Elevated prevalence of hepatitis B in Mexican hemodialysis patients. A multicentric survey.

BACKGROUND AND AIMS: The prevalence of hepatitis B virus (HBV) infection in patients on renal replacement has been reduced in developed countries, but information from developing nations is currently scarce and high prevalence rates are suspected. We undertook this study to analyze the prevalence of HBV infection and identify risk factors associated with it in a sample of Mexican hemodialysis patients. METHODS: A cross-sectional study was performed in patients on hemodialysis in Mexico. Adult patients from 10 hemodialysis centers were randomly selected. Patients answered a questionnaire for risk factors for HB infection and a blood sample was taken for HBsAg determination. RESULTS: We included 368 patients, 197 (53.5%) male, with a median age of 52 years (range: 18-93 years). In 26 patients HBsAg was positive with a prevalence of 7.1% (95% CI 4.4-9.7). Hepatitis C (HCV) was also tested, and 31 patients were positive with a prevalence of 8.4% (95% CI 5.5-11.2). Two patients (0.5%) were co-infected. Patients infected with HBV had been on hemodialysis longer (median time 50.5 months in HB positive vs. 34 months in HB negative; p = 0.005) and had history of more transfusions (median number of transfusions 5.5 vs 2; p < 0.009) compared with patients without HBV infection. CONCLUSIONS: The prevalence of HBV infection in patients on maintenance hemodialysis in Mexico is about 7%, 35 times higher compared with the general population (0.2%).

Factors associated with nosocomial surgical-site infections for craniotomy in Mexico City hospitals.

BACKGROUND: Nosocomial surgical-site infection (NSSI) after craniotomy is responsible for an increase in deaths and/or disabilities that affect quality of life. It is necessary to identify factors to be included in an index for their control. The aim of this study was to a) identify intrinsic and extrinsic factors associated with NSSI after craniotomy and b) obtain the infection risk attributed to both intrinsic and extrinsic factors as well as to compare their predictive capability with the NNISS (National Nosocomial Infection Surveillance System) index. METHODS: A case-control study was conducted during a 2-year period in patients who underwent craniotomy in hospitals affiliated with the Instituto Mexicano del Seguro Social. Patients were selected according to the Centers for Disease Control and Prevention criteria for NSSI. RESULTS: During the study period 737 craniotomies were performed, 41 of which presented with NSSI. Intrinsic factors associated with NSSI were the presence of chronic diseases (OR = 2.18) and craniotomy due to nontraumatic causes (OR = 1.87), whereas extrinsic factors were procedures performed during the late shift (OR = 2.6) and another surgery at the same surgical site (OR = 5.2). These factors comprised the index with intrinsic and extrinsic factors. Extrinsic factors were 1.7 times higher than intrinsic factors, in addition to having a larger area under the ROC curve (0.731). The risk obtained with the NNISS index for patients who had one factor was 1.5, whereas that for patients who had two or three factors was 4.7. CONCLUSIONS: In the studied population, patients who underwent a craniotomy with extrinsic factors showed a higher association with NSSI.

Factores asociados a infecciones nosocomiales en sitio quirúrgico para craneotomía / Factors associated with nosocomial surgical-site infections for craniotomy in Mexico City hospitals

Introducción: La infección nosocomial en sitio quirúrgico (INSQ) en craneotomía puede ocasionar la muerte o discapacidad que modifica la calidad de vida, por lo que se requiere encontrar factores que puedan ser utilizados para incluir en los índices de control. Por ello es necesario identificar factores asociados a esta infección y obtener el riesgo de infección atribuible y comparar su capacidad predictiva con el índice del NNISS (Sistema de Vigilancia Nacional de Infecciones Nosocomiales de Estados Unidos). Material y métodos: Se realizó un estudio de casos y controles durante dos años, en pacientes con craneotomía en hospitales del Instituto Mexicano del Seguro Social. Los pacientes cumplieron los criterios de los Centros de Control de Enfermedades de Atlanta para INSQ. Resultados: Se practicaron 737 craneotomías durante el estudio, 41 pacientes presentaron INSQ. Factores intrínsecos asociados: presencia de enfermedades crónicas (OR = 2.18) y craneotomía debida a causas no traumáticas (OR = 1.87); factores extrínsecos: turno vespertino (OR = 2.6) y la práctica de otra cirugía en el mismo sitio quirúrgico (OR = 5.2). Estos factores conformaron los índices de factores intrínsecos y extrínsecos. Con factores extrínseco se presentó 1.7 veces más riesgo en comparación con los factores intrínsecos, así como mayor área bajo la curva ROC (0.731). El riesgo con el índice NNISS con un factor fue de 1.5 y con dos a tres factores, de 4.7. Conclusiones: En esta población en estudio, los pacientes sometidos a una craneotomía tuvieron mayor asociación a INSQ con los factores extrínsecos.

BACKGROUND: Nosocomial surgical-site infection (NSSI) after craniotomy is responsible for an increase in deaths and/or disabilities that affect quality of life. It is necessary to identify factors to be included in an index for their control. The aim of this study was to a) identify intrinsic and extrinsic factors associated with NSSI after craniotomy and b) obtain the infection risk attributed to both intrinsic and extrinsic factors as well as to compare their predictive capability with the NNISS (National Nosocomial Infection Surveillance System) index. METHODS: A case-control study was conducted during a 2-year period in patients who underwent craniotomy in hospitals affiliated with the Instituto Mexicano del Seguro Social. Patients were selected according to the Centers for Disease Control and Prevention criteria for NSSI. RESULTS: During the study period 737 craniotomies were performed, 41 of which presented with NSSI. Intrinsic factors associated with NSSI were the presence of chronic diseases (OR = 2.18) and craniotomy due to nontraumatic causes (OR = 1.87), whereas extrinsic factors were procedures performed during the late shift (OR = 2.6) and another surgery at the same surgical site (OR = 5.2). These factors comprised the index with intrinsic and extrinsic factors. Extrinsic factors were 1.7 times higher than intrinsic factors, in addition to having a larger area under the ROC curve (0.731). The risk obtained with the NNISS index for patients who had one factor was 1.5, whereas that for patients who had two or three factors was 4.7. CONCLUSIONS: In the studied population, patients who underwent a craniotomy with extrinsic factors showed a higher association with NSSI.

Prospective, randomized, open label trial of Efavirenz vs Lopinavir/Ritonavir in HIV+ treatment-naive subjects with CD4+<200 cell/mm3 in Mexico.

OBJECTIVE: To compare the efficacy of efavirenz (EFV) vs lopinavir/ritonavir (LPV/r) in combination with azidothymidine/lamivudine in antiretroviral therapy naive, HIV+ individuals presenting for care with CD4 counts <200/mm. METHODS: Prospective, randomized, open label, multicenter trial in Mexico. HIV-infected subjects with CD4 <200/mm were randomized to receive open label EFV or LPV/r plus azidothymidine/lamivudine (fixed-dose combination) for 48 weeks. Randomization was stratified by baseline CD4 cell count (< or =100 or >100/mm). The primary endpoint was the percentage of patients with plasma HIV-1 RNA <50 copies/mL at 48 weeks by intention-to-treat analysis. RESULTS: A total of 189 patients (85% men) were randomized to receive EFV (95) or LPV/r (94). Median baseline CD4 were 64 and 52/mm, respectively (P = not significant). At week 48, by intention-to-treat analysis, 70% of EFV and 53% of LPV/r patients achieved HIV-1 RNA <50 copies/mL [estimated difference 17% (95% confidence interval 3.5 to 31), P = 0.013]. The proportion with HIV-1 RNA <400 copies/mL was 73% with EFV and 65% with LPV/r (P = 0.25). Virologic failure occurred in 7 patients on EFV and 17 on LPV/r. Mean CD4 count increases (cells/mm) were 234 for EFV and 239 for LPV/r. Mean change in total cholesterol and triglyceride levels were 50 and 48 mg/dL in EFV and 63 and 116 mg/dL in LPV/r (P = 0.24 and P < 0.01). CONCLUSIONS: In these very advanced HIV-infected ARV-naive subjects, EFV-based highly active antiretroviral therapy had superior virologic efficacy than LPV/r-based highly active antiretroviral therapy, with a more favorable lipid profile.

Epidemiology of adverse cutaneous drug reactions. A prospective study in hospitalized patients.

BACKGROUND: Drug reactions are commonly present in the skin; however, their frequency in our setting is unknown. METHODS: A 10-month prospective cohort study including all hospitalized patients was designed. Those with adverse cutaneous drug reactions (ACDR) were clinically identified. RESULTS: Thirty five drug reactions (prevalence of 0.7%) were seen among 4785 (2713 females, 2072 males) discharged patients. According to Begaud's imputability criteria, the reactions were most likely attributed to a drug in 4.87%, likely in 41.46% and possible in 53.65%. The most commonly seen dermatoses were morbilliform rash 51.2%, urticaria 12.2% and erythema multiforme 4.9%. Drugs most frequently associated with ACDR were amoxicillin clavulanate (8), amphotericin B (2) and metamizole (4). Expressed as risk by 1000 day-doses (Dd: the risk a patient has of developing an ACDR after receiving 1 day of treatment with the drug): amoxicillin clavulanate Dd 7.7, amphotericin B Dd 4.8 and metamizole Dd 3.7. Immunosuppressed patients were most frequently affected. Notably, patients with systemic lupus erythematosus (SLE) had a 4.68 higher risk (CI 95% 1.794-12.186 p <0.001) of developing an ACDR. AIDS patients showed a risk of 8.68 (CI 95% 2.18-33.19 p <0.001). Non-Hodgkin's lymphoma patients also had an increased risk of developing an ACDR. Six of the 35 identified cases were patients who had been hospitalized due to a severe drug reaction (1.3/1000 patients); one died from complications directly related to the ACDR, representing a 16.6% mortality rate among those admitted for an ACDR and 0.02% among the global mortality. CONCLUSIONS: We have a low prevalence of drug reactions compared to data reported in the literature. Pharmacovigilance with special attention to immunosuppressed SLE or AIDS patients is stressed.

Epidemiology of medical complaints in Mexico: identifying a general profile.

OBJECTIVE: To determine the problems that were the sources of the complaints most frequently received at the National Commission of Medical Arbitration (CONAMED) in Mexico, as well as the diagnoses most frequently related, the institutions involved, and the populations affected. DESIGN: From all complaints received from 1 January 1998 to 31 December 2000, we chose a random sample of 639 complaints and carried out our study using a cross-sectional design. SETTING: CONAMED receives complaints from Mexico City and the surrounding areas. PARTICIPANTS: Patients attending public and private health institutions from the three levels of medical attention who submitted a complaint to the CONAMED in Mexico. MAIN OUTCOME MEASURES: Assessment of health care quality (good practice or malpractice). Type of malpractice (negligence, lack of skill, or deceit). Main motives of complaint. RESULTS: We analyzed 639 complaints; 57.6% were submitted by women, average age 41.0 years. Surgical treatment was the main cause of complaint. Most frequent diagnoses were diseases of the digestive system. Evaluation of medical practice revealed 36.5% of malpractice. Lack of skill accounted for 67.4% of those cases. CONCLUSIONS: Malpractice was identified in a third of the complaints, and lack of skill was the main reason for malpractice. Surgical patients were the most frequently affected. The other two-thirds of the complaints were related to lack of communication between patients and physicians. These results suggest potential points of intervention to decrease the risk and the conflict.

[Confronting bioterrorism: Epidemiologic, clinical, and preventive aspects of smallpox]. / Enfrentando el bioterrorismo: aspectos epidemiológicos, clínicos y preventivos de la viruela.

The worldwide eradication of smallpox, a major achievement in public health, is currently threatened by the risk of bioterrorism. The debate on the destruction of the Variola virus in the two reference laboratories of the World Health Organization has dramatically switched to the preservation of the remaining virus after the September 2001 terrorist events in the U.S. along with the intentional release of Bacillus anthracis in the U.S. The risk of intentional release of Variola virus constitutes a minimal, yet possible risk. A smallpox epidemic could have a devastating impact due to its elevated morbidity and mortality that would inflict in non-immune human population, in addition to the ensuing panic and social unrest. Therefore, the development of national preparedness and response plans along with the availability of smallpox vaccine to be used in the post-exposure phase represent a fundamental part of the preventive efforts to cope with bioterrorism. Reestablishing a preventive vaccination program was recently recommended by the Advisory Committee on Immunization Practices (ACIP). However, the vaccine currently available has historically been associated with serious adverse reactions, even death. Thus, this recommendation has not been universally accepted. To counter an epidemic of smallpox, medical personnel in the frontline need to be prepared with updated smallpox information to identify, diagnose, isolate, and treat cases if a bioterrorist attack should occur. Herein we present an indepth review for health care personnel with relevant epidemiologic, clinical, and preventive information on smallpox.

Enfrentando el bioterrorismo: aspectos epidemiológicos, clínicos y preventivos de la viruela / Confronting bioterrorism: epidemiologic, clinical, and preventive aspects of smallpox

Uno de los grandes logros de la salud pública mundial, la erradicación de la viruela, puede verse mermado por el posible riesgo de bioterrorismo. El debate acerca de la destrucción de los restos del virus en los dos laboratorios de referencia de la Organización Mundial de la Salud ha cambiado diametralmente debido a los eventos terroristas y a la dispersión intencional de Bacillus anthracis ocurridos en poblaciones civiles en Estados Unidos de América en el año 2001. La liberación del virus Variola con fines terroristas constituye un riesgo mínimo no cuantificable, pero desafortunadamente real. El impacto podría ser devastador debido a la elevada morbimortalidad de la enfermedad aunada al pánico y a la desestabilización social que podría ocasionar. Es por ello que el establecimiento de un plan de respuesta, sumado a disponibilidad de vacuna para ser utilizada pos-exposición, es importante dentro de los planes de contingencia contra el bioterrorismo. El reiniciar un programa limitado de vacunación contra la viruela, como parte de dicho plan, ha sido recientemente recomendado por el Comité Asesor de Vacunación, del Centro para el Control de las Enfermedades, pero la vacuna disponible puede causar complicaciones graves e incluso la muerte, por lo que dicha recomendación no ha sido universalmente aceptada. No obstante, el personal médico y de salud pública requiere de información actualizada sobre la viruela y su prevención, ya que ellos son la primera línea de defensa en caso de un posible brote a consecuencia de un ataque bioterrorista. El presente artículo presenta una revisión dirigida a proporcionar al personal de salud un enfoque clínico, epidemiológico y preventivo sobre la viruela

Infecciones nosocomiales: tendencias seculares de un programa de control en México / Nosocomial infections. Secular trends of a control program in Mexico

Objetivo. Determinar la frecuencia de infecciones nosocomiales en el Instituto Nacional de la Nutrición Salvador Zubirán (INNSZ) desde la instauración del programa de vigilancia hasta la actualidad y conocer su impacto en estancia hospitalaria y mortalidad. Material y métodos. Se realizó un estudio descriptivo, retrospectivo y retrolectivo en un hospital de referencia de tercer nivel de atención. Se obtuvieron las frecuencias, el tipo y la distribución de infecciones nosocomiales de la base de datos del Departamento de Epidemiología Hospitalaria entre 1991 y 1996. Se determinó en cada paciente el grado de gravedad de su enfermedad mediante la escala de McCabe-Jackson, así como la edad promedio y el tiempo de estancia hospitalaria. Se aplicó la prueba de X² para tendencias de los diferentes parámetros evaluados. El estudio se dividió en tres etapas: prerremodelación (1991-1993), remodelación (1994-1995) y posremodelación (1996). Se compararon los periodos prerremodelación contra posremodelación. Resultados. Durante este periodo (1991-1996) la tasa de infecciones nosocomiales fue de 8.6 por 100 egresos en promedio, con una disminución de 20 por ciento en su frecuencia a lo largo del mismo (p<0.01), comparando las tasas que se observaron durante la prerremodelación con las de la posrremodelación. El área hospitalaria con mayor frecuencia de infecciones es la Unidad de Terapia Intensiva (26.9 infecciones por 100 egresos), seguida de áreas de hospitalización con cuartos compartidos (9.47 por ciento) y con cuartos privados (7.5 por ciento)...