiving immigrants from the endemic ones should develop policies to protect organ recipients from T. cruzi infection, prevent tainting the blood supply with T. cruzi, and implement secondary prevention...

Bases para la Modelación de Epidemias: el Caso del Síndrome Respiratorio Agudo Severo en Canadá / Modelling epidemics: the case of severe acute respiratory syndrome in Canada

Objetivo: Se ilustra el análisis de la propagación del síndrome respiratorio agudo severo en Canadá en 2003, mediante modelos simples, comparando la influencia de las medidas de aislamiento en dos ondas epidémicas. Métodos: Se utilizan los modelos Susceptible-Infectado y Susceptible- Infectado-Removido en versión determinista para ambas ondas epidémicas, utilizando información oficial publicada. Se estiman los parámetros deterministas con el programa NLREG 6,2 y se obtienen soluciones analíticas con Maple 9. Se obtienen indicadores para el análisis de la dinámica de la epidemia. Resultados: Se observó un adecuado ajuste de los datos con ambos modelos pero en la segunda onda se observó un menor ajuste con el modelo sin remoción. En la segunda onda, con un R0 ligeramente menor a 1, a pesar de presentar la mayor incidencia (8,8 casos por día), se tuvo el más alto ritmo de infección (35 caso nuevos por 10 000 susceptibles) compensado con un alto ritmo de remoción (11,5 casos por día), lo que llevó a una menor duración de la epidemia (11,1 días) y una menor tasa de ataque (1 caso por cada cien susceptibles). Conclusiones: El modelo susceptible - infectado puede ser útil en la fase inicial de la epidemia, previo a la instauración de la remoción pero se requiere una vigilancia estrecha de la evolución de la epidemia para incorporar la modelación de la fuerza de remoción y derivar información que sustente las decisiones.

Objective: Severe acute respiratory syndrome propagation in Canada during 2003 is analysed by means of simple models, comparing the influence of isolation measures on two epidemic waves. Methods: Deterministic susceptible-infected and susceptible-infected-removed models were used for both epidemic waves, using official published information. NLREG 6.2 was used for estimating deterministic parameters and analytical solutions were obtained with Maple 9 software. Dynamical indicators were obtained for the epidemic. Results: Suitable adjustment of the data was observed with both models, but smaller adjustment was observed during the second wave with the non- removed model. The highest rate of infectiousness was shown (35 new cases per 10 000 susceptible people) during the second wave (with R0 near to one), in spite of presenting greater incidence (8.8 cases per day), compensated for by a high rate of removal (11,5 cases per day) which lasted less than the epidemic (11,1 days), and a lower rate of attack (1 case per each 100 susceptible people). Conclusions: The susceptible-infected model can be useful during an epidemic's initial phase (prior to removal); however, closer monitoring of an epidemic's development is required for modelling the strength of removal and deriving useful information for decision-making.

Specific language impairment: effect on later language development: a literature review.

BACKGROUND: Children with specific language impairment (SLI) are at considerable risk for later language development. However there has not been a good literature review to provide understanding and to get information relative to parental counseling and decision making for further management. OBJECTIVE: To summarize the literature review on SLI and effect on later language development. MATERIAL AND METHOD: Longitudinal studies were systematically explored to seek evidence- based information to confirm the lasting effect of SLI in later language development. RESULTS: Natural history data indicated that approximately 50% of children with specific expressive language delay spontaneously remitted or outgrew it at age 5-8. However, long-term follow-up studies showed their language problems emerged later at age 15. The rest of the children's (50%), language impairment persisted and had a high risk for SLI later. CONCLUSION: The results suggest that active intervention should be performed as soon as possible for children with persisting SLI.

The threat of severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is a recently recognized infectious disease associated with severe morbidity and mortality. It presents with non-specific signs and symptoms and because no definitive laboratory test is readily available, it poses a great risk to healthcare workers as well as difficulty in quarantine. The global response has been coordinated and enthusiastic in trying to understand and control this disease. Severe acute respiratory syndrome poses a threat to the Caribbean because of easy and convenient travel and the vibrant tourist industry

Síndrome agudo respiratorio severo: un panorama mundial de la epidemia / Severe acute respiratory syndrome: a global view of the epidemic

A principios de febrero de 2003 la Organización Mundial de la Salud comenzó a recibir reportes de pacientes con un síndrome caracterizado por neumonía atípica, con rápida progresión hacia insuficiencia respiratoria sin una causa identificada. Los casos aparentemente se iniciaron en el sur de China y se han diseminado a otras regiones en Asia, Europa, Sudáfrica, Norte América y Sur América. La causa de este síndrome es una nueva variedad de Coronavirus, aislado en secreciones respiratorias y en otras. El síndrome ha sido definido en inglés como SARS (Severe acute respiratory syndrome) por la Organización Mundial de la Salud y se caracteriza por un periodo de incubación de 1 a 10 días (promedio de cinco días), una fase febril prodrómica que aparece entre los días 1 a 3. Posteriormente, aparecen síntomas respiratorios como tos, disnea, y signos como hipoxemia, que en 10 a 40 por ciento de los casos requieren de ventilación mecánica. La tasa de letalidad ha variado de 3 por ciento hasta 16 por ciento. Los hallazgos de laboratorio incluyen trombocitopenia, leucopenia, elevación de creatinin-fosfokinasa, y, en ocasiones, de transaminasas hepáticas y deshidrogenasa láctica. El tratamiento incluye medidas de apoyo; la utilización empírica del antiviral ribavirina es controvertida, debido a que hasta el momento no existe un tratamiento específico. Se recomienda el aislamiento respiratorio de los pacientes, la utilización de máscaras protectoras y el lavado estricto de manos como principales medidas de prevención. Desde el inicio de esta epidemia México estableció un sistema de vigilancia, así como recomendaciones al personal de salud para la identificación, prevención de casos secundarios y manejo clínico de casos sospechosos

Does health promotion work in relation to noise?

Noise is a health risk. The only scientifically established adverse health effect of noise is noise-induced hearing loss (NIHL). Besides noise may affect quality of life and cause annoyance and sleep disturbance. The present scientific evidence of potential non-auditory effects of noise on health is quite weak. Whether health promotion works in relation to noise may be reflected by permanent hearing threshold shift development in population studies. Hearing impairment continues to be the most prevalent disability in Western societies. The National Institute of Occupational Safety and Health (NIOSH) still rates noise induced hearing loss among the top ten work-related problems. Recent studies report that employees continue to develop noise induced hearing loss although to a lesser extent than before, in spite of occupational hearing conservation programmes. Besides socio-acusis and leisure noise seem to be an increasing hazard to hearing, also in young children and adolescents. This seems partly related to acute leisure noise exposure (e.g. toy pistols, amplified music). However, population studies increasingly find non-normal high-frequency hearing including the characteristic NIHL-"notch" around 6 kHz also in subjects who do not report noise exposure incidents or activities. Today 12.5% of US children 6-19 years show a noise-"notch" in one or both ears (n= 5249, Niskar et al 2001). A Norwegian county audiometry survey on adults >/= 20 years n=51.975) showed mean unscreened thresholds +10 dB at 6 kHz for both genders even or the youngest age group 20-24 years (Borchgrevink et al 2001). Accordingly, the present health promotion initiatives seem insufficient in relation to noise and noise-induced hearing loss.