Prophylactic versus endoscopy-driven treatment of Crohn's postoperative recurrence: A retrospective, multicentric European study (PORCSE study).

BACKGROUND AND AIMS: No consensus exists on optimal strategy to prevent postoperative recurrence (POR) after ileocecal resection (ICR) for Crohn's disease (CD).We compared early medical prophylaxis versus expectant management with treatment driven by findings at elective endoscopy 6-12 months after ICR. METHODS: A retrospective, multicentric, observational study was performed. CD-patients undergoing first ICR were assigned to cohort1 if a biologic or immunomodulator was (re)started prophylactically after ICR, or to cohort2 if no postoperative prophylaxis was given and treatment was started as reaction to elective endoscopic findings. Primary endpoint was rate of endoscopic POR (Rutgeerts>i1). Secondary endpoints were severe endoscopic POR (Rutgeerts i3/i4), clinical POR, surgical POR and treatment burden during follow-up. RESULTS: Of 346 included patients, 47.4% received prophylactic postoperative treatment (proactive/cohort1) and 52.6% did not (reactive/cohort2).Endoscopic POR (Rutgeerts>i1) rate was significantly higher in cohort2 (41.5% vs 53.8%, OR1.81, P=0.039) at endoscopy 6-12 months after surgery. No significant difference in severe endoscopic POR was found (OR1.29, P=0.517). Cohort2 had significantly higher clinical POR rates (17.7% vs 35.7%, OR3.05, P=0.002) and numerically higher surgical recurrence rates (6.7% vs 13.2%, OR2.59, P=0.051). Cox proportional hazards regression analysis showed no significant difference in time to surgical POR of proactive versus expectant/reactive approach (HR2.50, P=0.057). Quasi-Poisson regression revealed a significantly lower treatment burden for immunomodulator use in cohort2 (mean ratio 0.53, P=0.002), but no difference in burden of biologics or combination treatment. CONCLUSIONS: The PORCSE study showed lower rates of endoscopic POR with early postoperative medical treatment compared to expectant management after first ileocecal resection for Crohn's disease.

Successful Endoscopic Closure of Esophageal Perforation in Boerhaave Syndrome Using the Over-the-Scope Clip.

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.

A síndrome de Boerhaave (SB) é uma entidade rara, mas potencialmente fatal. Embora a cirurgia seja o tratamento padrão, o tratamento endoscópico tem adquirido um papel importante como opção minimamente invasiva. Os autores descrevem dois casos de doentes do sexo masculino de meia-idade, que apresentaram perfuração esofágica espontânea após esforço emético intenso e vómitos. No primeiro caso, o doente apresentou impactação de um osso no esófago superior, que foi removido com sucesso por esofagoscopia rígida. Após o procedimento, o doente realizou radiografia de tórax e tomografia computorizada (TC) cervico-torácica que evidenciou hidropneumotórax esquerdo e pneumomediastino com extravasamento de contraste oral ao nível do esófago inferior. No segundo caso, o doente apresentou-se no Serviço de Urgência com toracalgia intensa após episódio de vómito. A TC mostrou pneumomediastino exuberante, com enfisema subcutâneo e extravasamento de contraste oral compatível com SB. O doente foi inicialmente submetido a rafia cirúrgica, mas o esofagograma ao 12º dia mostrou persistência de extravasamento do contraste. Após discussão em reunião multidisciplinar, ambos os doentes realizaram endoscopia digestiva alta, com visualização de orifícios pericentimétricos no esófago distal, encerrados com sucesso com a aplicação de clip overthe- scope (OTSC). Após seguimento de pelo menos 9 meses, os doentes permaneceram clinicamente bem, sem evidência de recidiva. Os autores destacam a gravidade desses casos clínicos, bem como a opção endoscópica que se mostrou decisiva no tratamento da SB. Os resultados favoráveis sugerem um papel para a abordagem com OTSC no tratamento da perfuração esofágica espontânea, tanto como tratamento de primeira linha, como terapêutica de resgate após falência do tratamento cirúrgico.

Lymphogranuloma Venereum-Associated Proctitis Mimicking a Malignant Rectal Neoplasia: Searching for Diagnosis.

Background: Chlamydia trachomatis-lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) and an uncommon cause of proctitis. The diagnosis requires a high index of clinical suspicion, since the clinical, imaging, endoscopic, and histological findings can mimic multiple benign or malignant conditions like inflammatory bowel disease and rectal neoplasms. Case Presentation: We present the case of a 48-year-old Caucasian male with no significant previous medical history who was admitted due to the suspicion of a rectal neoplasia. He underwent an abdominopelvic computed tomography (CT) scan and pelvic magnetic resonance imaging (MRI) before admission due to complaints of anorectal pain, hematochezia, and constipation over the previous 2 weeks. The examination revealed a circumferential rectal wall thickening, infiltration of the perirectal fat and invasion of the mesorectal fascia, associated with perirectal fat lymphadenopathy. A radiological diagnosis of a rectal malignant neoplasia staged as T4N2MX was stated. Digital rectal examination identified a circumferential rectal tumor. Rectosigmoidoscopy showed an extensive and circumferential ulceration of the rectal mucosa, with elevated geographical borders, exudate, and aphthoid erosions at the proximal limit of the endoscopic mucosal ulceration. Biopsy specimens revealed acute ulcerative proctitis with lymphoplasmocytic inflammatory infiltrate but no evidence of dysplasia or malignancy. A STI screening was positive for HIV-1 (CD4+ 251/mm3; N = 700-1,100) and C. trachomatis, with an elevated IgA-specific antibody titer (52.000; N < 5.0), suggesting LGV disease. The diagnosis was confirmed by the identification of C. trachomatis DNA on rectal swab. Other infectious causes of acute proctitis were excluded. When faced with these results, the patient ended up mentioning that he had unprotected anal sex with men. He started treatment with doxycycline 100 mg twice a day for 21 days, with a drastic improvement. Rectosigmoidoscopy was repeated and showed clear signs of progressive resolution of the ulcerative proctitis. Discussion: LGV-associated proctitis, often undervalued, is a reemerging disease which should always be considered a benign cause of rectal mass, in order to avoid delay in diagnosis and development of complications. Diagnosis becomes more challenging in patients with unknown HIV status. A detailed clinical history, including sexual behaviors, is a vital step to achieve the final diagnosis.

Introdução: A infeção por Chlamydia trachomatis-linfogranuloma venéreo (LGV) é uma doença sexualmente transmissível (DST), sendo uma causa incomum de proctite. O diagnóstico exige um elevado grau de suspeição, dado que os achados clínicos, radiológicos, endoscópicos e histológicos podem mimetizar múltiplas condições benignas ou malignas, como a doença inflamatória intestinal e as neoplasias retais. Caso clínico: Apresentamos o caso de um homem de 48 anos, caucasiano, sem antecedentes relevantes, admitido por suspeita de neoplasia retal. Por queixas de dor anorretal, hematoquézias e obstipação com 2 semanas de evolução, realizou uma tomografia computadorizada abdominopélvica e uma ressonância magnética pélvica, que revelaram espessamento retal circunferencial, infiltração da gordura periretal e invasão da fáscia mesoretal, associados a linfadenopatias locais, sugestivos de malignidade retal (T4N2MX). O toque retal identificou uma tumoração retal circunferencial.A retosigmoidoscopia mostrou mucosa retal com ulceração extensa e circunferencial, bordos geográficos elevados, exsudado e erosões aftóides no limite proximal da ulceração mucosa. As biópsias revelaram proctite ulcerada aguda com infiltrado linfoplasmocitário difuso, sem displasia ou neoplasia. O screening de DST foi positivo para VIH-1 (CD4+ 251/mm3; N: 700­1100) e título elevado de IgA para C. trachomatis (52 000; N< 5), sugerindo LGV. O diagnóstico foi confirmado pela identificação do DNA de C. trachomatis em zaragatoa retal. Outras causas infecciosas de proctite aguda foram excluídas. Perante estes resultados, o doente acabou por mencionar que tinha tido relações homossexuais anais desprotegidas. Iniciou doxiciclina (100 mg duas vezes por dia, por 21 dias) com melhoria sintomática drástica. Repetiu retosigmoidoscopia, com sinais de proctite ulcerada em resolução. Discussão: A proctite por LGV, frequentemente desvalorizada, é uma doença re-emergente, que deve ser sempre equacionada como causa benigna de massa retal, de modo a evitar o atraso diagnóstico e o desenvolvimento de complicações. O diagnóstico torna-se mais desafiante em doentes com status VIH desconhecido. A história clínica detalhada, incluindo comportamentos sexuais de risco, é fundamental para o diagnóstico.

Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Shift in the Microbial Pattern? A Retrospective Analysis.

Introduction: Over the last decade, a shift in the spontaneous bacterial peritonitis (SBP) microbial pattern toward an increasing incidence of gram-positive and multidrug-resistant (MDR) bacteria has been reported. Systematic surveillance of the local microbiological scenario and antibiotic resistance is crucial to SBP treatment success. The main objective of this study was to evaluate the microbiological profile and bacterial resistance of SBP pathogens in a Portuguese cohort to allow selection of the most appropriate empirical antibiotics. Methods: This is a single-center retrospective study including 63 adult cirrhotic patients with culture-positive SBP. Patients were identified using a hospital general diagnostic database and searching for all SBP events (neutrophil count in ascitic fluid ≥250/mm3) from January 1, 2012, to December 31, 2017. Patients were excluded if they had culture-negative SBP, secondary peritonitis, peritoneal dialysis, a liver transplant, or immunodeficiency. The site of SBP acquisition was classified as nosocomial if it was diagnosed 48 h or longer after hospitalization or as nonnosocomial if it was diagnosed within the first 48 h. MDR bacteria were those with an acquired resistance to at least 1 agent in 3 or more antimicrobial categories. All statistical analyses were carried out using IBM SPSS Statistics software version 22 (IBM, New York, USA). Results: The study cohort comprised 53 (84.1%) men. The mean age of the patients was 60.6 ± 11.2 years. Alcohol was the most common etiology (88.9%) and most patients had advanced liver cirrhosis (87.1%, Child C). Gram-negative bacteria were slightly more frequent than gram-positive bacteria (56.9 vs. 43.1%). Escherichia coli was the most common pathogen (33.8%). Nineteen (31.7%) bacteria were classified as MDR. Resistance to third-generation cephalosporins, quinolones, piperacillin-tazobactam, and carbapenems was found in 31.7, 35, 26.7, and 18.3% of the cases, respectively. The rates of gram-positive bacteria were similar between nosocomial and nonnosocomial episodes (45 vs. 42.2%; p = 0.835). MDR bacteria were more common in the nosocomial group (50 vs. 23.8%; p = 0.046). Resistance to third-generation cephalosporins (50 vs. 23.8%; p = 0.046), piperacillin-tazobactam (44.4 vs. 19.1%; p = 0.041), and carbapenems (33.3 vs. 11.9%; p = 0.049) occurred more frequently in nosocomial episodes. Resistance to first-line antibiotic occurred in 29.3% of the patients, being more common in the nosocomial group (44.4 vs. 22.5%; p = 0.089). Conclusion: Although gram-negative bacteria remain the most common causative microorganisms, our results emphasize the shift in SBP microbiological etiology, as almost half of the isolated microorganisms were gram positive. The emergence of bacteria resistant to traditionally recommended empirical antibiotics underlines the importance of basing this choice on local flora and antibiotic susceptibility data, allowing a more rational and successful use of antibiotics.

Introdução: Na última década assistiu-se a uma mudança no padrão microbiológico da peritonite bacteriana espontânea (PBE), com aumento da incidência de bactérias gram-positivas e multirresistentes. Uma vigilância sistemática do cenário microbiológico e da resistência antibiótica é crucial para o sucesso do tratamento da PBE. O principal objetivo deste estudo foi avaliar o perfil microbiológico e os padrões de resistência antibiótica dos agentes bacterianos responsáveis pelos casos de PBE numa coorte portuguesa de doentes cirróticos, de modo a permitir uma seleção mais apropriada da antibioterapia empírica. Métodos: Estudo retrospetivo unicêntrico, que incluiu 63 doentes adultos cirróticos com PBE culturapositiva. A identificação dos doentes foi efetuada a partir da base de dados eletrónica do centro hospitalar, pesquisando todos os internamentos por PBE (contagem de neutrófilos no líquido ascítico ≥250/mm3) entre 1 janeiro de 2012 e 31 de dezembro de 2017. Foram aplicados como critérios de exclusão: cultura de líquido ascítico negativa, peritonite secundária, diálise peritoneal, transplante hepático ou imunodeficiência. O local de aquisição da PBE foi classificado como nosocomial se diagnóstico após as primeiras 48 horas de hospitalização, e não-nosocomial se diagnóstico nas primeiras 48 horas. Multirresistência foi definida como resistência adquirida a pelo menos um agente em três ou mais categorias antimicrobianas. A análise estatística foi efetuada com recurso ao software IBM SPSS Statistics versão 22 (IBM, New York, USA). Resultados: A coorte incluiu 53 (84.1%) doentes cirróticos do género masculino. A idade média dos doentes foi de 60.6 ± 11.2 anos. O álcool constituiu a etiologia mais comum (88.9%) e a maioria dos doentes apresentava uma cirrose em estadio avançado (87.1%, Child-C). As bactérias gram-negativas revelaram-se ligeiramente mais frequentes que as gram-positivas (56.9 vs. 43.1%). Escherichia coli foi o microrganismo mais frequente (33.8%). Dezanove (31.7%) das bactérias isoladas foram classificadas como multirresistentes. As resistências às cefalosporinas de terceira-geração, às quinolonas, à piperacilina-tazobactam e aos carbapenemes foram de 31.7, 35, 26.7 e 18.3%, respetivamente. A taxa de bactérias gram-positivas foi similar entre PBE nosocomial e não-nosocomial (45 vs. 42.2%; p = 0.835). As bactérias multirresistentes foram mais frequentes no grupo nosocomial (50 vs. 23.8%; p = 0.046). A resistência às cefalosporinas de terceira-geração (50 vs. 23.8%; p = 0.046), à piperacilina-tazobactam (44.4 vs. 19.1%; p = 0.041) e aos carbapenemes (33.3 vs. 11.9%; p = 0.049) foi significativamente superior nas infeções nosocomiais. A resistência à antibioterapia empírica de primeira linha ocorreu em 29.3% dos doentes, sendo mais frequente no grupo nosocomial (44.4 vs. 22.5%; p = 0.089). Conclusão: Apesar de as bactérias gram-negativas constituírem, nesta coorte, a maioria dos microrganismos responsáveis pela PBE, os nossos resultados enfatizam a mudança na etiologia microbiológica da PBE, na medida em que, quase metade dos microrganismos isolados foram gram-positivos. A emergência de bactérias resistentes aos antibióticos empíricos tradicionalmente recomendados sublinha a importância de basear esta escolha nos dados locais sobre flora bacteriana e susceptibilidade antibiótica, permitindo uma escolha mais racional e um uso bem-sucedido dos antibióticos.

Endoscopic necrosectomy - When the gastroenterologist faceshis greatest nightmare

A 69-year-old woman with severe acute necrotizing pancreatitis underwent a CT-scan, which revealed a peripancreatic collection near the pancreatic body/tail, with heterogeneous content and gas inside, suggestive of an infected walled-off-pancreatic-necrosis (WOPN). The patient was proposed to WOPN transgastric endoscopic drainage. Due to persistence of sepsis, endoscopic necrosectomy was deemed necessary. During the fifth session, the endoscopist noted a large pulsatile vessel at the posterior wall of the collection. Given location and morphologic features, it was assumed that vessel was the splenic artery. The procedure was suspended. (AU)

Endoscopic necrosectomy - when the gastroenterologist faces his greatest nightmare.

A 69-year-old woman with severe acute necrotizing pancreatitis underwent a CT-scan, which revealed a peripancreatic collection near the pancreatic body/tail, with heterogeneous content and gas inside, suggestive of an infected walled-off-pancreatic-necrosis (WOPN). The patient was proposed to WOPN transgastric endoscopic drainage. Due to persistence of sepsis, endoscopic necrosectomy was deemed necessary. During the fifth session, the endoscopist noted a large pulsatile vessel at the posterior wall of the collection. Given location and morphologic features, it was assumed that vessel was the splenic artery. The procedure was suspended.

Rapid diagnosis of COVID-19 using FT-IR ATR spectroscopy and machine learning.

Early diagnosis of COVID-19 in suspected patients is essential for contagion control and damage reduction strategies. We investigated the applicability of attenuated total reflection (ATR) Fourier transform infrared (FTIR) spectroscopy associated with machine learning in oropharyngeal swab suspension fluid to predict COVID-19 positive samples. The study included samples of 243 patients from two Brazilian States. Samples were transported by using different viral transport mediums (liquid 1 or 2). Clinical COVID-19 diagnosis was performed by the RT-PCR. We built a classification model based on partial least squares (PLS) associated with cosine k-nearest neighbours (KNN). Our analysis led to 84% and 87% sensitivity, 66% and 64% specificity, and 76.9% and 78.4% accuracy for samples of liquids 1 and 2, respectively. Based on this proof-of-concept study, we believe this method could offer a simple, label-free, cost-effective solution for high-throughput screening of suspect patients for COVID-19 in health care centres and emergency departments.

Dead-end stomach: a giant and pedunculated gastric pyloric gland adenoma conditioning gastric outlet obstruction and anemia.

We present the case of a 69-year-old female undergoing esophagogastroduodenoscopy for iron-deficiency anemia investigation. She reported intermittent bloating, nausea and vomiting. A pedunculated polyp was identified arising from the greater curvature of the middle gastric body, with a long fibroelastic stalk (30mm) and a 60mm congestive head that prolapsed towards the pyloric ring, causing a complete gastric outlet obstruction (GOO). An en-block polypectomy was performed. An intraprocedural oozing bleeding from a large visible vessel at the residual stalk was managed using endoloop®. Histo-immunohistochemistry showed a R0-resection of a mixed-type gastric pyloric gland adenoma (PGA) positive for MUC-5AC and MUC-6 mucins, in a surrounding H. pylori-negative non-atrophic chronic gastritis. She became asymptomatic with anemia resolution. Adenomas account for up to 10% of gastric polyps. Histologically, they are categorized into intestinal, foveolar, pyloric and oxyntic types (1). PGA is a rare subtype, accounting for less than 3% of all gastric polyps (2). PGAs are usually solitary at gastric body, and occur in association with autoimmune gastritis, H. pylori and chemical gastritis (2). A normal background gastric mucosa has also been described (35.8%) (3). PGAs are devoid of apical mucin cap and label by both MUC-5AC and MUC-6 (2). Choi et al. (3) defined three PGA immunohistochemical phenotypes: pure pyloric-type (25.4%), with strong MUC-6 expression; predominant foveolar-type (3%), with MUC-5AC diffuse expression but ≤10% of MUC-6 expression and no foveolar differentiation; and mixed-type (61.2%), with variable MUC-5AC/MUC-6 expression. Most PGAs are asymptomatic, but clinically significant because of their potential for malignant transformation (12-47%) and complications, including gastrointestinal bleeding and obstruction (1, 3). GOO is rare, causing intermittent symptoms by polyp intussusception (ball-valve-syndrome) (4, 5). PGA management is challenging, depending on size, morphology and location. This case illustrates a successful endoscopic resection as a minimally invasive procedure of a doubly complicated PGA.

Birth Defects and Long-Term Neurodevelopmental Abnormalities in Infants Born During the Zika Virus Epidemic in the Dominican Republic.

Background: When acquired during pregnancy, Zika virus (ZIKV) infection can cause substantial fetal morbidity, however, little is known about the long-term neurodevelopmental abnormalities of infants with congenital ZIKV exposure without microcephaly at birth. Methods: We conducted a cross sectional study to characterize infants born with microcephaly, and a retrospective cohort study of infants who appeared well at birth, but had possible congenital ZIKV exposure. We analyzed data from the Dominican Ministry of Health's (MoH) National System of Epidemiological Surveillance. Neurodevelopmental abnormalities were assessed by pediatric neurologists over an 18-month period using Denver Developmental Screening Test II. Results: Of 800 known live births from 1,364 women with suspected or confirmed ZIKV infection during pregnancy, 87 (11%) infants had confirmed microcephaly. Mean head circumference (HC) at birth was 28.1 cm (SD ± 2.1 cm) and 41% had a HC on the zero percentile for gestational age. Of 42 infants with possible congenital ZIKV exposure followed longitudinally, 52% had neurodevelopmental abnormalities, including two cases of postnatal onset microcephaly, during follow-up. Most abnormalities resolved, though two infants (4%) had neurodevelopmental abnormalities that were likely associated with ZIKV infection and persisted through 15-18 months. Conclusions: In the DR epidemic, 11% of infants born to women reported to the MoH with suspected or confirmed ZIKV during pregnancy had microcephaly. Some 4% of ZKV-exposed infants developed postnatal neurocognitive abnormalities. Monitoring of the cohort through late childhood and adolescence is needed.

Zika Virus Epidemic in Pregnant Women, Dominican Republic, 2016-2017.

Zika virus infection during pregnancy may result in birth defects and pregnancy complications. We describe the Zika virus outbreak in pregnant women in the Dominican Republic during 2016-2017. We conducted multinomial logistic regression to identify factors associated with fetal losses and preterm birth. The Ministry of Health identified 1,282 pregnant women with suspected Zika virus infection, a substantial proportion during their first trimester. Fetal loss was reported for ≈10% of the reported pregnancies, and 3 cases of fetal microcephaly were reported. Women infected during the first trimester were more likely to have early fetal loss (adjusted odds ratio 5.9, 95% CI 3.5-10.0). Experiencing fever during infection was associated with increased odds of premature birth (adjusted odds ratio 1.65, 95% CI 1.03-2.65). There was widespread morbidity during the epidemic. Our findings strengthen the evidence for a broad range of adverse pregnancy outcomes resulting from Zika virus infection.

Outbreak of Severe Histoplasmosis Among Tunnel Workers-Dominican Republic, 2015.

Background: Histoplasmosis is a fungal infection associated with exposure to bat guano. An outbreak of an unknown severe febrile illness occurred among tunnel workers in the Dominican Republic, and resulted in several deaths. We conducted an investigation to confirm etiology and recommend control measures. Methods: A case was defined as fever and ≥2 symptoms consistent with histoplasmosis in a tunnel worker, July-September 2015. We interviewed workers and family members, reviewed medical records, tested serum and urine for Histoplasma antigen/antibody, and conducted a cohort study to identify risk factors for histoplasmosis and severe infection (intensive care). Results: A crew of 36 male workers removed large amounts of bat guano from tunnels without respiratory protection for a median of 24 days per worker (range, 1-25 days). Median age was 32 years (range, 18-62 years); none were immunocompromised. Thirty (83%) workers had illness that met the case definition, of whom 28 (93%) were hospitalized, 9 (30%) required intensive care, 6 (20%) required intubation, and 3 (10%) died. The median time from symptom onset to antifungal treatment was 6 days (range, 1-11 days). Twenty-two of 34 (65%) workers had laboratory evidence of infection. Conclusions: Severe illnesses and death likely resulted from exposure to large inocula of Histoplasma capsulatum spores in an enclosed space, lack of respiratory protection, and delay in recognition and treatment. Clinician education about histoplasmosis, improved laboratory capacity to diagnose fungal infections, and occupational health guidance to protect workers against endemic fungi are recommended in the Dominican Republic.

Chikungunya: un reto para los servicios de salud de la República Dominicana / Chikungunya: a challenge for the Dominican Republic's health services

Desde diciembre de 2013, la Región de las Américas se enfrenta por primera vez a una epidemia de chikungunya. Los casos iniciales se registraron en el Caribe francés y, debido al comercio y la movilización de personas, esta epidemia no tardó en llegar a la República Dominicana, cuya población es de 10 millones de habitantes y comparte con Haití la isla La Española. En este artículo se difunde información extraída de diversos artículos y documentos oficiales sobre el virus, la infección y la epidemia de chikungunya, que han sido de gran ayuda para orientar la respuesta en la República Dominicana y pueden ser útiles para mejorar tanto el conocimiento como las actuaciones frente a la epidemia de los trabajadores del sector salud de la Región. Se destaca la importancia que revisten las investigaciones realizadas en países y territorios afectados del océano Índico, como la isla de Reunión, durante la epidemia declarada entre 2005 y 2007, cuando se registró una tasa de ataque mayor de 30%, se identificaron los grupos de riesgo, las formas graves y atípicas de la infección, la transmisión vertical del virus, las formas crónicas, que pueden provocar dolores recurrentes durante tres años, y las defunciones directa o indirectamente relacionadas con el virus chikungunya. Por su alta tasa de ataque, el virus chikungunya se convierte en un reto sin precedentes para los ministerios de salud, que exige una adecuada organización de los servicios de salud, la priorización de la atención a los grupos de riesgo y a los pacientes con formas graves de la enfermedad, así como una adecuada comunicación social y respuesta intersectorial.

The Region of the Americas has been affected since December 2013 by a chikungunya epidemic for the first time. Although the first cases were recorded in the French Caribbean, the epidemic quickly spread to the Dominican Republic due to trade and people movements. The Dominican Republic, which shares the island of Hispaniola with Haiti, has a population of 10 million. This article contains information from a range of different publications and official documents about the chikungunya virus infection and epidemic. These papers were extremely helpful for guiding the response to the epidemic in the Dominican Republic and may also be useful for enhancing knowledge of the virus and responses among health workers elsewhere in the region. Particular attention is drawn to the important research undertaken in countries and territories affected by the epidemic in the Indian Ocean area. This is the case, for example, of the island of La Réunion, where the epidemic had an attack rate of more than 30% between 2005 and 2007. Researchers were able to identify risk groups, severe and atypical forms of the infection, cases of vertical transmission, chronic disease causing recurrent pain over three years, and directly- or indirectly-related deaths from the virus. Given its high attack rate, the chikungunya virus has emerged as an exceptional challenge for health ministries and calls for appropriate organized responses from the health services, prioritization of care for risk groups and patients exhibiting severe forms of the disease, and effective social communication and intersectoral actions.

Chikungunya en la República Dominicana: lecciones aprendidas en los primeros seis meses / Chikungunya in the Dominican Republic: lessons learned in the first six months

La epidemia de chikungunya en la República Dominicana se inició en febrero de 2014. En los primeros seis meses se registraron 429 421 casos, que representaron 65% de todos los notificados a la Organización Panamericana de la Salud por 33 países y territorios de la Región de las Américas. Esta epidemia se ha transmitido con rapidez en dicho país y ha demandado una intensa respuesta intersectorial, que ha liderado el Ministerio de Salud Pública y, especialmente, el Sistema Nacional de Vigilancia Epidemiológica y la red de los servicios de salud. Considerando que afectará a miles de personas, el objetivo de este artículo es describir las actuaciones realizadas y compartir los resultados y las lecciones aprendidas durante estos primeros meses con los ministerios de salud y los profesionales de los países de la Región para ayudarles a preparar una respuesta adecuada para afrontarla de forma efectiva y eficiente.

The chikungunya epidemic in the Dominican Republic began in February 2014. During the first six months 429 421 cases were recorded, representing 65% of all those notified to the Pan American Health Organization by 33 countries and territories of the Region of the Americas. This epidemic has spread quickly in the Dominican Republic, requiring a focused intersectoral response, led by the Ministry of Public Health and involving major efforts by the National Epidemiological System and the health services network. Given that the virus will affect thousands of people, this article seeks to describe the actions that have already been carried out, and to share the results and lessons learned during these first months with health ministries and professionals in the countries of the Region, in order to assist them to prepare an appropriate response to confront the epidemic effectively and efficiently.

[Chikungunya in the Dominican Republic: lessons learned in the first six months]. / Chikungunya en la República Dominicana: lecciones aprendidas en los primeros seis meses.

The chikungunya epidemic in the Dominican Republic began in February 2014. During the first six months 429 421 cases were recorded, representing 65% of all those notified to the Pan American Health Organization by 33 countries and territories of the Region of the Americas. This epidemic has spread quickly in the Dominican Republic, requiring a focused intersectoral response, led by the Ministry of Public Health and involving major efforts by the National Epidemiological System and the health services network. Given that the virus will affect thousands of people, this article seeks to describe the actions that have already been carried out, and to share the results and lessons learned during these first months with health ministries and professionals in the countries of the Region, in order to assist them to prepare an appropriate response to confront the epidemic effectively and efficiently.

[Chikungunya: a challenge for the Dominican Republic's health services]. / Chikungunya: un reto para los servicios de salud de la República Dominicana.

The Region of the Americas has been affected since December 2013 by a chikungunya epidemic for the first time. Although the first cases were recorded in the French Caribbean, the epidemic quickly spread to the Dominican Republic due to trade and people movements. The Dominican Republic, which shares the island of Hispaniola with Haiti, has a population of 10 million. This article contains information from a range of different publications and official documents about the chikungunya virus infection and epidemic. These papers were extremely helpful for guiding the response to the epidemic in the Dominican Republic and may also be useful for enhancing knowledge of the virus and responses among health workers elsewhere in the region. Particular attention is drawn to the important research undertaken in countries and territories affected by the epidemic in the Indian Ocean area. This is the case, for example, of the island of La Réunion, where the epidemic had an attack rate of more than 30% between 2005 and 2007. Researchers were able to identify risk groups, severe and atypical forms of the infection, cases of vertical transmission, chronic disease causing recurrent pain over three years, and directly- or indirectly-related deaths from the virus. Given its high attack rate, the chikungunya virus has emerged as an exceptional challenge for health ministries and calls for appropriate organized responses from the health services, prioritization of care for risk groups and patients exhibiting severe forms of the disease, and effective social communication and intersectoral actions.

Multinational cholera outbreak after wedding in the Dominican Republic.

We conducted a case­control study of a cholera outbreak after a wedding in the Dominican Republic, January 22, 2011. Ill persons were more likely to report having consumed shrimp on ice (odds ratio 8.50) and ice cubes in beverages (odds ratio 3.62). Travelers to cholera affected areas should avoid consuming uncooked seafood and untreated water.