Provider-Guided Emergency Support for Persons Living With Type 1 Diabetes During Hurricanes Harvey, Irma, and Maria.

The 2017 Atlantic hurricane season was especially memorable for 3 major hurricanes-Harvey, Irma, and Maria-that devastated population centers across Texas, Florida, and Puerto Rico, respectively. Each storm had unique hazard properties that posed distinctive challenges for persons living with type 1 diabetes (T1D). Diabetes care specialists and educators took on leadership roles for coordinating care and establishing insulin supply lifelines for people with T1D living in the hardest-hit neighborhoods affected by these extreme storms. Strategies and resources were customized for each population. Diabetes specialists strategized to provide mutual support and shared insulins and supplies across sites.

Longitudinal Analysis of Ventilation Perfusion Mismatch in Congenital Diaphragmatic Hernia Survivors.

OBJECTIVE: To determine the natural history of pulmonary function for survivors of congenital diaphragmatic hernia (CDH). STUDY DESIGN: This was a retrospective cohort study of survivors of CDH born during 1991-2016 and followed at our institution. A generalized linear model was fitted to assess the longitudinal trends of ventilation (V), perfusion (Q), and V/Q mismatch. The association between V/Q ratio and body mass index percentile as well as functional status was also assessed with a generalized linear model. RESULTS: During the study period, 212 patients had at least one V/Q study. The average ipsilateral V/Q of the cohort increased over time (P < .01), an effect driven by progressive reduction in relative perfusion (P = .012). A higher V/Q ratio was correlated with lower body mass index percentile (P < .001) and higher probability of poor functional status (New York Heart Association class III or IV) (P = .045). CONCLUSIONS: In this cohort of survivors of CDH with more severe disease characteristics, V/Q mismatch worsens over time, primarily because of progressive perfusion deficit of the ipsilateral side. V/Q scans may be useful in identifying patients with CDH who are at risk for poor growth and functional status.

Longitudinal Analysis of Pulmonary Function in Survivors of Congenital Diaphragmatic Hernia.

OBJECTIVE: To analyze longitudinal trends of pulmonary function testing in patients with congenital diaphragmatic hernia (CDH) followed in our multidisciplinary clinic. STUDY DESIGN: This was a retrospective cohort study of CDH patients born between 1991 and 2013. A linear mixed effects model was fitted to estimate the trends of percent predicted forced expiratory volume in 1 second (FEV1pp), percent predicted forced vital capacity (FVCpp), and FEV1/FVC over time. RESULTS: Of 268 patients with CDH who survived to discharge, 119 had at least 1 pulmonary function test study. The FEV1pp (P < .001), FVCpp (P = .017), and FEV1/FVC (P = .001) decreased with age. Compared with defect size A/B, those with defect size C/D had lower FEV1pp by an average of 11.5% (95% CI, 2.9%-20.1%; P = .010). A history of oxygen use at initial hospital discharge also correlated with decreased FEV1pp by an average of 8.0% (95% CI, 1.2%-15.0%; P = .023). CONCLUSIONS: In a select cohort of CDH survivors, average pulmonary function declines with age relative to expected population normative values. Those with severe CDH represent a population at risk for worsening pulmonary function test measurements who may benefit from recognition and monitoring for complications.

Decline towards extinction of Mexico's vaquita porpoise (Phocoena sinus).

The vaquita (Phocoena sinus) is a small porpoise endemic to Mexico. It is listed by IUCN as Critically Endangered because of unsustainable levels of bycatch in gillnets. The population has been monitored with passive acoustic detectors every summer from 2011 to 2018; here we report results for 2017 and 2018. We combine the acoustic trends with an independent estimate of population size from 2015, and visual observations of at least seven animals in 2017 and six in 2018. Despite adoption of an emergency gillnet ban in May 2015, the estimated rate of decline remains extremely high: 48% decline in 2017 (95% Bayesian credible interval (CRI) 78% decline to 9% increase) and 47% in 2018 (95% CRI 80% decline to 13% increase). Estimated total population decline since 2011 is 98.6%, with greater than 99% probability the decline is greater than 33% yr-1. We estimate fewer than 19 vaquitas remained as of summer 2018 (posterior mean 9, median 8, 95% CRI 6-19). From March 2016 to March 2019, 10 dead vaquitas killed in gillnets were found. The ongoing presence of illegal gillnets despite the emergency ban continues to drive the vaquita towards extinction. Immediate management action is required if the species is to be saved.

Clinical Evaluation and Management of Patients with Suspected Fungus Sensitivity.

Fungus-sensitized patients usually present with symptoms that are similar to symptoms presented by those who are sensitized to other aeroallergens. Therefore, diagnosis and management should follow the same pathways used for patients with allergic conditions in general. The physician should consider that a relationship between fungal exposure and symptoms is not necessarily caused by an IgE-mediated mechanism, even when specific fungal IgE is detected. Until recently, IgE-mediated allergy has been documented only for a limited number of fungi. We propose a series of questions to be used to identify symptoms that occur in situations with high fungal exposure and a limited skin-prick-test panel (Alternaria, Cladosporium, Penicillium, Aspergillus, Candida) that can be amplified only in cases of high suspicion of other fungal exposure (eg, postfloods). We also review in vitro testing for fungi-specific IgE. Treatment includes environmental control, medical management, and, when appropriate, specific immunotherapy. Low-quality evidence exists supporting the use of subcutaneous immunotherapy for Alternaria to treat allergic rhinitis and asthma, and very low quality evidence supports the use of subcutaneous immunotherapy for Cladosporium and sublingual immunotherapy for Alternaria. As is the case for many allergens, evidence for immunotherapy with other fungal extracts is lacking. The so-called toxic mold syndrome is also briefly discussed.

Effects of corneal cross-linking on contrast sensitivity, visual acuity, and corneal topography in patients with keratoconus.

PURPOSE: To assess the effects of corneal collagen cross-linking (CXL) on contrast sensitivity (CS), visual acuity, and corneal topography investigating possible predictors of efficacy. METHODS: Sixty-eight eyes of 34 patients with progressive keratoconus were enrolled in this prospective study. CXL was performed in one eye and the other eye was left untreated as a control. CS, best spectacle-corrected visual acuity (BSCVA), simulated keratometry in the steepest meridian (SimK-s), mean power in the central 3-mm zone (C-MP), mean power in the paracentral 3- to 5-mm zone (P-MP), maximum keratometric power in the central zone (C-Kmax), and maximum keratometric power in the paracentral zone (P-Kmax) were evaluated at baseline, 40 days, 3 months, 6 months, 1 year, and after 2 years of follow-up. RESULTS: Treated eyes showed an improvement (P < 0.001) of +0.16 logCS and -0.16 logarithm of the minimum angle of resolution (logMAR) and a reduction in SimK-s of -0.61 diopter (D), C-Kmax -1.11 D, P-Kmax -0.99 D, C-MP -0.39 D, and P-MP -0.30 D. Of the treated eyes, 43.3% had a decrease in C-Kmax greater than 1 D, 50% by 0 to 0.99 D, and 6.7% had an increase of up to +0.89 D. Treated eyes with keratometric apex in the central 3-mm zone (CKA) improved BSCVA -0.19 logMAR and CS +0.19 logCS; whereas in treated eyes with paracentral keratometric apex (PKA), the improvement was -0.13 logMAR and +0.16 logCS. CONCLUSIONS: CXL with riboflavin and UV-A improved CS and inhibited the progression of keratoconus. As a predictor of treatment efficacy, eyes with CKA showed greater improvement in BSCVA after CXL when compared with eyes with PKA.

Dengue virus immunoglobulin M detection in a reference laboratory setting during the 2010 dengue virus outbreak on Caribbean islands.

A large outbreak of dengue virus (DV) infections occurred on Caribbean islands during 2010, with cases peaking during the second half of the year. In conjunction with the outbreak, we observed an unprecedented spike in the number of sera submitted for DV antibody testing between June and December 2010, with a concomitant increase in the number of IgM-positive specimens, indicative of acute DV infection. Analysis of the place of residence of the IgM-positive patients identified from June to December of 2010 revealed that 58.1% were residents of Caribbean islands (Puerto Rico and the U.S. Virgin Islands), whereas 40.6% were residents of the U.S. mainland or Hawaii. The U.S. residents represented 42 states plus the District of Columbia, but most (53%) were from just 3 states (California, Florida, and New York). In comparison to the Caribbean IgM-positive patient group, the U.S. IgM-positive patient group contained proportionately more adults 21 to 60 years old and fewer individuals <21 years old. These findings indicate that the 2010 Caribbean DV outbreak affected many U.S. residents (mostly adults, presumably travelers) from diverse geographic areas and emphasize the potential for a viremic DV-infected returning traveler to spark a local DV outbreak by introducing DV into a community with competent mosquito vectors.

An enigmatic frog of the genus Atelopus (Family Bufonidae) from Parque Nacional Chirripó, Cordillera de Talamanca, Costa Rica.

A distinctive new species of Atelopus is described from Parque Nacional Chirrip6 Grande, Cordillera de Talamanca (3,400-3,500 m). It closely resembles populations of the Atelopus ignescens complex from the Andes of northern Ecuador and southern Colombia. It differs most significantly from these frogs in the pattern of spiculae and coni development on the throat, chest, hands and feet. The Costa Rican species appears to be an outlier of the complex inexplicably separated geographically from its nearest allies by an over land distance of about 1,600 km.

An enigmatic frog of the genus Atelopus (Family Bufonidae) from Parque Nacional Chirripó, Cordillera de Talamanca, Costa Rica

A distinctive new species of Atelopus is described from Parque Nacional Chirripó Grande, Cordillera de Talamanca (3 400-3 500 m). It closely resembles populations of the Atelopus ignescens complex from the Andes of northern Ecuador and southern Colombia. it differs most significantly from these frogs in the pattern of spiculae and coni development on the throat, chest, hands and feet. The Costa Rican species appears to be an outlier of the complex inexplicably separated geographically from its nearest allies by an over land distance of about 1 600 km. Rev. Biol. Trop. 57 (1-2): 381-386. Epub 2009 June 30.

Se describe una nueva especie de Atelopus del Parque Nacional Chirripó Grande, Cordillera de Talamanca (3 400-3 500 m sobre el nivel del mar). Se parece a poblaciones del complejo de Atelopus ignescens de los Andes del norte de Ecuador y del sur de Colombia. Principalmente difiere de estas ranas en el patrón de desarrollo de espículas y conos en la garganta, pecho, manos y pies. La especie de Costa Rica es atípica dentro del complejo por estar inexplicablemente separada geográficamente de sus más cercanos representantes por una distancia aproximada de 1 600 km por tierra.

New types of immunotherapy in children.

Injection immunotherapy has been shown to be particularly beneficial in treating allergic rhinitis, mild to moderate asthma, and anaphylaxis caused by bee and wasp venom. It also produces a long-term, antigen-specific, protective immune effect and is the only treatment that offers the possibility of reducing the risk of asthma development in children with allergic rhinitis. Nonetheless, the potentially severe side effects associated with this form of immunotherapy limit its widespread use. Diverse preparations are being developed to increase its safety and improve its efficacy. These include alternative routes of administration, particularly the sublingual route; use of novel adjuvants, such as CpG oligonucleotides and mycobacterial vaccines; and other approaches, such as peptide immunotherapy, recombinant allergens, DNA vaccination, and combined therapy. Some of these immunotherapy forms have been evaluated in children.

A new species of Celestus from west-central Panama, with consideration of the status of the genera of the Anguidae: Diploglossinae (Squamata)

A recently discovered new species of diploglossine lizard is described from west-central Panama. The distinctiveness of the nominal genera Celestus and Diploglossus is confirmed; the new form represents the southernmost record for the genus Celestus. A summary of selected characteristics and general distribution is presented for all recent species of diploglossines, including members of the Antillean genera Saurisia and Wetmorea and the South American genus Ophiodes. A systematic key to mainland members of the genus Celestus is provided. Rev. Biol. Trop. 56 (2): 845-859. Epub 2008 June 30.

Se describe una especie nueva de lagarto diploglossino recientemente descubierta en el centro-oeste de Panamá. Confirmamos la peculiaridad de los géneros nominales Celestus y Diploglossus. La nueva especie representa el registro más al sur del género Celestus. Se presenta un resumen de características selectas y de la distribución general de todas las especies recientes de diploglossinos, incluyendo a los miembros de los géneros antillanos Saurisia y Wetmorea y del género suramericano Ophiodes. Se provee una clave sistemática para los miembros de tierra firme del género Celestus.

A new species of Celestus from west-central Panama, with consideration of the status of the genera of the Anguidae: Diploglossinae (Squamata).

A recently discovered new species of diploglossine lizard is described from west-central Panama. The distinctiveness of the nominal genera Celestus and Diploglossus is confirmed; the new form represents the southernmost record for the genus Celestus. A summary of selected characteristics and general distribution is presented for all recent species of diploglossines, including members of the Antillean genera Saurisia and Wetmorea and the South American genus Ophiodes. A systematic key to mainland members of the genus Celestus is provided.

Amphibian and reptile declines over 35 years at La Selva, Costa Rica.

Amphibians stand at the forefront of a global biodiversity crisis. More than one-third of amphibian species are globally threatened, and over 120 species have likely suffered global extinction since 1980. Most alarmingly, many rapid declines and extinctions are occurring in pristine sites lacking obvious adverse effects of human activities. The causes of these "enigmatic" declines remain highly contested. Still, lack of long-term data on amphibian populations severely limits our understanding of the distribution of amphibian declines, and therefore the ultimate causes of these declines. Here, we identify a systematic community-wide decline in populations of terrestrial amphibians at La Selva Biological Station, a protected old-growth lowland rainforest in lower Central America. We use data collected over 35 years to show that population density of all species of terrestrial amphibians has declined by approximately 75% since 1970, and we show identical trends for all species of common reptiles. The trends we identify are neither consistent with recent emergence of chytridiomycosis nor the climate-linked epidemic hypothesis, two leading putative causes of enigmatic amphibian declines. Instead, our data suggest that declines are due to climate-driven reductions in the quantity of standing leaf litter, a critical microhabitat for amphibians and reptiles in this assemblage. Our results raise further concerns about the global persistence of amphibian populations by identifying widespread declines in species and habitats that are not currently recognized as susceptible to such risks.

Sensitivity of bone marrow aspirates in the diagnosis of visceral leishmaniasis.

Bone marrow aspirates are believed to provide a safer but less sensitive method in the diagnosis of visceral leishmaniasis (VL) compared with splenic aspirates. We examined the effect of the number of fields and the time of observation on bone marrow smear sensitivity and compared it to our experience with spleen aspiration. Bone marrow smears of 98 patients and splenic aspirates from 120 patients were examined. Among 87 patients with VL, the sensitivity of bone marrow aspirates was 40.2%, 65.5%, 89.7%, 92%, and 95.4% at 1, 5, 20, 30, and 60 minutes, respectively. The sensitivity of spleen aspirate examination was 93% for 114 patients. One patient died of shock after spleen aspiration. A bone marrow smear is very sensitive if examined thoroughly, reaching a sensitivity similar to that of spleen aspirate. We propose that a bone marrow smear be established as the technique of choice for the parasitologic diagnosis of VL.

Proceso de Prioridades para Clasificación de Proyectos Agropecuarios

Priorización de la selección y administración de proyectos orientados al desarrollo agropecuario (Asesoramiento - FDTA Trópico Humedo)

Reingeniería, Fortalecimiento y Planificación Estratégica

Planeamiento estratégico propuesto para enfocar la orientación y el curso de las actividades propias de la Cámara Agropecuaria del Oriente (Asesoramiento - CAO)

Predictors of an unsatisfactory response to pentavalent antimony in the treatment of American visceral leishmaniasis

Although treatment of visceral leishmaniasis with pentavalent antimony is usually successful, some patients require second-line drug therapy, most commonly with amphotericin B. To identify the clinical characteristics that predict an inadequate response to pentavalent antimony, a case-control study was undertaken in Teresina, Piaui, Brazil. Over a two-year period, there were 19 cases of VL in which the staff physicians of a hospital prescribed second-line therapy with amphotericin B after determining that treatment with pentavalent antimony had failed. The control group consisted of 97 patients that were successfully treated with pentavalent antimony. A chart review using univariate and multivariate analysis was performed. The cure rate was 90 percent with amphotericin B. The odds ratio for the prescription of amphotericin B was 10.2 for children less than one year old, compared with individuals aged over 10 years. Patients who presented coinfection had an OR of 7.1 while those on antibiotics had an OR of 2.8. These data support either undertaking a longer course of therapy with pentavalent antimony for children or using amphotericin B as a first-line agent for children and individuals with coinfections. It also suggests that chemoprophylaxis directed toward bacterial coinfection in small children with VL may be indicated