Implementation and outcome evaluation of the medical education partnership initiative biostatistical reasoning workshops for faculty and postgraduate students at the university of kwazulu-natal; durban; south africa

Background. There is a shortage of biostatistics expertise at the University of KwaZulu-Natal (UKZN); Durban; South Africa and in the African region. This constrains the ability to carry out high-quality health research in the region.Objectives. To quantitatively and qualitatively evaluate a programme designed to improve the conceptual and critical understanding of bio statistical concepts of UKZN health researchers.Methods. A 40-hour workshop in biostatistical reasoning was conducted annually between 2012 and 2015. The workshops were structured around interpretation and critical assessment of nine articles from the medical literature; with a mix of in-class sessions and small group discussions. Quantitative evaluation of the knowledge gained from the workshops was carried out using a pre- and post-workshop quiz; and qualitative evaluation of the workshop process was done using a mid-workshop questionnaire and focus group discussions.Results. For each year that the workshop was conducted; post-workshop quiz scores were significantly higher than pre-workshop scores. When quiz assessments from all 4 years of training were combined; the pretest median score was 55% (interquartile range (IQR) 40 - 62%) and the post-test median score was 68% (IQR 62 - 76%); with p0.0001 for the overall comparison of pre- v. post-scores. There was a general consensus among participants that the workshop improved their reasoning skills in biostatistics. Participants also recognised the value of the workshop in building biostatical capacity at UKZN. Conclusion. The workshops were well received and improved the critical and conceptual understanding of the participants. This education mode offers the opportunity for health researchers to advance their knowledge in settings where there are few professional biostatistician collaborators

Bacteriemia en daño hepático crónico / Bacteremia in patients with liver cirrhosis

Las infecciones bacteriémicas son más frecuentes en el paciente cirrótico que en la población general. Se identificaron retrospectivamente 59 pacientes cirróticos con bacteriemia, hospitalizados entre los años 2005 y 2008. La bacteriemia sin foco fue la más frecuente (29 por ciento), seguida de aquellas de origen pulmonar (22 por ciento). Cincuenta y dos por ciento de los agentes aislados correspondieron a cocáceas grampositivas y 48 por ciento a bacilos gramnegativos, siendo estos últimos los agentes predominantes en las bacteriemias nosocomiales. Los principales agentes aislados fueron Staphylococcns aureus (24 por ciento) y Escherichia col i (22 por ciento). La mortalidad de los pacientes cirróticos bacteriémicos fue mayor que la del total de cirróticos hospitalizados (37 vs 9,4 por ciento; p < 0,001) y la medición del puntaje de MELD a las 72 horas se correlacionó significativamente con la mortalidad. Conclusión: La bacteriemia es una complicación grave del paciente cirrótico y el MELD podría ser útil en su categorización de riesgo.

Bacteremic infections are more frequent in patients with cirrhosis, as their immune system is compromised. Series of cirrhotic patients with bacteremia has seldom been reported in Chile. We retrospectively collected, from 2005 to 2008, 59 episodes of bacteremia in cirrhotics representing 9 percent of the overall number of bacteremic episodes seen in our center in the period. Spontaneous bacteremia accounted for 29 percent followed by those of pulmonary origin (22 percent). Grampositive cocci and gramnegative bacilli were responsible in 52 percent and 48 percent respectively, however gramnegative rods predominated in nosocomial bacteremias. Overall, the most frequent organisms were Staphylococcus aureus (24 percent) and Escherichia col i (22 percent). Mortality in bacteremic patients was significantly higher compared with all cirrhotic patients hospitalized in the period (37.0 vs 9.4 percent; p < 0.001) and MELD score was significantly correlated with mortality. Conclusion: bacteremia is a severe complication of cirrhosis and MELD score could be a useful tool to stratify risk in these patients.

ApoE polymorphisms and diarrheal outcomes in Brazilian shanty town children

A series of studies have shown that the heavy burdens of diarrheal diseases in the first 2 formative years of life in children living in urban shanty towns have negative effects on physical and cognitive development lasting into later childhood. We have shown that APOE4 is relatively common in shanty town children living in Brazil (13.4 percent) and suggest that APOE4 has a protective role in cognitive development as well as weight-for-height in children with heavy burdens of diarrhea in early childhood (64/123; 52 percent), despite being a marker for cognitive decline with Alzheimer’s and cardiovascular diseases later in life. APOE2 frequency was higher among children with heaviest diarrhea burdens during the first 2 years of life, as detected by PCR using the restriction fragment length polymorphism method, raising the possibility that ApoE-cholesterol balance might be critical for growth and cognitive development under the stress of heavy diarrhea burdens and when an enriched fat diet is insufficient. These findings provide a potential explanation for the survival advantage in evolution of genes, which might raise cholesterol levels during heavy stress of diarrhea burdens and malnutrition early in life.

Listeria monocytogenes: informe de un aumento de casos en mujeres embarazadas y revisión de la literatura / Listeria monocytogenes: report of a rise in pregnant women and literature review

Listeria monocytogenes, rare pathogen in the general population, causes serious infections in patients at the extreme ages of life, pregnant woman, and those with immunosuppression. The clinical manifestations are essential to suspect the disease in patients at risk, allowing an early prescription of antimicrobial therapy, before the results of the cultures are available. Clinical course and prognosis depends on how early treatment is started and, in pregnant women, the gestational age. In Clínica Alemana, at Santiago, we detected a 15 fold rate rise of neonatal listeriosis between year 2007 and 2008. Ten cases were diagnosed between January and July 2008 and the seven cases occurring in pregnant women are reported here. All these patients were in their first pregnancy, which could be associated with similar lifestyle and food habits. Considering this new epidemiological scenario, it is important to educate the population, and to conduct an epidemiological study in order to determine the national situation of Listeria monocytogenes infection.

Listeria monocytogenes, es un patógeno poco frecuente en la población general, causante de infecciones graves en pacientes en edades extremas de la vida, mujeres embarazadas e inmunodeprimidos. La sospecha de la enfermedad en pacientes de riesgo se basa principalmente en el cuadro clínico, lo que permite iniciar un tratamiento empírico antes de contar con los resultados de los cultivos. La evolución y pronóstico dependen de la precocidad con que se inicia la terapia y de la edad gestacional. En Clínica Alemana de Santiago detectamos un aumento de 15 veces en la tasa de listeriosis comparando el año 2007 con el 2008. Entre enero y julio 2008, se diagnosticaron 10 casos, de los cuales siete fueron en primigestas, lo que podría tener relación con un hábito alimentario y características de vida similar. Es fundamental, a la vista de esta nueva realidad epidemiológica, educar a la población en hábitos alimentarios y de higiene, como también realizar un estudio epidemiológico que determine la situación nacional de infección por L. monocytogenes.

Modulation of store-operated Ca2+ entry by cyclic-ADP-ribose

Store-operated Ca2+ entry plays an important role in Ca2+ homeostasis in cells but the mechanisms of control of these channels are not completely understood. We describe an investigation of the role of the CD38-cyclic-ADP-ribose (cADPR)-ryanodine-channel (RyR) signaling pathway in store-operated Ca2+ entry in human smooth muscle. We observed that human myometrial cells have a functional store-operated Ca2+ entry mechanism. Furthermore, we observed the presence of transient receptor potential 1, 3, 4, 5, and 6 ion channels in human myometrial cells. Store-operated Ca2+ transient was inhibited by at least 50-70 percent by several inhibitors of the RyR, including ryanodine (10 µM), dantrolene (10 µM), and ruthenium red (10 µM). Furthermore, the cell permeable inhibitor of the cADPR-system, 8-Br-cADPR (100 µM), is a potent inhibitor of the store-operated entry, decreasing the store operated entry by 80 percent. Pre-incubation of cells with 100 µM cADPR and the hydrolysis-resistant cADPR analog 3-deaza-cADPR (50 µM), but not with ADP-ribose (ADPR) leads to a 1.6-fold increase in the store-operated Ca2+ transient. In addition, we observed that nicotinamide (1-10 mM), an inhibitor of cADPR synthesis, also leads to inhibition of the store-operated Ca2+ transient by 50-80 percent. Finally, we observed that the transient receptor potential channels, RyR, and CD38 can be co-immunoprecipitated, indicating that they interact in vivo. Our observations clearly implicate the CD38-cADPR-ryanodine signaling pathway in the regulation of store-operated Ca2+ entry in human smooth muscle cells.

The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain

Background: The objective of this paper is to describe the numbers; characteristics; and trends in the migration to the United States of physicians trained in sub-Saharan Africa. Methods: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA. Results :More than 23of America's 771 491 physicians received their medical training outside the USA; the majority (64) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group; a number that represents more than 6of the physicians practicing in sub-Saharan Africa now. Nearly 86of these Africans practicing in the USA originate from only three countries: Nigeria; South Africa and Ghana. Furthermore; 79were trained at only 10 medical schools. Conclusions: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain

Fusariosis diseminada por Fusarium oxysporum en un paciente adulto con leucemia mieloide aguda y neutropenia severa febril / Disseminated fusariosis by Fusarium oxysporum in an adult patient with acute myeloid leukemia and severe febrile neutropenia

Reportamos el primer caso de fusariosis diseminada en un paciente adulto en Chile, con una neoplasia hematológica y tratamiento quimioterápico, quien evolucionó con neutropenia febril prolongada, refractaria, fuera tratado con un amplio esquema antibacteriano y desarrollara una infección multisistémica, con compromiso cutáneo, sinusal y pulmonar por Fusarium oxysporum. Cursó con refractariedad al tratamiento antifúngico con anfotericina B deoxicolato y caspofungina, utilizados en forma secuencial. El desenlace fatal de este paciente se asoció a la persistencia de la neutropenia y a la infección por un hongo filamentoso habitualmente resistente a terapia antifúngica.

Consenso: manejo racional del paciente con cáncer, neutropenia y fiebre / Consensus: rational approach towards the patient with cancer, fever and neutropenia

La intensidad y duración de la neutropenia post quimioterapia fueron identificadas en la década del 60 como los factores de mayor relevancia predisponentes a infecciones en pacientes con cáncer. A inicios de la década del 70 se estableció un manejo estandarizado para todos los episodios de neutropenia febril (NF), consistente en hospitalización y terapia antimicrobiana intravenosa empírica, de amplio espectro, lo que se tradujo en una importante disminución de la mortalidad por infecciones bacterianas en estos pacientes. En los últimos 10 a 15 años, distintos grupos de investigadores han considerado poco beneficiosas estas estrategias estandarizadas, que proporcionan un manejo uniforme a todos los pacientes con episodios de NF, independiente de la gravedad de estos. Así, se acuñaron en la década pasada los conceptos de NF de alto y bajo riesgo, lo que ha permitido implementar estrategias terapéuticas diferenciadas según el riesgo que entrañe el episodio para cada paciente en particular. La Sociedad Chilena de Infectología ha tenido la iniciativa de proponer, en un trabajo conjunto con dos programas gubernamentales: Programa Infantil de Drogas Antineoplásicas y Programa Adulto de Drogas Antineoplásicas y la Sociedad Chilena de Hematología, un consenso de diagnóstico, manejo terapéutico y prevención de NF en adultos y niños con cáncer, considerando básicamente dos aspectos: el cambio de enfoque que esta patología ha tenido en la última década, lo que obliga a una revisión sistematizada del tema, y en segundo lugar, una población creciente de pacientes oncológicos, cada vez con mejores expectativas terapéuticas para su patología de base, lo que exige ofrecer en forma acorde un muy buen manejo de esta complicación. Entregamos este documento con una completa revisión de la literatura médica sobre epidemiología, exploración de laboratorio, categorización de riesgo, enfoque terapéutico y quimioprofilaxis, con la mayor cantidad de datos nacionales disponibles, para ofrecer al equipo de salud que atiende a estos pacientes recomendaciones basadas en evidencias, y acotadas a nuestra realidad nacional.

Microbiología en endocarditis infecciosa: análisis crítico de la bacteriología en Chile: el desafío de los hemocultivos negativos / Microbiology in infectious endocarditis: critical analysis of bacteriology in Chile: the challenge of the negative hemocultures

El diagnóstico etiológico de la EI (Endocarditis Infecciosa) se realiza fundamentalmente con el hemocultivo, el cual permite conocer el agente etiológico y su patrón de susceptibilidad para una adecuada antibioterapia. Esta técnica tradicionalmente manual, se automatizó en la década de los ochenta, logrando ampliar el espectro de agentes aislados, acortar los tiempos de detección y disminuir las tasas de contaminación. Desafortunadamente el acceso a esta tecnología no es uniforme en nuestro país lo que genera gran variabilidad en el rendimiento de los hemocultivos. Las EI con hemocultivos negativos representan un gran desafío clínico y microbiológico: el uso de antimicrobianos constituye la primera causa de hemocultivos negativos, sin embargo existen microorganismos fastidiosos o de nulo crecimiento que deben sospecharse en estos casos y con una buena comunicación con el laboratorio, evaluar el empleo de otras herramientas diagnósticas, como serología y PCR del hemocultivo y/o de vegetaciones en busca de ADN bacteriano, tecnología que ya se está evaluando en nuestro país. Por otro lado, el estudio microbiológico e histopatológico de válvulas removidas por EI debe ser obligatorio y constituye también un aporte, con resultados positivos aun bajo antibioterapia, dadas las dificultades para erradicar un microorganismo a ese nivel. Mejorar el diagnóstico etiológico de EI en Chile requiere educación, fundamentalmente para disminuir el empleo indiscriminado de antimicrobianos y cumplir con las normas de toma de muestras de hemocultivos. Además, implementar sistemas automatizados en todo el país constituiría un enorme avance, con beneficios innegables en el diagnóstico microbiológico.

The effects of background noise on cognitive performance during a 70 hour simulation of conditions aboard the International Space Station.

A total of twenty-five subjects were cloistered for a period of 70 hours, five at a time, in a hyperbaric chamber modified to simulate the conditions aboard the International Space Station (ISS). A recording of 72 dBA background noise from the ISS service module was used to simulate noise conditions on the ISS. Two groups experienced the background noise throughout the experiment, two other groups experienced the noise only during the day, and one control group was cloistered in a quiet environment. All subjects completed a battery of cognitive tests nine times throughout the experiment. The data showed little or no effect of noise on reasoning, perceptual decision-making, memory, vigilance, mood, or subjective indices of fatigue. Our results suggest that the level of noise on the space station should not affect cognitive performance, at least over a period of several days.

Anemia hemolítica autoinmune en paciente infectado por virus de inmunodeficiencia humana y enfermedad de Castleman / Autoimmnune hemolytic anemia in AIDS-HIV patient

We present a case of a 41 years old C3 phase AIDS patient on antiretroviral therapy for 5 years, who developed a severe hemolytic anemia refractory to usual treatment, which progressed to death. Anemia in AIDS patients is a common finding (60-80%); however hemolytic anemia is unusual and when it is present, it is generally mild; severe anemia is associated with bad prognosis. The etiology of hemolytic anemia in HIV patients is due to multiple causes, the one mediated by autoantibodies against the red cell, usually IgG, being most common. The antibodies most frequently detected are against U or i antigen. Drug-related hemolysis, in glucose 6-phosphate dehydrogenase (G-6PD)-deficient patients, may also occur. A third mechanism of hemolysis is related to microangiopathy secondary to bacterial sepsis or hemolytic uremic syndrome (HUS). Some reports associate haemolytic anemia and Castleman´s disease, a lymphoproliferative disease with localized widespread adenopathy, fever, autoimmune manifestations and recurring infections.

Se presenta un paciente con SIDA etapa C3, 41 años de edad, en tratamiento antiretroviral durante 5 años, que cursó con linfoadenopatías generalizadas y anemia hemolítica severa refractaria a tratamiento, con progresión hacia la muerte. La anemia en pacientes con SIDA es un hallazgo común (60-80%). Sin embargo, la anemia hemolítica es poco frecuente y generalmente de escasa magnitud, pero si es severa se relaciona con mal pronóstico. La etiología de la anemia hemolítica en pacientes VIH es múltiple siendo más común la mediada por autoanticuerpos contra antígenos del eritrocito, en su mayoría IgG. Los más frecuentes son dirigidos contra antígeno U e i. Otra causa frecuente es la inducida por fármacos, en pacientes con déficit de G-6PD. Un tercer mecanismo de hemólisis es el producido por microangiopatía secundaria a sepsis bacteriana o síndrome hemolítico urémico. Algunas publicaciones asocian anemia hemolítica y enfermedad de Castleman, desorden linfoproliferativo que se puede presentar clínicamente como una masa localizada o una alteración sistémica con linfoadenopatías, fiebre, manifestaciones autoinmunes e infecciones recurrentes.

Síndrome retroviral agudo / Acute retroviral syndrome: case report

A 37 years old male developed fever for 20 days, along with headache, anorexia malaise, sweating, pharyngitis, lymphadenopathy and splenomegaly. At this stage, Ag p 24 was positive and anti HIV was negative. The patient recovered fully but 6 monts later positive HIV titers were demonstrated by immunofluorescence and Westernblot. A retrospective HIV titers were demonstrated by immunofluorescence and Westernblot. A retrospective diagnosis of acute retroviral syndrome was made. The dioddicult