Untrapped: bilateral hypoplasia of the trapezius muscle / 대한해부학회지

Agenesis or congenital hypoplasia of skeletal muscles occurs infrequently but may occur with specific conditions such as Poland syndrome. The trapezius muscle can vary in the extent of its bony attachments or may have additional slips, however congenital absence or hypoplasia is extremely rare. There are only a few reports of partial or complete absence of the trapezius muscle. Two cases of bilateral absence of the trapezius were both in males and were accompanied by the absence of additional muscle in the pectoral girdle. Herein, we describe a case of a 56-year-old male cadaver with bilateral hypoplasia of the trapezius. The muscle was largely represented by atrophied muscle fibers with an abundance of fibrotic or fatty connective tissue. This subject had very minor hypoplasia of the left pectoralis major muscle, but the remaining muscles of the pectoral girdle were normal. The spinal accessory nerve terminated in the sternocleidomastoid muscle on both sides, failing to reach the trapezius. We interpret these findings to be consistent with a minor variant of Poland syndrome.

Função Ventricular Direita e Tolerância ao Exercício em Pacientes com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST / Right Ventricular Function and Exercise Tolerance in Patients with ST-Elevation Myocardial Infarction

Resumo Fundamento: Pacientes com disfunção cardíaca apresentam limitações na realização de atividades físicas após a ocorrência de infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). A função do ventrículo direito (VD) é determinante na melhora da capacidade funcional, sendo a reabilitação cardíaca (RC) essencial para essa coorte de pacientes. Objetivo: Avaliar a associação da função do VD com a tolerância ao exercício após um programa de RC em pacientes com IAMCSST. Métodos: Estudo de coorte retrospectivo em pacientes com IAMCSST, realizado de janeiro a dezembro de 2019. Os pacientes foram submetidos a uma avaliação ecocardiográfica da função do VD antes de um programa de RC de 16 sessões. Um teste de exercício cardiopulmonar (ECP) foi realizado antes e após o programa de RC. Analisamos se a função do VD, medida antes da RC, estava significativamente associada à tolerância ao exercício antes e depois do programa de RC e ao grau de melhora. Comorbidades e variáveis demográficas e anatômicas foram documentadas. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados: No total, 109 pacientes foram incluídos. Destes, 3,7% apresentaram disfunção global do VD, 10,1% apresentaram disfunção radial do VD e 11% apresentaram disfunção longitudinal do VD. Observou-se associação entre a disfunção radial ou longitudinal do VD e a ausência de melhora da aptidão cardiorrespiratória (> 1 equivalente de pico de VO2) (p = 0,028, p = 0,008, respectivamente). Observou-se correlação significativa entre a disfunção longitudinal do VD com equivalentes de picos de VO2 (pVO2eq) iniciais (p = 0,046), pVO2eq final (p = 0,003) e diferença de pVO2eq (p = 0,009). Também foi identificada correlação entre a disfunção global do VD e pVO2eq inicial (p = 0,045), pVO2eq final (p = 0,012) e diferença de pVO2eq (p = 0,032). Conclusões: A disfunção do VD está associada a uma menor tolerância ao exercício; Os programas de RC podem ser estendidos ou modificados nesses pacientes.

The Upper Esophageal Sphincter Distensibility Index Measured Using Functional Lumen Imaging Probe Identifies Defective Barrier Function of the Upper Esophageal Sphincter

Background/Aims@#The mechanism via which supra-esophageal symptoms are generated is unclear. We assessed upper esophageal sphincter (UES) function in novel fashion using functional lumen imaging probe (FLIP) topography. We hypothesize that symptoms related to aspiration of esophageal contents may be associated with a more distensible UES. @*Methods@#FLIP and reflux symptom index score data from patients undergoing diagnostic evaluation for an esophageal complaint over a 10-month period were analyzed retrospectively. UES distensibility on FLIP was studied at 40-70 mL volumes with in-depth analysis at 50 and 60 mL. Symptoms were compared between patients with low, middle, and high UES-distensibility index (UES-DI). Receiveroperating characteristic analysis was performed to determine associations between the UES-DI and individual reflux symptom index symptom item scores. @*Results@#One hundred and eleven subjects were included. Overall, the associations between UES-DI and symptoms that could be related to supra-esophageal aspiration were strongest at the 50 mL FLIP volume. Choking item score was highest in the high UES-DI group (2.8) vs 1.4 (P < 0.001) in the middle UES-DI and 1.1 (P = 0.004) in the low UES-DI groups. Similarly, the cough item score was highest in the high UES-DI group (2.7) vs 1.5 (P = 0.009) and 0.9 (P = 0.002) groups. @*Conclusion@#A higher UES-DI measures defective barrier function which could may be the main pathophysiology that generates supra-esophageal symptoms.

Programas de alimentación escolar en Costa Rica y Guatemala: Percepciones de la comunidad escolar acerca de su funcionamiento en escuelas urbanas públicas

RESUMEN El objetivo de esta investigación fue comparar las principales características que influyen en el funcionamiento de los Programas de Alimentación Escolar (PAE) en escuelas urbanas y públicas de Costa Rica y Guatemala y la percepción de la comunidad escolar sobre dicho funcionamiento. Se realizó una revisión documental de informes y normativas vigentes relacionadas con los PAE de cada país para comparar características principales. Se realizaron 32 entrevistas y 43 grupos focales con la comunidad escolar para captar sus percepciones sobre el funcionamiento. Se realizó un análisis temático de transcripciones aplicando teoría fundamentada. Como principales hallazgos, se destaca que los PAE en Costa Rica y Guatemala han sido una estrategia para luchar contra el hambre y malnutrición infantil, contando ambos países con un gran respaldo normativo y político que le da sostenibilidad. Sin embargo, existen barreras como recursos limitados, problemas administrativos y falta de fiscalización de las normas. En conclusión, apesar de que en ambos países existe una normativa robusta para hacer cumplir el derecho a una alimentación saludable, se encontraron algunas barreras que dificultan una correcta implementación del PAE.

ABSTRACT The aim of this study was to compare the functioning of School Feeding Programs (SFP) in Costa Rica and Guatemala and the perceptions about operationalization among the public school community. We conducted a comparative review of government reports and existing regulations related to SFP in each country to compare key characteristics. We conducted 32 individual interviews and 43 focus group discussions with actors at different levels of the school community to capture their perceptions about SFP functioning. We conducted thematic analysis applying grounded theory. SFP in both countries have been used as a strategy to address hunger and child malnutrition. Both countries have an important body of regulations and policies that support program sustainability. However, the research revealed some barriers to effective implementation including: limited resources, administrative problems, and a lack of oversight of regulations. In conclusion, while SFP are important instruments of social protection for the right to nutrition in both countries, there are a number of barriers to optimal SFP implementation.

Clinical findings influencing time to menarche post gonadotropin-releasing hormone agonist therapy in central precocious puberty

Purpose@#This study aimed to evaluate the time interval to menarche after gonadotropin-releasing hormone agonist (GnRHa) treatment in females with central precocious puberty (CPP) and to identify factors contributing to timing of menarche. @*Methods@#We retrospectively reviewed medical records of 39 females with CPP who reached menarche after GnRHa treatment (leuprolide or histrelin). CPP diagnostic criteria were breast development at <8 years old, measurable pubertal luteinizing hormone and/or estradiol concentrations, and bone age advancement. Indications to treat were advanced bone age and psychosocial concerns. Descriptive summaries were reported as frequency and proportion for categorical variables and mean and standard deviation for continuous measures. Linear regression models were developed to evaluate the associations of clinical factors with the time interval to menarche. @*Results@#Mean age was 9.4±1.6 years at treatment onset, and treatment duration was 2.2±1.4 years. Menarche occurred at 12.6±1.1 years, which was 1.04±0.5 years after treatment discontinuation. This was negatively associated with Tanner stage of breast development and bone age at treatment onset and change in bone age during treatment. No association was seen between time interval to menarche and treatment duration, medication, or body mass index. @*Conclusion@#We found the average time interval to menarche after GnRHa treatment in our population of female patients with CPP to be 1.04±0.5 years; this is in agreement with other reports. Tanner stage of breast development, bone age at treatment onset, and change in bone age were negatively associated with time interval to menarche. These data provide clinical correlates that assist providers during anticipatory guidance of patients with CPP after GnRHa treatment.

API Driven On-Demand Participant ID Pseudonymization in Heterogeneous Multi-Study Research / 대한의료정보학회지

Objectives@#To facilitate clinical and translational research, imaging and non-imaging clinical data from multiple disparate systems must be aggregated for analysis. Study participant records from various sources are linked together and to patient records when possible to address research questions while ensuring patient privacy. This paper presents a novel tool that pseudonymizes participant identifiers (PIDs) using a researcher-driven automated process that takes advantage of application-programming interface (API) and the Perl Open-Source Digital Imaging and Communications in Medicine Archive (POSDA) to further de-identify PIDs. The tool, on-demand cohort and API participant identifier pseudonymization (O-CAPP), employs a pseudonymization method based on the type of incoming research data. @*Methods@#For images, pseudonymization of PIDs is done using API calls that receive PIDs present in Digital Imaging and Communications in Medicine (DICOM) headers and returns the pseudonymized identifiers. For non-imaging clinical research data, PIDs provided by study principal investigators (PIs) are pseudonymized using a nightly automated process. The pseudonymized PIDs (P-PIDs) along with other protected health information is further de-identified using POSDA. @*Results@#A sample of 250 PIDs pseudonymized by O-CAPP were selected and successfully validated. Of those, 125 PIDs that were pseudonymized by the nightly automated process were validated by multiple clinical trial investigators (CTIs). For the other 125, CTIs validated radiologic image pseudonymization by API request based on the provided PID and P-PID mappings. @*Conclusions@#We developed a novel approach of an ondemand pseudonymization process that will aide researchers in obtaining a comprehensive and holistic view of study participant data without compromising patient privacy.

Clinical findings influencing time to menarche post gonadotropin-releasing hormone agonist therapy in central precocious puberty

Purpose@#This study aimed to evaluate the time interval to menarche after gonadotropin-releasing hormone agonist (GnRHa) treatment in females with central precocious puberty (CPP) and to identify factors contributing to timing of menarche. @*Methods@#We retrospectively reviewed medical records of 39 females with CPP who reached menarche after GnRHa treatment (leuprolide or histrelin). CPP diagnostic criteria were breast development at <8 years old, measurable pubertal luteinizing hormone and/or estradiol concentrations, and bone age advancement. Indications to treat were advanced bone age and psychosocial concerns. Descriptive summaries were reported as frequency and proportion for categorical variables and mean and standard deviation for continuous measures. Linear regression models were developed to evaluate the associations of clinical factors with the time interval to menarche. @*Results@#Mean age was 9.4±1.6 years at treatment onset, and treatment duration was 2.2±1.4 years. Menarche occurred at 12.6±1.1 years, which was 1.04±0.5 years after treatment discontinuation. This was negatively associated with Tanner stage of breast development and bone age at treatment onset and change in bone age during treatment. No association was seen between time interval to menarche and treatment duration, medication, or body mass index. @*Conclusion@#We found the average time interval to menarche after GnRHa treatment in our population of female patients with CPP to be 1.04±0.5 years; this is in agreement with other reports. Tanner stage of breast development, bone age at treatment onset, and change in bone age were negatively associated with time interval to menarche. These data provide clinical correlates that assist providers during anticipatory guidance of patients with CPP after GnRHa treatment.

Toolkit to Compute Time-Based Elixhauser Comorbidity Indices and Extension to Common Data Models / 대한의료정보학회지

Objectives@#The time-dependent study of comorbidities provides insight into disease progression and trajectory. We hypothesize that understanding longitudinal disease characteristics can lead to more timely intervention and improve clinical outcomes. As a first step, we developed an efficient and easy-to-install toolkit, the Time-based Elixhauser Comorbidity Index (TECI), which pre-calculates time-based Elixhauser comorbidities and can be extended to common data models (CDMs). @*Methods@#A Structured Query Language (SQL)-based toolkit, TECI, was built to pre-calculate time-specific Elixhauser comorbidity indices using data from a clinical data repository (CDR). Then it was extended to the Informatics for Integrating Biology and the Bedside (I2B2) and Observational Medical Outcomes Partnership (OMOP) CDMs. @*Results@#At the University of Arkansas for Medical Sciences (UAMS), the TECI toolkit was successfully installed to compute the indices from CDR data, and the scores were integrated into the I2B2 and OMOP CDMs. Comorbidity scores calculated by TECI were validated against: scores available in the 2015 quarter 1–3 Nationwide Readmissions Database (NRD) and scores calculated using the comorbidities using a previously validated algorithm on the 2015 quarter 4 NRD. Furthermore, TECI identified 18,846 UAMS patients that had changes in comorbidity scores over time (year 2013 to 2019). Comorbidities for a random sample of patients were independently reviewed, and in all cases, the results were found to be 100% accurate. @*Conclusions@#TECI facilitates the study of comorbidities within a time-dependent context, allowing better understanding of disease associations and trajectories, which has the potential to improve clinical outcomes.

Genetic Architecture of Circulating Very-Long-Chain (C24:0 and C22:0) Ceramide Concentrations

OBJECTIVE: Total ceramide concentrations are linked with increased insulin resistance and cardiac dysfunction. However, recent studies have demonstrated that plasma concentrations of specific very-long-chain fatty ceramides (C24:0 and C22:0) are associated with a reduced incidence of coronary heart disease and all-cause mortality. We hypothesized that specific genetic loci are associated with plasma C22:0 and C24:0 concentrations.METHODS: Heritability and genome-wide association studies of plasma C24:0 and C22:0 ceramide concentrations were performed among 2,217 participants in the Framingham Heart Study Offspring Cohort, adjusting for cardiovascular risk factor covariates and cardiovascular drug treatment.RESULTS: The multivariable-adjusted heritability for C22:0 and C24:0 ceramides was 0.42 (standard error [SE], 0.07; p=1.8E-9) and 0.25 (SE, 0.08; p=0.00025), respectively. Nineteen single nucleotide polymorphisms (SNPs), all on chromosome 20, significantly associated with C22:0 concentrations; the closest gene to these variants was SPTLC3. The lead SNP (rs4814175) significantly associated with 3% lower plasma C22:0 concentrations (p=2.83E-11). Nine SNPs, all on chromosome 20 and close to SPTLC3, were significantly associated with C24:0 ceramide concentrations. All 9 were also significantly related to plasma C22:0 levels. The lead SNP (rs168622) was significantly associated with 10% lower plasma C24:0 ceramide concentrations (p=9.94E-09).CONCLUSION: SNPs near the SPTLC3 gene, which encodes serine palmitoyltransferase long chain base subunit 3 (SPTLC3; part of the enzyme that catalyzes the rate-limiting step of de novo sphingolipid synthesis) were associated with plasma C22:0 and C24:0 ceramide concentrations. These results are biologically plausible and suggest that SPTLC3 may be a potential therapeutic target for C24:0 and C22:0 ceramide modulation.

Dystrophic muscle distribution in late-stage muscular dystrophy

There is scant information about the comprehensive distribution of dystrophic muscles in muscular dystrophy. Despite different clinical presentations of muscular dystrophy, a recent multi-center study concluded that phenotypic distribution of dystrophic muscles is independent of clinical phenotype and suggested that there is a common pattern of involved muscles. To evaluate this possibility, the present case report used cadaveric dissection to determine the whole-body distribution of fat-infiltrated, dystrophic muscles from a 72-year-old white male cadaver with adult-onset, late-stage muscular dystrophy. Severely dystrophic muscles occupied the pectoral, gluteal and pelvic regions, as well as the arm, thigh and posterior leg. In contrast, muscles of the head, neck, hands and feet largely appeared unaffected. Histopathology and a CT-scan supported these observations. This pattern of dystrophic muscles generally conformed with that described in the multi-center study, and provides prognostic insight for patients and the physicians treating them.

Experiences from the field: Chilean healthcare providers' perspectives on partner notification for syphilis - a qualitative case study / Experiencias en el campo: perspectivas de los proveedores de salud chilenos sobre la notificación de parejas para sífilis ­ un estudio de caso cualitativo

Introduction: Partner Notification (NP) has long been considered an essential strategy for the control of sexually transmitted infections (STIs). Although the delivery of clinical services for STIs has improved in Chile, syphilis in the general population is one of the most commonly reported STIs. Objective: To understand PN current practices and challenges, we explored health care providers' (HCPs) perspectives about PN for syphilis in public health services in Chile. Methods: Semi-structured interviews were conducted with HCPs in 14 primary health care centres and 6 sexual health units located at two regional Health Services as well as with key informants from different backgrounds. Interviews were transcribed verbatim and coded using QSR International's NVivo 11 PRO Software, for cross-case thematic analysis, which followed an inductive approach. Selected quotes were translated from Spanish to English. Consensus on codes and themes was reached by the multi-disciplinary research team. Results: A total of 58 interviews were conducted. Forty-eight HCPs were interviewed across both Health Services; most with midwives with more than 10 years of work experience; and ten were key informants. Participants acknowledged PN as a syphilis control strategy with patient referral being the most common approach. Participants commented that index cases do not provide information about their partners easily and the delivery of PN is further impacted by gender and the socio-cultural context of Chile. PN was perceived by HCPs as an exhausting and difficult process. Conclusion: This is the first study to identify the perceptions of Chilean HCPs about PN for syphilis. PN is a valuable strategy for syphilis control in Chile; however, our findings suggest that HCPs consider this strategy a challenge both for them and for the Chilean population. Improving current practices and increasing awareness about PN would strengthen the work that has been done by HCPs for syphilis control and enhance the long-term impact of existing policies.

la Notificación de Pareja (NP) se ha considerado durante mucho tiempo una estrategia esencial para el control de las infecciones de transmisión sexual (ITS). Aunque la prestación de servicios clínicos para las ITS ha mejorado en Chile, la sífilis en la población general es una de las ITS más comúnmente reportadas. Objetivo: Para comprender las prácticas y los desafíos actuales de la NP, exploramos las perspectivas de los proveedores de salud (PS) sobre la NP para la sífilis en los servicios de salud pública en Chile. Métodos: Se realizaron entrevistas semiestructuradas con PS en 14 centros de atención primaria de salud y 6 unidades de salud sexual ubicadas en dos servicios de salud regionales, así como con informantes clave (IC) de diferentes orígenes. Las entrevistas se transcribieron textualmente y se codificaron utilizando el software NVivo 11 PRO de QSR International, para el análisis temático de casos cruzados, que siguió un enfoque inductivo. Las citas seleccionadas fueron traducidas del español al inglés. El equipo de investigación multidisciplinario llegó a un consenso sobre códigos y temas. Resultados: Se realizaron un total de 58 entrevistas. Se entrevistaron 48 PS en ambos Servicios de Salud; la mayoría con matrones con más de 10 años de experiencia laboral; y diez eran IC. Los participantes reconocieron la NP como una estrategia de control de la sífilis, siendo la derivación de pacientes el enfoque más común. Los participantes comentaron que los casos índice no proporcionan información sobre sus parejas fácilmente y que la entrega de NP se ve afectada aún más por el género y el contexto sociocultural de Chile. La NP fue percibida por los PS como un proceso agotador y difícil. Conclusión: Este es el primer estudio que identifica las percepciones de los PS chilenos sobre la NP para la sífilis. La NP es una estrategia valiosa para el control de la sífilis en Chile; sin embargo, nuestros hallazgos sugieren que los PS consideran esta estrategia como un desafío tanto para ellos como para la población chilena. Mejorar las prácticas actuales y aumentar la conciencia sobre la NP fortalecería el trabajo realizado por los profesionales de la salud para el control de la sífilis y mejoraría el impacto a largo plazo de las políticas existentes

Crecimiento in vitro y morfología inusual de Campylobacter aislada de un paciente con bacteriemia / In Vitro growth and unusual Campylobacter morphology isolated from a patient with bacteremia

Resumen Campylobacter sp. es una bacteria que se adapta a diferentes condiciones y permite un cambio en su forma y requerimientos metabólicos, dificultando su diagnóstico microbiológico. Presentamos el caso de un paciente oncológico de 65 años con bacteriemia por Campylobacter sp. Se desarrolló el cultivo de microbiología clásico en microaerofilia a 42 o C, cultivo aeróbico en agar sangre a 37 o C y hemocultivo aeróbico a 37 o C. Además, se realizó la reacción en cadena de la polimerasa para identificar el agente. La bacteria creció en todos los medios mostrando su termotolerancia y tolerancia a diferentes concentraciones de oxígeno, además de presentar una forma en espiral en el hemocultivo aeróbico. Finalmente, enfatizamos la flexibilidad fisiológica de la bacteria para adaptarse a diferentes condiciones y la importancia de la prueba molecular para identificar al agente, en especial en el crecimiento aeróbico en forma de espiral que pudiera confundirse con otras espiroquetas que causan episodios febriles.

Abstract Campylobacter sp. It is a bacterium that adapts to different conditions and allows a change in its form and metabolic requirements, making microbiological diagnosis difficult in such conditions. We present the case of a 65-year-old cancer patient with bacteremia caused by Campylobacter sp. The culture of classical microbiology was developed in microaerophilic at 42 o C, aerobic culture on blood agar at 37 o C and aerobic blood culture at 37 o C. In addition, the polymerase chain reaction was performed to identify the agent. The bacteria grew in all media showing its thermotolerance and tolerance to different concentrations of oxygen, in addition to presenting a spiral shape in the aerobic blood culture. Finally, we emphasize the physiological flexibility of the bacterium to adapt to different conditions and the importance of the molecular test to identify the agent especially in aerobic growth in spiral form, which could be confused with other spirochetes that cause febrile episodes.

Relationships among classifications of ayurvedic medicine diagnostics for imbalances and western measures of psychological states: An exploratory study

Background: According to Ayurveda, the traditional medical system of India, doshas are a combination ofcharacteristics based on a five-element philosophy that drive our mental and physical tendencies. Whenthe doshas, or functional principles, are out of balance in quality or quantity, wellbeing is adverselyaffected and symptoms manifest.Objective: This study examined relationships among imbalances in the doshas (termed Vikruti) reportedvia questionnaire and Western measures of psychological states.Materials and methods: Study participants were 101 women (n ¼ 81) and men (n ¼ 20), mean age 53.9years (SD ¼ 11.7; range 32e80). Participants completed questionnaires to categorize their Vikruti typeand psychological states, which included depressed mood (CESD), anxiety (PROMIS), rumination &reflection (RRQ), mindfulness (MAAS), stress (PSS), and quality of life (Ryff).Results: Multivariate general linear modeling, controlling for age, gender and body mass index (BMI),showed that Vata imbalance was associated with more anxiety (p 0.05), more rumination (p 0.01),less mindfulness (p 0.05), and lower overall quality of life (p 0.01). Pitta imbalance was associatedwith poorer mood (p 0.01) and less mindfulness (p 0.05), more anxiety (p 0.05) and stress(p 0.05). Kapha imbalance was associated with more stress (p 0.05), more rumination (p 0.05) andless reflection (p 0.05).Conclusion: These findings suggest that symptoms of mind-body imbalances in Ayurveda are differentially associated with western assessments of psychological states. Ayurvedic dosha assessment may bean effective way to assess physical as well as emotional wellbeing in research and clinical settings.© 2018 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services byElsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Ministry of Health Clinical Practice Guidelines: Chronic Obstructive Pulmonary Disease

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Chronic Obstructive Pulmonary Disease (COPD) to provide doctors and patients in Singapore with evidence-based treatment for COPD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on COPD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: https://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Resistance among Gram-negative ESKAPE pathogens isolated from hospitalized patients with intra-abdominal and urinary tract infections in Latin American countries: SMART 2013-2015

ABSTRACT Gram-negative ESKAPE pathogens (Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are important etiologic agents of nosocomial infection that are frequently resistant to broad-spectrum antimicrobial agents. Gram-negative ESKAPE pathogens were collected from hospitalized patients in 11 Latin American countries from 2013 to 2015 as part of the Study for Monitoring Antimicrobial Resistance Trends (SMART) global surveillance program. In total, 2113 isolates from intra-abdominal infections (IAI) and 970 isolates from urinary tract infections (UTI) were tested against antimicrobial agents using standardized CLSI broth microdilution methodology. Of the agents tested, amikacin demonstrated the highest rates of susceptibility (%) for K. pneumoniae (92.2, 92.3), Enterobacter spp. (97.5, 92.1), and P. aeruginosa (85.3, 75.2) isolates from both IAI and UTI, respectively. Ertapenem (68.5, 62.6) and imipenem (79.2, 75.9) showed substantially higher rates of susceptibility (%) than other β-lactams, including piperacillin-tazobactam (35.9, 37.4) against ESBL-positive isolates of K. pneumoniae from IAI and UTI, respectively. Rates of susceptibility to all agents tested against A. baumannii were ≤30.9%. Gram-negative ESKAPE pathogens isolated from Latin America demonstrated compromised in vitro susceptibility to commonly prescribed broad-spectrum, parenteral antimicrobial agents. Continued surveillance is warranted. New antimicrobial agents with potent activity against Gram-negative ESKAPE pathogens are urgently needed.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua / La atención integrada de las infecciones infantiles en la comunidad salva vidas en las comunidades de difícil acceso de Nicaragua / O manejo integrado de casos na comunidade (iCCM) aplicado às infecções infantis salva vidas em comunidades de difícil acesso na Nicarágua

ABSTRACT Objective To describe Nicaragua’s integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. Method This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007–2013 in 120 remote Nicaraguan communities where brigadistas (“health brigadiers”) offered iCCM services to children 2–59 months old. The study used program monitoring data from brigadistas’ registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. Results Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25–0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21–0.81). Conclusions The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

RESUMEN Objetivo Describir el programa nicaragüense de atención integrada en la comunidad destinado a las comunidades rurales de difícil acceso y evaluar sus efectos a partir de los datos de seguimiento, como los datos censales anuales sobre la mortalidad infantil (menores de 1 año). Método Este estudio de observación tuvo como objetivo valorar la ejecución de la atención integrada en la comunidad y medir las tendencias de la mortalidad infantil (menores de 1 año) entre el 2007 y el 2013 en 120 comunidades nicaragüenses remotas donde los brigadistas brindan servicios de atención integrada en la comunidad a niños de 2 a 59 meses. El estudio se valió de datos programáticos de seguimiento obtenidos de los registros y las listas de verificación utilizadas para la supervisión de los brigadistas, así como datos de mortalidad derivados de los censos anuales realizados por el Ministerio de Salud. Se calculó la razón de mortalidad (defunciones de lactantes por cantidad de menores de un año vivos) y se informaron estimaciones puntuales e intervalos de confianza binomiales exactos. Resultados Los datos de seguimiento mostraron una ejecución sólida del programa de atención integrada en la comunidad en el período del estudio, dado que la disponibilidad de medicamentos, los registros completos y la clasificación correcta siempre superaron el 80%. Como parte del tratamiento proporcionado contra la neumonía y la diarrea, los brigadistas llevaron a cabo un seguimiento minucioso de los casos previstos y los cuidadores solicitaron tratamiento de los brigadistas con más frecuencia que de los establecimientos de salud. La razón de mortalidad infantil (menores de 1 año) disminuyó más en las zonas atendidas por el programa que en aquellas no atendidas. Se observó una disminución estadísticamente significativa del 52% en el 2010 (razón de la tasa de mortalidad 0,48; IC del 95%: 8%-75%) al 59% en el 2013 (razón de la tasa de mortalidad 0,41; IC del 95%: 19%-79%). Conclusiones El programa de atención integrada en la comunidad es una estrategia eficaz y factible para salvar la vida de los lactantes en las comunidades de difícil acceso de Nicaragua. Estos efectos probablemente estuvieron mediados por la mayor prestación de intervenciones curativas, que estuvieron accesibles y disponibles en el ámbito de la comunidad, y fueron brindadas por los brigadistas por medio de servicios de buena calidad.

RESUMO Objetivo Descrever o programa de manejo integrado de casos na comunidade (iCCM) para comunidades rurais e de difícil acesso na Nicarágua e avaliar seu impacto usando dados de monitoramento, inclusive dados censitários anuais de mortalidade infantil. Método Este estudo observacional avaliou o nível de implementação da estratégia iCCM e calculou tendências de mortalidade infantil nos anos 2007-2013 em 120 comunidades remotas da Nicarágua onde “brigadistas de saúde” prestam serviços de iCCM para crianças de 2 a 59 meses de idade. Foram utilizados dados de monitoramento obtidos dos cadastros e checklists de supervisão de brigadistas e dados de mortalidade obtidos dos censos anuais realizados pelo Ministério da Saúde. Foi calculado o coeficiente de mortalidade infantil (número de óbitos infantis dividido pelo número de crianças menores de 1 ano vivas), além de estimativas pontuais e intervalos de confiança (IC) binomiais exatos. Resultados Os dados de monitoramento evidenciaram forte implementação da estratégia iCCM durante o período de estudo; a disponibilidade de medicamentos, a integralidade dos registros e a classificação correta sempre excederam 80%. O tratamento da pneumonia e da diarreia por brigadistas acompanhou de perto o número de casos esperado, e os responsáveis pelas crianças sistematicamente buscaram tratamento com maior frequência junto aos brigadistas do que nos serviços de saúde. O coeficiente de mortalidade infantil diminuiu mais nas áreas com iCCM do que nas áreas sem iCCM. A redução foi estatisticamente significante, variando de 52% em 2010 (razão de taxa de mortalidade: 0,48; IC95%: 8%–75%) a 59% em 2013 (razão de taxa de mortalidade: 0,41; IC95%: 19%–79%). Conclusões Constatou-se que a iCCM é uma estratégia eficaz e viável para salvar vidas de crianças em comunidades de difícil acesso na Nicarágua. O impacto provavelmente foi mediado pelo aumento do uso de intervenções resolutivas, disponibilizadas de maneira acessível no âmbito da comunidade, através do serviço qualificado prestado pelos brigadistas.

Analysis of the clinical indications for opiate use in inflammatory bowel disease

BACKGROUND/AIMS: Opiate use for inflammatory bowel disease (IBD), particularly high-dose (HD) use, is associated with increased mortality. It's assumed that opiate use is directly related to IBD-related complaints, although this hasn't been well defined. Our goal was to determine the indications for opiate use as a first step in developing strategies to prevent or decrease opiate use. METHODS: A retrospective cohort was formed of adults who were diagnosed with IBD and for whom outpatient evaluations from 2009 to 2014 were documented. Opiate use was defined if opiates were prescribed for a minimum of 30 days over a 365-day period. Individual chart notes were then reviewed to determine the clinical indication(s) for low-dose (LD) and HD opiate use. RESULTS: After a search of the electronic records of 1,109,277 patients, 3,226 patients with IBD were found. One hundred four patients were identified as opiate users, including 65 patients with Crohn's and 39 with ulcerative colitis; a total of 134 indications were available for these patients. IBD-related complaints accounted for 49.25% of the opiate indications, with abdominal pain (23.13%) being the most common. Overall, opiate use for IBD-related complaints (81.40% vs. 50.82%; P=0.0014) and abdominal pain (44.19% vs. 19.67%; P=0.0071) was more common among HD than among LD. CONCLUSIONS: Our findings show that most IBD patients using opiates, particularly HD users, used opiates for IBD-related complaints. Future research will need to determine the degree to which these complaints are related to disease activity and to formulate non-opiate pain management strategies for patients with both active and inactive IBD.

Time volunteered on community health activities by brigadistas in Nicaragua / Tiempo de trabajo voluntario dedicado a actividades relacionadas con la salud en la comunidad de los brigadistas en Nicaragua

ABSTRACT Objective To report on how brigadistas (“health brigadiers”) in Nicaragua volunteer their time before the introduction of expanded responsibilities (beyond the scope of integrated community case management (iCCM)) for sick children 2–59 months old. Methods Three complete teams of brigadistas (n = 12 brigadistas total) were selected from remote communities in the department of Matagalpa. Each respondent brigadista was interviewed privately regarding the frequency and duration (i.e., preparation, round-trip travel, and implementation time) of 13 separate activities. The correlation between their overall estimates and summed times of individual activities were measured. Results Brigadista mean density was 1 per 156 total population (range: 120–217). Each team had one encargado/a (“manager”) with an iCCM drug box plus two to four asistentes (“assistants”). All resided in the community they served. Eight reported competing time demands during one to nine months of the year. Brigadistas volunteered an average of 75 hours per month (range: 35–131). Encargados were busier than asistentes (98 versus 68 hours per month). Three activities accounted for 70% of their time: 1) iCCM (30%: treatment (11%), follow-up (19%)); 2) receiving training (21%); and 3) promoting birth planning (19%). Brigadistas’ time was divided among preparation (12%), travel (27%), and implementation (61%). Overall estimates were highly correlated (+0.70) with summed implementation time. Conclusions Brigadistas from these remote Nicaraguan communities were busy with different activities, levels of effort, and patterns of task-sharing. These findings, plus an ongoing job satisfaction survey and a follow-on time study after the introduction of the new interventions, will inform policy for this valuable volunteer cadre.

RESUMEN Objetivo Informar sobre el trabajo voluntario de los brigadistas en Nicaragua antes de la ampliación de sus responsabilidades (más allá del manejo de casos a nivel comunitario) para que se ocuparan también de los niños enfermos de 2 a 59 meses. Métodos Se seleccionaron tres equipos completos de brigadistas (n = 12 brigadistas en total) de comunidades remotas del departamento de Matagalpa. Cada brigadista fue entrevistado en privado sobre la frecuencia y la duración (es decir, preparación, viaje de ida y vuelta, y tiempo de ejecución) de 13 actividades diferentes. Se midió la correlación entre sus cálculos generales y la suma de los tiempos de las actividades individuales. Resultados La densidad promedio de brigadistas era de 1 por 156 habitantes (intervalo: 120-200). Cada equipo tenía un encargado con una caja de medicamentos para el manejo de casos comunitario y de dos a cuatro asistentes. Todos residían en la comunidad que atendían. Ocho informaron exigencias de tiempo conflictivas de uno a nueve meses al año. Los brigadistas trabajaban como voluntarios un promedio de 75 horas por mes (intervalo: 35-131). Los encargados estaban más ocupados que los asistentes (98 horas frente a 68 horas por mes). Tres actividades insumían el 70% de su tiempo: 1) manejo de casos a nivel comunitario (30%: tratamiento [11%], seguimiento [19]); 2) participación en actividades de capacitación (21%), y 3) promoción de la planificación del nacimiento (19%). El tiempo de los brigadistas se repartía entre la preparación (12%), el viaje (27%) y la ejecución (61%). Se observó una elevada correlación (+0,70) entre los cálculos generales y la suma de los tiempos de ejecución. Conclusiones Los brigadistas de estas comunidades remotas nicaragüenses realizaban distintas actividades, con niveles de esfuerzo y esquemas de división de tareas diferentes. Estos resultados, además de una encuesta en curso sobre la satisfacción en el trabajo y un estudio de seguimiento de los tiempos después de la introducción de las nuevas intervenciones, servirán para fundamentar las políticas en relación con este valioso equipo de voluntarios.