Ectima gangrenoso, manifestación cutánea infrecuente de una infección por diversos agentes / Ecthyma gangrenosum, a rare cutaneous manifestation of infection by various agents

El ectima gangrenoso es un trastorno infeccioso infrecuente clásicamente relacionado a bacteriemia, descrito principalmente en poblaciones inmunodeprimidas. El agente más comúnmente relacionado es Pseudomonas aeruginosa, sin embargo, se han descrito otras etiologías bacterianas, hongos filamentosos y levaduras. Su patogénesis está dada por la invasión de la pared de los vasos sanguíneos, causando trombosis arterial y venosa, desencadenando necrosis de epidermis y tejidos subdérmicos. Clínicamente, se manifiesta como máculas, vesículas o pústulas hemorrágicas que evolucionan a úlceras de superficie necrótica rodeadas por un halo eritematoso característico, habitualmente en un contexto clínico de sepsis. El diagnóstico de este cuadro es clínico, sin embargo, el estudio microbiológico es clave en la identificación del agente etiológico y un posterior tratamiento dirigido. En su manejo es esencial una alta sospecha clínica y el inicio de tratamiento antibiótico en forma precoz. La duración del tratamiento es variable y en algunos casos debe asociarse a debridación quirúrgica. El pronóstico es variable dependiendo de múltiples factores: estado inmunológico, agente etiológico, presencia de sepsis y el tiempo de inicio de tratamiento.(AU)

Ecthyma gangrenosum is an infrequent infectious disorder classically related to bacteremia, described mainly in immunosuppressed populations. The most related agent is Pseudomonas aeruginosa, however other bacterial etiologies, filamentous fungi and yeasts have been described. Its pathogenesis is given by the invasion of the blood vessel wall, causing arterial and venous thrombosis, triggering necrosis of epidermis and subdermal tissues. Clinically, it manifests as hemorrhagic macules, vesicles or pustules that evolve into ulcers with a necrotic surface surrounded by a characteristic erythematous halo, usually in a clinical setting of sepsis. The diagnosis of this condition is clinical, however the microbiological study is key in the identification of the etiological agent and a subsequent directed treatment. In its management, a high clinical suspicion and an early start of antibiotic treatment are essential. The duration of treatment is variable and in some cases it must be associated with surgical debridement. The prognosis is variable depending on multiple factors: immunological status, etiological agent, presence of sepsis and time of initiation of treatment.(AU)

Chemotherapy and PARP inhibitors in heavily pretreated BRCA1/2 mutation ovarian cancer (BMOC) patients.

OBJECTIVES: The hallmarks of germline(g) and/or somatic(s) BRCA1/2 mutation ovarian cancer (BMOC) patients are increased sensitivity to platinum-based chemotherapy (PCT) and PARP inhibitors (PARPi). There is little information on the effectiveness of chemotherapy in heavily pretreated (≥3 CT lines) g/sBMOC patients. METHODS: g/sBMOC patients who received CT from 2006 to 2016 at 4 cancer centers in Spain were selected. Overall survival (OS) and time to progression (TTP) were calculated with Kaplan Meier and Cox models. RESULTS: 135 g/sBMOC patients were identified (6% sBRCA1/2 mutations). The median number of chemotherapy lines was 2 (1-7). The 6-years OS rate was 69.4% and 71% in BRCA1 or BRCA2 mutation carriers (p = 0.98). A total of 57 (42%) patients had ≥3 CT lines (3-7), which encompassed a total of 155 treatments. The median overall TTP across all treatment lines beyond 2nd line was 10.2 months (CI 95% 8.4-11.9 months). In the platinum-sensitive setting, TTP was improved with PCT plus PARPi (17.1 m), PCT (12.6 m) or PARPi (12.4 m) versus non-PCT (4.9 m; p < 0.001 all comparisons). In the platinum-resistant setting, these differences in TTP were not statistically significant. A multivariate model confirmed that primary platinum-free interval (PFI) > 12 months and exposure to PCT and PARPi associated with improved outcomes. PARPi exposure did not compromise benefit of subsequent CT beyond 2nd relapse. CONCLUSIONS: Heavily pretreated g/sBMOC demonstrated CT sensitivity, including for non-PCT choices. Primary platinum-free interval (PFI) >12 months and exposure to both platinum-based chemotherapy and PARPi associate with improved prognosis in heavily pretreated g/sBMOC patients.

Development of a specific health-related quality of life test in drug abusers using the Rasch rating scale model.

A test has recently been designed for the measurement of health-related quality of life in drug abusers (Health-Related Quality of Life for Drug Abusers Test - HRQOLDA Test) based on the bi-axial concept of addiction. The aim of this work is to find out the metric properties of the test by applying the polytomous Rasch Rating Scale Model (RSM). The HRQOLDA Test was given to a sample of 358 drug abusers who began treatment in a Therapeutic Community. The Rating Scale Model (RSM) and the WINSTEPS programme were used for the analysis of its metric properties. The results shown here are an overall fit of data to the model. The items are adequately distributed over the HRQOL continuum. The response categories appear to be in order except for the category 'a little'. The test region which measures most accurately, and is most informative, is in the middle of the continuum. The test properties studied confirm the adequacy of the RSM for accurate measurement of HRQOL in drug abusers, providing a test for measuring this specific construct in this population.

Test para la Evaluación de la Calidad de Vida en Adictos a Sustancias Psicoactivas (TECVASP): estudios de fiabilidad y validez / Assessment of the quality of life in psychoactive substance addicts test: reliability and validity studies

Objetivo. Estudiar la fiabilidad y aportar evidencias de validez del Test para la Evaluación de la Calidad de Vida en Adictos a Sustancias Psicoactivas (TECVASP). Método. En la investigación participaron 359 pacientes de cinco comunidades terapéuticas gestionadas por la Fundación Andaluza para la Atención a las Drogodependencias. Además del TECVASP, se aplicó la sección de «uso de sustancias» de la versión española del Maudsley Addiction Profile (MAP) y se recogió información sociodemográfica de los pacientes. Resultados. La estimación de fiabilidad, calculada con el coeficiente alfa de Cronbach, fue adecuada, con un valor de 0,861. En los tres estudios de validación se muestran evidencias a favor del uso de las puntuaciones del test para el objetivo previsto, ya que se detectan diferencias en la calidad de vida relacionada con la salud (CVRS) en pacientes: 1) incluidos en programa de desintoxicación con la de otros que están en deshabituación, 2) consumidores de «rebujo» (mezcla de heroína y cocaína base) que están en programa de tratamiento con metadona con la de otros que no están en tratamiento con metadona, y 3) al ingreso en comunidad terapéutica y al finalizar el tratamiento. Conclusiones. Las propiedades métricas obtenidas señalan la pertinencia del TECVASP para medir la CVRS de personas drogodependientes, recomendando su uso cuando se quiera estimar la CVRS de pacientes que se encuentran en distintas fases del tratamiento de la dependencia

Objective. In this work, different studies of the metric properties —estimate of reliability and evidences of validity— of Test for the Evaluation of the Quality of Life in Addicts to Psychoactive Substances (TEQLAPS) is carried out. Method. In the investigation 359 patients of five therapeutic communities participated egotiated by the Andalusian Foundation for Attention to Drugs Addictions. Besides the TEQLASP, the section of «use of substances» of the Spanish version of the Maudsley Addiction Profile (MAP) were delivered, and the patients’ sociodemographics information was picked up. Results. The estimate of reliability, calculated with Cronbach alpha coefficient, it was adequate, with a value of 0,861. In the three studies of validation evidences are shown in favour of test use for foreseen objective, since: 1) differences in the Health Related Quality of Live (HRQL) between patients in detoxification and dishabituation program are detected; 2) differences in the HRQL between heroin with base cocaine abusers that are in treatment program with methadone and not in treatment with methadone are detected; and, 3) differences in the HRQL from the patients to the entrance in the therapeutic communities and when concluding the treatment are detected. Conclusions. The obtained metric properties point out the relevancy of the TEQLASP to measure the HRQL of drug addict people, recommending their use when the HRQL of patients that are in different phases of the treatment of the dependence to differ

Multiple origins of the Juan Fernández kelpfish fauna and evidence for frequent and unidirectional dispersal of cirrhitoid fishes across the South Pacific.

Phylogenetic relationships were reconstructed among chironemid fishes based on morphological and molecular (lrRNA, NADH4, S7 ribosomal protein) characters. Two sympatric species from Juan Fernández in the southeast Pacific are not sister taxa, but rather exhibit independent relationships to Australian/New Zealand chironemids. The most plausible explanation for these relationships and contemporary distributions is an Australian/New Zealand origin of the family, followed by two trans-Pacific dispersal and colonization events, facilitated by larval entrapment within the West Wind Drift. This study demonstrates that the diversity of taxa on an island can reflect multiple colonizations, rather than in situ diversification, even in the case of very small, isolated, and geologically recent islands. When taken in conjunction with studies of related taxa, our results indicate that transoceanic dispersal of temperate cirrhitoid fishes in the South Pacific has been frequent and unidirectional. Molecular estimates of divergence time between southeast Pacific chironemids and their western relatives predate the emergence of Juan Fernández, consistent with hypotheses that much of the marine nearshore faunas of young southeast Pacific islands may be the product of successive transfer from older, now submerged islands.

In vitro activity of telithromycin against mefA and ermB erythromycin-resistant viridans streptococci isolated from bacteremia of oral origin in Spain.

Erythromycin-resistant viridans streptococci are often responsible of bacteremias following dental manipulations. The aim of this study was to evaluate the in vitro activity of telithromycin against erythromycin-susceptible and erythromycin-resistant viridans streptococci. Venous blood samples were collected from 84 patients, 30 s after dental extractions. Viridans streptococci were identified by conventional microbiological techniques. A set of 36 viridans streptococci were selected to investigate the in vitro activity of telithromycin by the agar dilution method. Macrolide resistance genes were amplified with specific primers for the mefA and ermB genes and visualized by electrophoresis. For erythromycin-susceptible viridans streptococci, telithromycin minimal inhibitory concentration90 (MIC90) was <0.008 microg/ml. For erythromycin-resistant viridans streptococci, telithromycin MIC90 was 1 microg/ml. The MIC90 to telithromycin of the mefA-positive and ermB-negative viridans streptococci was lower than that of the mefA-negative and ermB-positive viridans streptococci (0.128 microg/ml versus 1 microg/ml). The in vitro activity of telithromycin was high, irrespective of the erythromycin susceptibility and the mechanism of erythromycin resistance identified.

In vitro activity of moxifloxacin compared to other antimicrobials against streptococci isolated from iatrogenic oral bacteremia in Spain.

BACKGROUND/AIMS: Systemic dissemination of oral bacteria to distant body sites may be the cause of focal infections. The unsuitable use and overexposure to antimicrobial therapy in clinical dental practice may contribute to the worldwide problem of antimicrobial resistance. The aim of this study was to determine the susceptibilities of streptococci isolated from the bloodstream after dental extractions against penicillin, ampicillin, amoxicillin, erythromycin, clindamycin, and a new fluoroquinolone, moxifloxacin. PATIENTS AND METHODS: Eighty-four patients who required dental extractions were studied. Venous blood samples were collected from each patient at baseline (before dental manipulation) and 30 s after dental extractions. The samples were processed in the Bactec 9240. The isolated bacteria were identified by conventional microbiological techniques. The antimicrobial susceptibility of 81 streptococci was determined by the E-test method. The NCCLS performance standards were followed. RESULTS: 88.9-92.5% of the streptococci were sensitive to beta-lactam agents tested with a minimum inhibitory concentration (MIC)(90s) ranging from 0.094 to 0.19 mg/l. The resistance to erythromycin and clindamycin was 40.8% (MIC(90HR) = 256 mg/l) and 21% (MIC(90HR) = 256 mg/l), respectively. The MIC(90) to moxifloxacin was 0.125 mg/l. CONCLUSION: Most of the streptococci isolated from the bloodstream after dental extractions were susceptible in vitro to penicillin, ampicillin, and amoxicillin. The high percentage of streptococci resistant to erythromycin and clindamycin could restrict their usefulness as prophylactic drugs. All the isolates showed a low MIC of moxifloxacin in vitro, making it a promising antimicrobial alternative for the prevention of streptococcal focal infections associated with certain dental manipulations, when the administration of beta-lactam agents is not indicated.

Asociación entre integrones de clase 1 con resistencia a múltiples antimicrobianos y plásmidos conjugativos en Enterobacteriaceae / Class 1 integrons in Enterobacteriaceae and its association with multidrug resistance and conjugative plasmids

La amplia diseminación de genes de resistencia a antimicrobianos es motivo de preocupación. La asociación de los genes de resistencia con elementos génicos móviles favorece su presencia en distintas especies de bacterias, siendo los integrones un elemento importante. En este trabajo se estudia en 123 enterobacterias la presencia de integrones, identificándose éstos en el 20,3 por ciento de las cepas. La asociación entre integrones y resistencia múltiple a antimicrobianos fue estadísticamente significativa (p <0.001). Los aislamientos con integrones fueron con mayor frecuencia, estadísticamente significativa (p <0.05), resistentes a amoxicilina-ácido clavulánico, quinolonas y trimetoprima-sulfametoxazol. Todos los integrones formaban parte de plásmidos conjugativos. La prevalencia de integrones se incrementó del 21,2 por ciento en 1992-1994 al 72 por ciento en 1995-1997 (p <0.001). Los genes aacC1 y aacC2 se identificaron en el 80 por ciento de los integrones. La relación entre integrones y plásmidos conjugativos debe preocuparnos, ya que podría contribuir a la diseminación de los genes de resistencia a antimicrobianos entre diferentes poblaciones bacterianas (AU)

Búsqueda de la atención médica y determinates de la utilización de servicio de salud / Determinants of health services utilization and search for medical care

There are four different conceptual approaches to assess the factors that explain, condition and determine the use of health services. This article discusses the epidemiological, psychosocial, sociological and economical models. The stages and determinants of the health service use process are described and a cross study is made with each of the four models, using a contingency matrix. A holistic analysis is proposed, as a starting point, for the search of a model that will allow the identification of factors that determine the use of health services. This analysis should be used as a conceptual framework for future work on health services utilization

[Class 1 integrons in Enterobacteriaceae and its association with multidrug resistance and conjugative plasmids]. / Asociación entre integrones de clase 1 con resistencia a múltiples antimicrobianos y plásmidos conjugativos en Enterobacteriaceae.

The prevalence of antimicrobial resistance genes is a cause of concern. The combination of antimicrobial resistance genes and mobile genetic elements leads to their widespread presence in different bacterial species, in which integrons are a new and important element. We studied the presence of integrons in 123 unrelated enterobacteria and identified them in 20.3% of the strains. The combination of integrons and multidrug resistance was shown to be statistically significant (p <0.001). Integron-positive isolates were statistically (p <0.05) more likely to be resistant to amoxicillin-clavulanic acid, quinolones and trimethoprim-sulfamethoxazole. All the integrons were identified in conjugative plasmids. The prevalence of integrons increased from 21.2% in 1992-1994 to 72% in 1995-1997 (p <0.001). The aacC1 and aacC2 genes were identified in 80% of the integrons. The relationship between integrons and conjugative plasmids is a matter of concern because it could contribute to the dissemination of antimicrobial resistance genes among different bacterial populations.

[Congenital mitral stenosis. Experience in 1991-2001]. / Estenosis mitral congénita. Experiencia 1991-2001.

OBJECTIVE: To describe ten years of experience with congenital mitral stenosis. METHOD: All cases with congenital mitral stenosis from January 1991 to 2001 were analized. RESULTS: 16 patients with congenital mitral stenosis were found, mean age 3 +/- 3.08 years. TYPES OF OBSTRUCTIONS: Mitral commisures combined with tendinous cords fusion (45%), parachute mitral valve 37%, supravalvar mitral ring in one, fusion between papillary muscle and leaflets in one, and double mitral orifice in one. Hemodynamic (in mmHg) findings: wedge pressure 18.4 +/- 4, pulmonary artery systolic 61 +/- 21, diastolic 34 +/- 15, mean 47 +/- 18 mmHg, mean transvalvar gradient (MTG) 12.9 +/- 7.3, PRU 5.5 +/- 3.8. Four patients received medical treatment. Surgical results: Six patients underwent mitral repair, and four were subjected to mitral valve replacement (two with previous mitral repair). Global mortality was 2 (12.5%). Follow-up was 3.5 +/- 3 years. There was a significant difference when the initial MTG 22.6 +/- 11.5 mmHg before surgical repair was compared with the final MTG 4.75 +/- 1.5 (P < 0.05), also when initial MTG 12 +/- 2.3 before mitral valve replacement was compared with the final MTG 6 +/- 1.15 mmHg (P < 0.05). CONCLUSION: Most patients are candidates for mitral surgical repair, however at mid term one third will require mitral valve replacement.

Automatic identification of metaphase spreads and nuclei using neural networks.

The mitotic index (MI) is an important measure in cell proliferation studies. Determination of the MI is usually made by light-microscope analysis of slide preparations. The analyst identifies and counts thousands of cells and reports the percentage of mitotic shapes found among the interphase nuclei. Full automation of this process is an ambitious task, because there can exist very few mitotic shapes among hundreds of nuclei and thousands of artifacts, resulting in a high probability of false positives, i.e. objects erroneously identified as mitosis or nuclei. A semi-automated approach for MI calculation is reported, based on the development of a neural network (NN) for automatic identification of metaphase spreads and stimulated nuclei in digital images of microscope preparations at 10X magnification. After segmentation of the objects on each image, ten different morphometrical, photometrical and textural features are measured on each segmented object. An NN is used to classify the feature vectors into three classes: metaphases, nuclei and artifacts. The system has been able to classify correctly approximately 91% of the objects in each class, in a test set of 191 mitosis, 331 nuclei and 387 artifacts, obtained from 30 different microscope slides. Manual editing of false positives from the metaphase classification results allows the calculation of the MI with an error of 6.5%.

Meningioma con localización extracraneal: informe de un caso / Extracranial meningioma

Se presenta un caso de meningioma que destruyo la totalidad del piso de la fosa craneal media derecha, localizándose en la fosa pterigomaxilar y con extension a la region parotidea, tratado en el Hospital Universitario de Barranquilla. Se evaluo a una mujer campesina de 40 años, a quien se le encontro al inicio un tumor en la region parotidea derecha con extension de la masa de consistencia quistica a la rinofaringe. Se le realizaron estudios radiográficos para establecer la extension del tumor y posteriormente fue tratada mediante cirugia como unico metodo terapeutico. En la actualidad, al completar dos años y medio de evolución, se encuentra asintomática y sin recidiva tumoral

[Evaluation of arterial hypertension program in a primary care center]. / Evaluación del programa de hipertensión arterial de un centro de atención primaria.

The rate of detection, confirmation, control and follow-up of hypertension in the Canteres Primary Care Center was evaluated two years after the beginning of the hypertension program from a sample of 1219 clinical records. It was found that 572 individuals (46.9%) had at least one blood pressure reading. Of these, 68.2% had values within the normal range, whereas 9.6% of females and 2.8% of males were known hypertensives. High BP levels were found in 69 (19.9%) females and in 34 (15%) males. Of these 103 individuals, the three BP readings were only completed in 34 (49.3%) females and 12 (35.3%) males, and only 26 and 3, respectively, were considered as new hypertensives. In 87% of hypertensives the follow-up was correct, and 59% had BP within normal limits. It is concluded that priority should be given to more deprived and higher risk groups (males of working age), a new evaluation being proposed at 5 years with the following standards; greater than 80% with BP readings (greater than 95% in individuals older than 30 years), with correct confirmation of the diagnosis in greater than 95% and greater than 80% of control and follow-up.

Antecedentes psiquiátricos en el suicidio por precipitación de altura / Psychiatric conditions in suicide by jumping from heights

Se estudian las características demográficas y los antecentes psiquiátricos de las víctimas de suicidios por precipitación de altura acaecidos entre 1983 y 1985 (Instituto Médico Legal de Santiago). En el período señalado hubo 26 suicidios por precipitación de altura, correspondientes a 13 hombres y a 13 mujeres. En los hombres el suicidio se dio con una frecuencia similar en los distintos grupos etarios. En las mujeres, el 69,2% de las suicidas eran mayores de 50 años. En el 86,3% de los casos había antecedentes de trastornos psicológicos o conductuales y en un 54,5% había un diagnóstico psiquiátrico formal, siendo la Esquizofrenia el más frecuentemente formulado. El 59% de los suicidas había tenido ideación o conductas autodestructivas previas. Los presuntos motivos desendenantes predominantes fueron las dificultades económicas en los hombres (85,7%) y el aislamiento social en las mujeres (66,6%)