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INTRODUCTION: KMT2B-related dystonia is a childhood-onset movement disorder characterized by focal dystonia of the lower extremities progressing to generalized dystonia with predominant cervical, cranial, and laryngeal involvement. So far, fewer than 100 variants have been reported, the vast majority being de novo mutations. The presenting frame of KMT2B dystonia, with dysmorphology features and other complex neurologic symptoms shows the spectrum of KMT2B dystonia as a probable syndromic disease, rather than an isolated early-onset dystonia, which has been the classic view of the condition. CASE REPORTS: We report three patients who presented regression in their neurodevelopment, focal dystonia of the lower limbs with subsequent generalization, in whom two de novo variants were reported in the KMT2B gene, with a mean age of presentation lower than the average reported worldwide. CONCLUSIONS: We describe the largest local series of patients with KMT2B dystonia in Colombia (to our knowledge), which allows us to expand the genotype-phenotype relationship of this genetic dystonia. Although many affected individuals follow a similar disease course, it is important to determine clinical features that may be associated such as neurodevelopmental regression.
TITLE: Espectro fenotípico y genotípico de la distonía causada por el gen KMT2B. Descripción de tres casos colombianos.Introducción. La distonía relacionada con KMT2B es un trastorno del movimiento hipercinético, de inicio en la infancia, caracterizado inicialmente por distonía focal de las extremidades inferiores que progresa a una distonía generalizada con mayor afectación cervical, craneal y laríngea. Hasta el momento se han descrito aproximadamente 100 variantes causantes de enfermedad, y la mayoría son de novo. La presentación clínica de la distonía con hallazgos fenotípicos comunes en los pacientes, asociada a frecuente afectación del neurodesarrollo, afectación intelectual y otros trastornos del movimiento, hace pensar más en el espectro KMT2B como una condición sindrómica, más que en una distonía aislada de inicio temprano, como clásicamente se ha clasificado. Casos clínicos. Se presenta el caso de tres pacientes con regresión del neurodesarrollo, distonía focal de los miembros inferiores con posterior generalización, en quienes se identificaron tres variantes en el gen KMT2B, en dos de los casos de novo (en una de ellas se desconoce la segregación), y dos de ellas comunicadas por primera vez en la bibliografía. La edad media de presentación fue menor a la edad promedio notificada a nivel mundial. Conclusiones. Describimos una serie de pacientes colombianos con distonía DYT-KMT2B (la más grande en nuestro conocimiento a nivel local), lo que nos permite ampliar la relación genotipo-fenotipo de esta distonía genética. Si bien múltiples individuos afectados siguen un curso de enfermedad similar, es importante determinar las características clínicas que pueden estar asociadas, como la regresión del neurodesarrollo y su potencial clasificación como distonía compleja. Describimos, además, dos nuevas variantes asociadas al fenotipo.
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Trastornos Distónicos , N-Metiltransferasa de Histona-Lisina , Fenotipo , Adolescente , Niño , Femenino , Humanos , Masculino , Colombia , Trastornos Distónicos/genética , Genotipo , N-Metiltransferasa de Histona-Lisina/genética , MutaciónRESUMEN
AIM: The objective of this study is to evaluate effects of SARS-CoV-2 vaccination on seizure pattern in paediatric patients with epilepsy that attended our tertiary center in the city of Bogota, Colombia. PATIENTS AND METHODS: Children with epilepsy who were treated at our center and have had SARS-CoV-2 vaccination and their caregivers were asked to report their experience following vaccination. We documented age, sex, age at onset of epilepsy, duration of epilepsy, epilepsy type, seizure frequency, number of medications, time from last crisis, vaccination schemes, and seizures two weeks after vaccination. RESULTS: One hundred and one patients with epilepsy were included (58%, male; and 42%, female). The average age was 11 years, 73% had focal epilepsy, and 27%, generalized. Twenty-one fulfilled criteria for refractory epilepsy and 11 had a personal history of febrile seizures. Forty-seven patients had been vaccinated with Sinovac's vaccine; 41 patients, with Pfizer's; 12 patients, with Moderna's; and one, with CoronaVac's. Three patients presented seizures 24 hours after the application of the vaccine with no clear relation between vaccination and seizure frequency, and one patient required admission to the hospital for a prolonged seizure. CONCLUSION: Vaccination against SARS-CoV-2 in paediatric patients with epilepsy is safe. Approximately 3% of patients with epilepsy could eventually have seizures in the post-vaccination period.
TITLE: Vacunación contra el SARS-CoV-2 en pacientes pediátricos con epilepsia: experiencia de un centro terciario en Colombia.Objetivo. El objetivo de este estudio es evaluar los efectos de la vacunación contra el SARS-CoV-2 sobre el patrón convulsivo en pacientes pediátricos con epilepsia que acudieron a nuestro centro terciario en la ciudad de Bogotá, Colombia. Pacientes y métodos. Se pidió a los niños con epilepsia que fueron tratados en nuestro centro y que habían recibido la vacuna contra el SARS-CoV-2 y a sus cuidadores que informaran de su experiencia después de la vacunación. Se documentaron la edad, el sexo, la edad de inicio de la epilepsia, la duración de la epilepsia, el tipo de epilepsia, la frecuencia de las convulsiones, el número de medicamentos, el tiempo transcurrido desde la última crisis, los esquemas de vacunación y las convulsiones dos semanas después de la vacunación. Resultados. Se incluyó a 101 pacientes con epilepsia (58%, hombres; y 42%, mujeres). La edad promedio fue de 11 años, el 73% tenía epilepsia focal, y el 27%, generalizada. Veintiuno cumplían los criterios para la epilepsia refractaria y 11 tenían antecedentes personales de convulsiones febriles. Cuarenta y siete pacientes habían sido vacunados con la vacuna de Sinovac; 41, con Pfizer; 12, con Moderna; y uno, con CoronaVac. Tres pacientes presentaron convulsiones 24 horas después de la aplicación de la vacuna sin una relación clara entre la vacunación y la frecuencia de las convulsiones, y un paciente requirió ingreso en el hospital por una convulsión prolongada. Conclusión. La vacunación contra el SARS-CoV-2 en pacientes pediátricos con epilepsia es segura. Aproximadamente el 3% de los pacientes con epilepsia podría eventualmente tener convulsiones en el período posterior a la vacunación.
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COVID-19 , Epilepsia , Estado Epiléptico , Niño , Humanos , Masculino , Femenino , Recién Nacido , Vacunas contra la COVID-19 , Colombia , SARS-CoV-2 , COVID-19/prevención & control , VacunaciónRESUMEN
INTRODUCTION: Currently, to manage rotator cuff injury (RCI), there is a tendency to replace mini-open (MO) surgery with arthroscopy, but results and costs are controversial. OBJECTIVE: To analyze the cost-result of surgical techniques for RCI. MATERIAL AND METHODS: A partial economic evaluation of cost-result type was performed on 113 patients with RCI surgically operated by mini-open technique (n = 6), or arthroscopy (n = 91), or both (n = 16). Direct costs included: hospital stay, days of work disability, surgery, implants (anchors), medical assessments, laboratory and imaging. One-year shoulder functionality was evaluated with Constant-Murley scale (EscC-M). RESULTS: The MO technique was the most economical (X = $42,950.60 MXN) and the most expensive was the arthroscopy + MO with anchors (X = $89,594.80 MXN); with a non-significant difference in shoulder functionality (EscC-M = 56.33 ± 7.0 vs. 64.25 ± 9.0 points, respectively) (p 0.05; Kruskal-Wallis; post hoc Mann-Whitney). Difference of $46,644.1 MXN between techniques corresponded to 7.92 points. There was a mild relationship between the technique and the functionality of shoulder (rs = 0.26; p = 0.005; Spearman). CONCLUSION: The mini-open technique showed best cost-result, with similar functionality in shoulder to that obtained with the more expensive technique.
INTRODUCCIÓN: Actualmente, para manejar la ruptura del manguito de los rotadores (LMR), se prefiere la artroscopía sobre técnicas abiertas (mini-open [MO]), con resultados y costos controversiales. OBJETIVO: Analizar el costo-resultado de las técnicas quirúrgicas para la LMR. MATERIAL Y MÉTODOS: Se realizó una evaluación económica parcial de tipo costo-resultado a 113 pacientes con LMR intervenidos mediante técnica mini-open (n = 6) o artroscopía (n = 91) o ambas (n = 16). Los costos directos incluyeron: estancia, días de incapacidad laboral, cirugía, implantes (anclas), valoraciones médicas, laboratorio e imagen. Se evaluó la funcionalidad del hombro a un año mediante la escala de Constant-Murley (EscC-M). RESULTADOS: La técnica MO fue la más económica (X = $42,950.60 MXN) y la más costosa fue la artroscopía + MO con anclas (X = $89,594.80 MXN); con una diferencia no significativa en la funcionalidad del hombro (EscC-M = 56.33 ± 7 vs 64.25 ± 9 puntos, respectivamente) (p 0.05; Kruskal-Wallis; post hoc Mann-Whitney). Una diferencia de $46,644.10 MXN entre técnicas correspondió a 7.92 puntos. Hubo relación leve entre la técnica y la funcionalidad del hombro (rs = 0.26; p = 0.005; Spearman). CONCLUSIÓN: La técnica mini-open mostró mejor costo-resultado, con una ganancia en la funcionalidad de hombro similar a la que se obtiene con la técnica más costosa.
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Lesiones del Manguito de los Rotadores , Artroscopía , Humanos , Manguito de los Rotadores/cirugía , Lesiones del Manguito de los Rotadores/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: Early initiation of antiretroviral therapy (ART) during acute HIV infection is associated with favourable clinical and epidemiological outcomes. Barriers to prompt treatment initiation limit the benefits of universal access to ART in Mexico. We sought to create an algorithm for the immediate detection and treatment of patients with acute HIV infection. METHODS: A nationwide cohort of patients with acute HIV infection was created in 2015. In order to identify cases and treat them promptly at our centre, an interdisciplinary group coordinated through an instant-messaging tool using smart phones was established. When a probable case was detected, a discussion was initiated to confirm the diagnosis and facilitate the administrative processes to initiate ART as soon as possible. We compared time to ART initiation with that in a comparison group of patients with chronic HIV infection enrolled during the same period (May 2015 to February 2017) through routine care, using survival analysis estimators and log-rank tests. RESULTS: We recruited 29 patients with acute HIV infection. The median time to ART initiation was 2 days in these patients, in contrast to 21 days for patients with chronic infection. There were no significant differences in the percentages of patients engaged in care, on treatment or virologically suppressed at 1 year of follow-up. CONCLUSIONS: Implementing immediate ART initiation programmes is feasible in Mexico, in spite of the substantial administrative barriers that exist in the country. More extensive replication of this model in other centres and in patients with chronic infection is warranted to evaluate its effect on the continuum of care.
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Fármacos Anti-VIH/administración & dosificación , Infecciones por VIH/tratamiento farmacológico , Adulto , Algoritmos , Fármacos Anti-VIH/uso terapéutico , Estudios de Cohortes , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Relaciones Médico-Paciente , Teléfono Inteligente , Análisis de Supervivencia , Centros de Atención Terciaria , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
OBJECTIVE: To validate the Spanish version of the CAM-ICU. DESIGN: Validation study. The inter-rater reliability and validity were evaluated using a blind comparison with the DSM-IVTR criteria (reference standard) in a group of patients hospitalized in an Intensive Care Unit (ICU). SETTING: Medical-surgical ICU. PATIENTS: 129 adults with RASS >-4 score, within the 24-48 h of ICU admission. Independent application of the CAM-ICU by two intensive care specialists and evaluation by a psychiatrist using the DSM-IVTR criteria for delirium. RESULTS: Prevalence of delirium in the sample was 26.4%, this being and 48.3% in the 29 patients who received mechanical ventilation. Inter-rater reliability in the whole sample according to the Kappa index was 0.792 (95% CI 0.662-0.922, p<0.001) and in those who received mechanical ventilation was 0.726 (95% CI 0.487-0.965, p<0.001). The sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were 79.4% (95% CI 63.2-89.7%); 97.9% (95% CI 92.6-99.4%); 93.1% (95% CI 78.0-98.1%); 93.0% (95% CI 86.3-96.6%); 37.72 (95% CI 9.47-150.20) and 0.21(95% CI 0.11-0.41), respectively, in the whole sample. In mechanically-ventilated patients, sensitivity, specificity, PPV, NPV, +LR and -LR were 92.9% (95% CI 68.5-98.7%); 86.7% (95% CI 62.1-96.3%); 86.7% (95% CI 62.1-96.3%); 92.9% (95% CI 68.5-98.7%); 6.96(95% CI 1.90-25.51) and 0.08 (95% CI 0.01-0.55), respectively. CONCLUSION: The Spanish version of the CAM-ICU is reliable. Its sensitivity, specificity and predictive values should be considered good.
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Cuidados Críticos/métodos , Enfermedad Crítica/psicología , Delirio/diagnóstico , Índice de Severidad de la Enfermedad , Adulto , Anciano , Colombia/epidemiología , Coma/diagnóstico , Delirio/epidemiología , Delirio/psicología , Demencia/diagnóstico , Demencia/epidemiología , Demencia/psicología , Diagnóstico Diferencial , Humanos , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Variaciones Dependientes del Observador , Proyectos Piloto , Valor Predictivo de las Pruebas , Prevalencia , Reproducibilidad de los Resultados , Respiración Artificial , Sensibilidad y Especificidad , Método Simple CiegoRESUMEN
Measles ranks fifth among the five major childhood conditions which are responsible for 21% of all deaths in low and middle-income countries. Measles immunization is considered the most cost-effective public health intervention in the world. In recent years, there has been a critical need to identify alternative routes of measles immunization, which are rapid, reliable, cost-effective, needle-free, and suitable for use in mass campaigns. Aerosol administration of measles vaccines in mass campaigns was first proposed by Dr. Albert Sabin. We review the different clinical trials that have been conducted using the classic Mexican device as well as issues regarding vaccine strain, presentation, and manufacturer. Results of clinical trials indicate that the method is safe and immunogenic in infants and school age children. The viral inoculum will probably need to be increased when administered to infants. From the logistical point of view, the use of the aerosol method has not been evaluated in routine immunization although feasibility of its routine implementation was proved in mass campaigns in Mexico. Cost savings will probably be demonstrated. As to licensure, its compliance with the appropriate international regulatory requirements for medical aerosol delivery devices is in process.
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Vacuna Antisarampión/administración & dosificación , Sarampión/prevención & control , Administración por Inhalación , Aerosoles , Humanos , Sarampión/epidemiología , Sarampión/inmunología , Vacuna Antisarampión/inmunologíaRESUMEN
Amebiasis and rabies are public health problems, and they have in common a poor inflammatory effect in the target organs that they affect. In the GenBank, it was found that the anti-inflammatory peptide monocyte locomotion inhibitory factor (MLIF) produced by Entamoeba histolytica homologates 80%, with a fragment of the N protein of the rabies virus. We speculated if the N protein could contribute to the scant inflammatory reaction produced by rabies virus in central nervous system. The N protein was obtained and studied in vitro and in vivo. The N protein, as MLIF, inhibited the respiratory burst in human mononuclear phagocytes (43%, p<0.05), but in contrast to MLIF, it increased chemotaxis and it did not significantly inhibit delayed hypersensitivity skin reaction to 1-chloro-2-4-dinitrobenzene in guinea pigs. Therefore, the full peptide sequence has to be present or it has to be cleaved-free from the large recombinant N protein molecule (55 kDa) to become active.
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Entamoeba histolytica/metabolismo , Inflamación/metabolismo , Proteínas de la Nucleocápside/farmacología , Oligopéptidos/metabolismo , Proteínas Protozoarias/metabolismo , Animales , Línea Celular , Movimiento Celular , Factores Quimiotácticos , Entamoeba histolytica/efectos de los fármacos , Cobayas , Hipersensibilidad Tardía , Mariposas Nocturnas/citología , Proteínas de la Nucleocápside/química , Proteínas de la Nucleocápside/metabolismo , Oligopéptidos/química , Estallido RespiratorioRESUMEN
BACKGROUND: Tuberculosis, declared a global emergency by the World Health Organization, continues to be an important public health problem in Mexico, included in the first twenty causes of death. OBJECTIVE: To know the impact of drug resistance of Mycobacterium tuberculosis on treatment outcome, need of re-treatment and mortality in a cohort of patients with pulmonary tuberculosis receiving directly observed therapy, short course (DOTS). METHODS: We conducted a population-based study in a suburban region in Southern Mexico. People who had been coughing for more than two weeks underwent sputum acid-fast bacilli smear. Patients with a positive smear were recruited and underwent clinical exam, chest X-ray, HIV testing, and sputum cultures. Identification, drug susceptibility testing and restriction fragment length polymorphism analysis (RFLP) were performed in all isolates. Patients were followed every 12 months for new episodes of tuberculosis and vital status. Patients were referred for clinical care to the local program of tuberculosis. Deaths were corroborated with death certificates. Informed consent was obtained from participants. RESULTS: Between March 1995 and February 1999, tuberculosis was diagnosed in 371 patients who were followed for an average of 32 months. M. tuberculosis was cultured from 316 patients; resistance to any drug occurred in 25.0% of isolates (primary 18.8%, acquired 49.2%); only to isoniazid in 6.8% (primary 7.3%, acquired 4.8%); to isoniazid and rifampin in 6.2% (primary 1.6%, acquired 23.8%). Patients with drug resistance had a higher probability of treatment failure (OR = 16.9, CI 95% 4.5-63.0) and patients with MDR strains had a higher probability of need of re-treatment (RR = 24.4, CI 95% 8.8-67.6), and of death (RR = 4.0, CI 95% 1.5-10.7). Additional variables were found to be associated with subsequent episodes of disease and mortality: Cocaine use, chronic disease, type of radiological lesions, HIV co-infection, non-compliance and treatment delay, as well as RFLP clustering. CONCLUSIONS: In this study, we observed that drug resistance showed a severe impact on the outcome and survival; drug-resistance was the most significant factor for these negative outcomes; DOTS may not be sufficient in areas where drug resistance is considerable, and patient follow-up for longer periods of time, as compared to evaluation at the end of treatment, provides additional information which is useful for prevention and control programs.
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Antituberculosos/uso terapéutico , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Pulmonar/prevención & control , Adulto , Antituberculosos/farmacología , Farmacorresistencia Microbiana , Femenino , Humanos , Masculino , México/epidemiología , Mycobacterium tuberculosis/efectos de los fármacos , Tuberculosis Resistente a Múltiples Medicamentos/prevención & control , Tuberculosis Pulmonar/mortalidadRESUMEN
Results from prospective surveillance of nosocomial infections (NIs) in a small community hospital were evaluated, and a case-control study was conducted. The rate of 1.4 NIs per 100 discharges determined by prospective surveillance was found to be underestimated. Prematurity, pediatric service, surgery, length of stay, and age were independently associated with NI.
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Infección Hospitalaria/epidemiología , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Modelos Logísticos , México/epidemiología , Análisis Multivariante , Oportunidad Relativa , Vigilancia de la Población , Estudios Prospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To identify risk factors associated with tuberculin reactivity in healthcare workers (HCWs). DESIGN: Cross-sectional survey of tuberculin reactivity (2 TU of purified protein derivative (PPD) RT23, using the Mantoux two-step test). SETTING: Two general hospitals located in a region with a high prevalence of tuberculosis and high bacille Calmette-Guerin (BCG) coverage. PARTICIPANTS: Volunteer sample of HCWs. RESULTS: 605 HCWs were recruited: 71.2% female; mean age, 36.4 (standard deviation [SD], 8.2) years; 48.9% nurses, 10.4% physicians, 26.8% administrative personnel; mean time of employment, 10.9 (SD, 6.7) years. PPD reactivity (> or =10 mm) was found in 390 (64.5%). Multivariate analysis revealed an association of tuberculin reactivity with occupational exposure in the hospital: participation in autopsies (odds ratio [OR], 9.3; 95% confidence interval [CI95], 2.1-40.5; P=.003.), more than 1 year of employment (OR, 2.4; CI95, 1.1-5.0; P=.02), work in the emergency or radiology departments (OR, 2.0; CI95, 1.03-3.81; P=.04), being physicians or nurses (OR, 1.5; CI95, 1.04-2.11; P=.03), age (OR, 1.04; CI95, 1.02-1.07 per year of age; P<.001), and BCG scar (OR, 2.1; CI95, 1.2-3.4; P=.005). CONCLUSIONS: Although the studied population has a high baseline prevalence of tuberculosis infection and high coverage of BCG vaccination, nosocomial risk factors associated with PPD reactivity were identified as professional risks; strict early preventive measures must be implemented accordingly.
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Infección Hospitalaria/epidemiología , Exposición Profesional/análisis , Personal de Hospital/estadística & datos numéricos , Prueba de Tuberculina , Tuberculosis/diagnóstico , Tuberculosis/epidemiología , Adulto , Estudios Transversales , Femenino , Hospitales Generales/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , México/epidemiología , Análisis Multivariante , Exposición Profesional/estadística & datos numéricos , Prevalencia , Factores de Riesgo , Población Urbana , Recursos HumanosRESUMEN
The purpose of this series of articles is to present to health personnel an updated summary on bioterrorism associated agents. In this first article an updated summary on anthrax is presented. Emphasis has been placed on the characteristics of cases which occurred during October in the United States of America and on the experience of governmental agencies of that country to face the emergency. Measures implemented in Mexico are described as well. The authors are convinced that the best arm against terror is timely and updated information.
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Carbunco , Bioterrorismo , Personal de Salud , Carbunco/diagnóstico , Carbunco/prevención & control , Carbunco/terapia , Guerra Biológica/prevención & control , Humanos , México , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/etiología , Infecciones del Sistema Respiratorio/terapia , Factores de Riesgo , Enfermedades Cutáneas Bacterianas/diagnóstico , Enfermedades Cutáneas Bacterianas/etiología , Enfermedades Cutáneas Bacterianas/terapiaRESUMEN
BACKGROUND: This study aimed to evaluate purified protein derivative (PPD) reactivity and its interrelationship with anergy panel and CD4+ lymphocytes in HIV-infected subjects as compared to PPD reactivity in HIV-uninfected individuals in a tuberculosis endemic and high Bacillus Calmette-Guérin (BCG) coverage environment. METHODS: Clients of four Mexico City HIV detection centres were screened for HIV-1 antibodies (ELISA or haemagglutination, Western Blot); reactivity to PPD (Mantoux PPD, 5TU RT-23), Candida (1:1000, 0.1 ml), and tetanus toxoid (10Lf, 0.1 ml); and CD4+ T cells. Active tuberculosis was excluded. Informed consent was obtained. RESULTS: From 5130 clients 1168 subjects were enrolled; of these 801 (68.6%) were HIV positive. Reactivity to PPD among HIV-positive subjects was found in 174 (22%), 261 (32.6%), and 296 (37%), at PPD cutoff levels of > or =10 mm, > or =5 mm, and > or =2 mm as compared to 224 (61%) of 367 HIV-negative individuals' reactors to PPD (> or =10 mm) (P < 0.001). After exclusion of anergic individuals using two cutoff levels for cutaneous allergens (< or =2 mm and < or =5 mm), PPD reactivity between HIV-infected and uninfected individuals continued to be significantly different. Only HIV-infected individuals with CD4+ T cells > or =500 cells/mm3 had similar reactivity to PPD as HIV-uninfected individuals. Variables associated with PPD reactivity were CD4+ T cell counts, BCG scar, HIV infection and age. CONCLUSIONS: PPD reactivity was useful to diagnose tuberculosis infection only among HIV-infected individuals with CD4+ counts > or =500 cells/mm3. Among individuals with lower counts, lowering cutoff levels or using anergy panel did not permit comparable reactivity as that observed among HIV-uninfected individuals.
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Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , Anticuerpos Antibacterianos/análisis , Mycobacterium tuberculosis/inmunología , Prueba de Tuberculina , Tuberculosis Pulmonar/epidemiología , Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/microbiología , Adyuvantes Inmunológicos/uso terapéutico , Adolescente , Adulto , Vacuna BCG/uso terapéutico , Recuento de Linfocito CD4 , Femenino , Anticuerpos Anti-VIH/análisis , VIH-1/inmunología , Humanos , Masculino , México/epidemiología , Prevalencia , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/microbiología , Población UrbanaRESUMEN
BACKGROUND: Consequences of drug-resistant tuberculosis (TB) in developing countries using directly observed treatment, short-course (DOTS), are not well defined. OBJECTIVE: To determine the impact of drug resistance on clinical outcome and transmission of TB under programmatic conditions. PATIENTS AND METHODS: A prospective cohort and molecular epidemiologic study was conducted in southern Mexico. Between March 1995 and February 1998 all patients with persistent cough whose sputa had acid-fast bacilli (AFB) underwent clinical and mycobacteriologic evaluation (species identification, drug susceptibility testing, and IS6110-based genotyping). Treatment was provided in accordance with Mexico's National Tuberculosis Program. Clinical and microbiologic outcomes and molecular epidemiologically defined transmission were measured. RESULTS: Mycobacterium tuberculosis was isolated from 238 of the 284 AFB smear-positive persons. The overall rate of resistance was 28.4% (new, 20.7%; retreated, 54.7%), and 10.8% (new, 3.3%; retreated, 35.8%) had multi-drug-resistant TB (ie, resistance to isoniazid and rifampin). After treatment, 75% (new, 81.0%; retreated, 52.8%) were cured, 8% (new, 7.8%; retreated, 7.5%) abandoned therapy, 9% (new, 3.9%; retreated, 28.3%) had treatment failure, and 4% (new, 3.3%; retreated, 7.5%) died. Another 2% of patients relapsed, and 9% died during a median of 24.4 months of follow-up. Drug-resistance was a strong independent risk factor for treatment failure. Being infected with multi-drug-resistant TB was the only factor associated with a decreased likelihood of being in a restriction fragment length polymorphism cluster. CONCLUSIONS: Despite the use of DOTS, patients with drug-resistant TB had a dramatically increased probability of treatment failure and death. Although multi-drug-resistant TB may have a decreased propensity to spread and cause disease, it has a profoundly negative impact on TB control.
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Antituberculosos/farmacología , Mycobacterium tuberculosis/efectos de los fármacos , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/transmisión , Adulto , Antituberculosos/uso terapéutico , Análisis por Conglomerados , Farmacorresistencia Microbiana , Femenino , Humanos , Masculino , México/epidemiología , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Retratamiento , Factores de Riesgo , Insuficiencia del Tratamiento , Tuberculosis Pulmonar/epidemiologíaRESUMEN
SETTING: A community in Southern Mexico with a high prevalence of tuberculosis. OBJECTIVE: To characterize the transmission dynamics in a region with a DOTS-based tuberculosis control program. DESIGN: Community-based screening of chronic coughers between 1 March 1995 and 31 August 1996. Individuals with acid-fast bacilli (AFB) in their sputum were enrolled, interviewed, and had mycobacterial cultures and fingerprinting performed. In-depth interviews were conducted on all persons with DNA fingerprinting. RESULTS: AFB smears were performed on 1424 individuals, 124 of whom were microbiologically confirmed. Of the 95 cases for whom bacterial DNA fingerprints were available, 38 were in clusters. The largest cluster involved seven individuals who were members of a social network centered on a series of unlicensed bars. CONCLUSION: This population-based molecular epidemiologic study showed that a focus of transmission within a social network accounted for one fourth of transmission which rapidly progressed to disease. These observations raise questions about the potential benefit of targeted tuberculosis control interventions in health jurisdictions approaching WHO-defined DOTS benchmarks.
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Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/transmisión , Análisis por Conglomerados , Dermatoglifia del ADN , Femenino , Humanos , Masculino , Tamizaje Masivo , México/epidemiología , Epidemiología Molecular , Mycobacterium tuberculosis/aislamiento & purificación , Prevalencia , Esputo/microbiología , Tuberculosis Pulmonar/genéticaRESUMEN
OBJECTIVE: To determine the impact of drug resistance (DR) on the clinical outcome and transmission of tuberculosis under programmatic conditions. METHODS: Prospective cohort and molecular epidemiologic study in the Orizaba Health Jurisdiction of Mexico. Between March 1995 and July 1999, chronic coughers with positive acid-fast bacilli (AFB) detected in sputum smear underwent clinical and mycobacteriologic evaluation (species identification, drug susceptibility testing and IS6110-based genotyping). Treatment was provided in accordance with official norms. RESULTS: Mycobacterium tuberculosis was isolated from 326/387 AFB-positive cases. The rate of DR was 24.2% and that of multidrug resistance (MDR, defined as resistance to both isoniazid and rifampin at least) was 7.7%; 78% were cured, 8% abandoned treatment, 6% failed treatment, and 5% died. An additional 13.5% received retreatment and 8.9% died during a median 28.6 months of follow up. Factors associated with DR by multivariate analysis were chronicity of tuberculosis (OR 4.8, 95%CI 2.7-8.4, P < 0.001), age >40 years (OR 1.9, 95%CI 1.1-3.2, P = 0.02) and indigenous origin (OR 0.3, 95%CI 0.13-0.75, P = 0.01). Cox-adjusted relative risks showed that MDR (RR 2.5, 95%CI 1.02-6.16, P = 0.04), HIV infection (RR 31.3, 95%CI 11.6-84.8, P < 0.001), and chronicity of tuberculosis (RR 2.1, 95%CI 1.0-4.4, P = 0.06) were associated with mortality, controlling for age. Predictors of retreatment were DR (not including MDR) (RR 2.2 95%CI 0.89-5.31, P < 0.087), MDR (RR 12.6, 95%CI 5.46-28.88, P < 0.001), and living in a household with an earthen floor (RR 2.8, 95%CI 1.27-6.13, P = 0.011). Being infected with MDR-TB was the only factor associated with a decreased likelihood of being in an RFLP cluster (OR 0.31, 95%CI 0.12-0.81, P = 0.02). CONCLUSIONS: Although MDR-TB may have a decreased propensity to spread and cause disease, it has a profoundly negative impact on tuberculosis control.
Asunto(s)
Mycobacterium tuberculosis/clasificación , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Adulto , Dermatoglifia del ADN , ADN Bacteriano/genética , Farmacorresistencia Microbiana/genética , Resistencia a Múltiples Medicamentos/genética , Femenino , Humanos , Modelos Logísticos , Masculino , México/epidemiología , Mycobacterium tuberculosis/genética , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Tasa de Supervivencia , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Resistente a Múltiples Medicamentos/microbiologíaRESUMEN
To determine markers of Taenia solium transmission and risk factors in an urban community, we studied 1,000 soldiers from a military camp in Mexico City and their relatives. Serum samples were used to detect antigens and antibodies and fecal specimens were examined for Taenia coproantigens and helminth eggs. Prevalences of 12.2% and 5.8% for cysticercosis were found among soldiers and their relatives, respectively. Taeniasis was found in 0.5% and none of the groups, respectively. Relatives of soldiers positive for cysticercosis and taeniasis markers ate more pork from street stores than restaurants or markets compared with relatives of soldiers without these indicators of infection. Also, 12.0% of the relatives of positive soldiers had a history of expelling tapeworm proglottids in the feces in contrast to 3.7% of the family members of the control group. Prevalence values and risk factors in this urban population are similar to those of previous studies performed in rural populations.
Asunto(s)
Cisticercosis/epidemiología , Personal Militar , Teniasis/epidemiología , Salud Urbana , Adulto , Animales , Anticuerpos Antihelmínticos/sangre , Antígenos Helmínticos/sangre , Western Blotting , Estudios Transversales , Cisticercosis/parasitología , Ensayo de Inmunoadsorción Enzimática , Salud de la Familia , Heces/parasitología , Femenino , Humanos , Masculino , México/epidemiología , Recuento de Huevos de Parásitos , Prevalencia , Factores de Riesgo , Taenia/crecimiento & desarrollo , Taenia/aislamiento & purificación , Teniasis/parasitologíaRESUMEN
BACKGROUND: Tuberculosis (TB) rates remain high in regions of Southern Mexico despite the existence of a National Tuberculosis Program. Understanding TB epidemiology in such settings would assist in the design of improved TB control and highlight the challenges confronting TB control in developing countries. METHODS: We conducted a retrospective review of treatment control cards from 1991 to 1994 in five municipalities in a semiurban region of Southern Mexico. RESULTS: The relatively high rate of TB observed, 42.6 per 100,000 inhabitants, did not change significantly during the study period. Cure rates among new cases were 79% and significantly lower among retreatment cases (62%). Directly observed therapy (DOT) was administered to 84% of patients. Approximately one-half of the retreatment cases who were not cured were compliant with therapy, suggesting that drug resistance contributed to these poor results. Of particular concern was a core group of 16 patients who had received at least three treatments. CONCLUSIONS: This region of Mexico has persistently high TB rates despite a DOT-based TB control programme which achieves an overall cure rate of 77%. There exist many retreatment cases for whom cure rates are significantly lower. These cases may serve as a core group for the dissemination of drug resistant TB. The control programme is being reinforced by a nominal register of patients, decreasing administrative barriers for drug supply to individual patients and the availability of mycobacteria cultures. In addition to these measures, in regions which are approaching the levels of efficacy recommended by the WHO it may be appropriate to consider focusing efforts on the identification and treatment of chronic cases.
Asunto(s)
Tuberculosis/prevención & control , Adolescente , Adulto , Anciano , Análisis de Varianza , Niño , Preescolar , Control de Enfermedades Transmisibles/organización & administración , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , México/epidemiología , Persona de Mediana Edad , Oportunidad Relativa , Vigilancia de la Población/métodos , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Resultado del Tratamiento , Tuberculosis/epidemiologíaRESUMEN
OBJECTIVE: To evaluate the efficacy and efficiency of tuberculosis treatment administered by the Secretaría de Salud (SSA) in the sanitary jurisdictions of Cuernavaca and Cuautla, Morelos, for the 1992-1996 period by retrospectively reviewing tuberculosis treatment control cards. MATERIAL AND METHODS: Official Norm for Tuberculosis Prevention and Control in Primary Care Units outcome definitions were used. Data was collected on standardized forms and analyzed with SAS and Epi Info programs; 149 primary care units and 4 hospitals in the study area were visited. RESULTS: There were found 288 patients cards, of which 260 were new cases. These patients received 311 treatments of which 85% were directly observed. Reviewed cards represented 60% of SSA notified cases for this period. There were analyzed 246 treatments of which 32% were bacteriological cures, 26% probable cures, 18% dropouts, 1% failures and 3% deaths. In 20% of treatments the outcome was unknown. Cure rate was better in new cases (61%) than in retreatments (38%), p < 0.01. Efficacy of treatment was 71% and efficiency 58%. Patients receiving retreatment abandoned it more frequently (32%) than new cases (16%), p < 0.01. A statistically significant association was found between abandoned treatment and being retreated (OR = 3.3, CI 95% 1.3-8.5, p = 0.01) or belonging to a lower socioeconomic level (OR = 2.3, CI 95% 1.0-4.9, p = 0.04). In the 34 retreatment programs, 22 were initiated after abandonment, failure or relapse. CONCLUSIONS: Proportion of cure rate (58%) compares unfavorably with WHO recommendations (85%). Implications of a high dropout rate and probability of circulation of resistant strains of M tuberculosis are discussed. Creative strategies to reinforce patient compliance which take into account the patient and not only the health services, extension of cultures to known M. tuberculosis drug resistance and evaluation of modifications to drug regimens are proposed. Review of treatment control cards is a useful tool for program evaluation.
Asunto(s)
Tuberculosis/tratamiento farmacológico , Adulto , Notificación de Enfermedades/estadística & datos numéricos , Femenino , Humanos , Masculino , México/epidemiología , Cooperación del Paciente , Estudios Retrospectivos , Factores Socioeconómicos , Resultado del Tratamiento , Tuberculosis/epidemiologíaRESUMEN
OBJECTIVE: To describe an uncommon case of bladder calculus arising from an intrauterine device (IUD). METHODS/RESULTS: A female patient with an IUD for the past 10 years consulted for frequent episodes of cystitis. Patient evaluation demonstrated a bladder calculus that warranted surgery. Treatment was by cystolithotomy, which disclosed a 6 cm calculus attached to the IUD. CONCLUSION: Bladder calculus arising from an IUD is rare. The case described herein was successfully managed by cystolithotomy.