Infectious endocarditis by Bartonella species: report of two cases / Endocarditis infecciosa por Bartonella: descripción de dos casos en Chile

ABSTRACT Infectious endocarditis (IE) by Bartonella species is an emerging problem worldwide. We report two cases of native valve Bartonella-associated IE events, both affecting adult male patients with a history of alcohol abuse and a low socioeconomic status. Admissions were due to pancytopenia and bleeding in one case and embolic stroke in the other. Blood cultures were negative and IgG indirect immunofluorescence assays (IFA) were positive for B. henselae/B. quintana in high titers (1/16,384-1/16,384, and 1/32,768 -1/16,384, respectively). Cases were classified as definitive IE events according to modified Duke criteria due to the presence of valve vegetations with at least three minor criteria. One patient required aortic mechanical valve replacement and survived, and the other died after a massive hemorrhagic transformation of his stroke. PCR amplification and sequencing of the 16S ribosomal bacterial DNA from a valve tissue sample obtained at surgery in the patient who survived, confirmed B. quintana as the etiological agent. Bartonella-associated IE is an emerging problem in Chile, present in disadvantaged populations. It should be suspected in patients with culture-negative IE. IFA does not discriminate between B. henselae and B. quintana infection, but high titers suggest IE. Complementary PCR techniques may help to elucidate the final causative agent.

La endocarditis infecciosa(EI) asociada a Bartonella es un problema emergente a nivel mundial. Publicamos los 2 primeros casos de EI en válvula nativa asociados a Bartonella en Chile, los que afectaron a pacientes masculinos con historia de consumo de alcohol y bajos ingresos. La hospitalización fue provocada por pancitopenia y hemorragias en un caso y por un evento cerebrovascular en el otro. Se solicitó serología para Bartonella por inmunofluorescencia indirecta (IFI) para ampliar el estudio ante hemocultivos negativos y en ambos casos se reportaron resultados intensamente positivos para B. henselae y B. quintana1/16.384-1/16.384 y 1/32.768 -1/16.384, respectivamente). Los casos se clasificaron como eventos definitivos de EI según los criterios modificados de Duke debido a la presencia de vegetaciones valvulares con al menos 3 criterios menores. Un paciente requirió reemplazo valvular aórtico y sobrevivió, y el otro falleció tras una transformación hemorrágica masiva del infarto cerebral. La amplificación del ADN ribosomal 16S por RCP y posterior secuenciación de una muestra de tejido valvular confirmó la presencia de B. quintana. La EI por Bartonella sp. es un problema emergente en Chile, probablemente asociada a poblaciones desfavorecidas, la que debe ser sospechada en pacientes con cultivos negativos. La IFI no permite discriminar infecciones por B. henselae o B. quintana pero los títulos altos sugieren EI. Técnicas complementarias por RCP pueden ayudar a dilucidar el diagnóstico.

Factores relacionados con hábitos y conductas de adultos con sobrepeso. Caldas, Colombia / Factors Related to Habits and Behaviors of Overweight Adults in Caldas, Colombia

Resumen Antecedentes: la obesidad es una condición de salud que ha aumentado su prevalencia en Colombia y en Caldas. Objetivo: identificar factores relacionados con hábitos y conductas de adultos con sobrepeso, residentes en tres zonas urbanas de Manizales, La Dorada y Chinchiná durante 2015. Materiales y métodos: estudio cualitativo en 23 adultos seleccionados por conveniencia. El procedimiento para la recolección de datos se centró en entrevistas a profundidad. Se desarrolló una guía de entrevista y se realizó una prueba piloto para optimizar la secuencia temática en la interacción con los participantes. El análisis de datos se realizó con el software Dedosse. En la codificación de fragmentos y categorización se utilizó codificación abierta nombrando códigos de frases en vivo y se debatieron procedimientos entre los investigadores para lograr consenso. Resultados: se identificaron cuatro categorías de factores relacionados con hábitos y conductas: 1) hábitos y conductas no saludables en ambiente obesogénico; 2) información nutricional; 3) conductas racionales y no racionales/actitudes e imaginarios; y 4) la atención de salud. Conclusiones: un estilo de vida sedentario, ambiente obesogénico, ausencia de políticas públicas para el control del sobrepeso y poca oferta y disponibilidad de programas, de servicios y de nutricionistas se identifican como factores relacionados con hábitos y conductas de adultos con sobrepeso en Caldas.

Abstract Background: Obesity is a health condition that has increased in prevalence in Colombia and the city of Caldas. Objective: To identify factors related to habits and behaviors of overweight adults living in three urban areas of Manizales, La Dorada and Chinchiná during 2015. Materials and Methods: This was a qualitative study with a convenience sample of 23 adults. The procedure for data collection focused on in-depth interviews. An interview guide was developed and a pilot test was conducted to optimize the thematic sequence in the interaction with the participants. Data analysis was done using the software Dedosse. In the coding of fragments and categorization, open coding was used, naming live codes of sentences and procedures were discussed among researchers to achieve consensus. Results: Four categories of factors related to habits and behaviors were identified: unhealthy habits and behaviors in an obesogenic environment, nutritional information, rational and irrational behavior / attitudes, and imaginary and health care services. Conclusions: Sedentary lifestyle, obesogenic environment, absence of public policies for the control of overweight, and low supply and availability of programs, services, and nutritionists are identified as factors related to habits and behaviors of overweight adults in Caldas.

Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago / Sonothrombolysis for acute ischemic stroke

Background: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.

Validez del Doppler transcraneal en el diagnóstico de muerte encefálica / Validation of transcranial Doppler in the diagnosis of brain death

Background: The clinical diagnosis of brain death is complex. Aim: To evaluate the diagnostic accuracy of transcranial Doppler (TCD) for brain death. Patients and Methods: Patients seen on the intensive care unit of a private hospital between January 2004 to December 2008, were included if they were in structural coma, had no craniectomy and had a blind evaluation by a neurologist and TCD done in less than three hours. The diagnosis of brain death was based on a clinical evaluation that considered the absence of sedative drugs, median blood pressure >60 mmHg, body temperature over 35º Celsius and complete absence of brainstem refexes. An expert neurosonologist, with a TCD-PMD-100, 2 Mhz transducer, used an institutional protocol that considers the examination as positive for brain circulatory arrest when there is presence of reverberating, small systolic peaks or the disappearance of a previous signal present on both middle cerebral arteries and intracranial vertebral arteries. Results: Fifty three patients were evaluated, 25 with clinical brain death. On 45 cases (84.9 percent), the interval between both evaluations was less than one hour. The sensitivity, specifcity, positive and negative predictive values for the diagnosis of brain death with TCD were 100, 96, 96.1 and 100 percent respectively. Positive and negative likelihood ratios for brain death were 28 and 0, respectively. Conclusions: TCD is a valid and useful technique for the diagnosis of brain death and can be used on complicated cases.