RESUMO
BACKGROUND: Comprehensive healthcare for patients with gender dysphoria includes access to gender-affirming hormone therapy. It may cause cutaneous and adnexal side effects, which often affect quality of life, are underdiagnosed, and do not receive timely treatment. The literature on this subject is scarce. The main objective was to identify skin manifestations secondary to hormone treatment in adults with gender dysphoria. METHODS: Observational, descriptive, cross-sectional study. A search was performed in the database of patients with gender dysphoria older than 18 years treated at the dermatology and/or endocrinology outpatient clinic of the Hospital de San José de Bogotá in the period 2015-2021. Medical records of patients on hormone therapy with skin manifestations were selected, while patients using other medications as possible triggers were excluded. RESULTS: In total, 85 patients were included, with a predominance of young transgender men (average age was 27 ± 9 years) in whom the main manifestation was acne (87%), followed by androgenetic alopecia and acanthosis nigricans. Transgender women presented more acne, androgenetic alopecia, hypertrichosis, seborrheic dermatitis, and melasma. The majority received treatment, mainly topical therapies. More than half of the patients were treated by the endocrinology and dermatology services. CONCLUSIONS: Skin manifestations in patients with gender dysphoria on hormone therapy are frequent, so they should be known and taken into account in the multidisciplinary approach to these patients, which should involve dermatologists. This is the first Colombian and Latin American study focused on documenting skin manifestations in patients with gender dysphoria undergoing hormone therapy.
Assuntos
Acne Vulgar , Disforia de Gênero , Masculino , Adulto , Humanos , Feminino , Adolescente , Adulto Jovem , Colômbia/epidemiologia , Disforia de Gênero/tratamento farmacológico , Disforia de Gênero/complicações , Estudos Transversais , Qualidade de Vida , Alopecia/induzido quimicamente , Alopecia/tratamento farmacológico , Alopecia/complicações , Acne Vulgar/tratamento farmacológico , Acne Vulgar/etiologia , Instituições de Assistência Ambulatorial , Hormônios/efeitos adversosRESUMO
In a prospective, multicenter cohort of infants hospitalized with bronchiolitis, we found infants born late pre-term (ie, gestational age of 34-36.9 weeks) had 35% higher odds of having asthma by age 5 years compared with infants born at full-term.
Assuntos
Asma/etiologia , Bronquiolite/fisiopatologia , Doenças do Prematuro/fisiopatologia , Pré-Escolar , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/etiologia , Masculino , Gravidade do Paciente , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To assess for possible missed hypothyroidism in infants of very low birth weight (VLBW) whose initial newborn screening (NBS) was within normal reference range. STUDY DESIGN: We analyzed serum thyroid-stimulating hormone (TSH) obtained at 36 weeks of corrected gestational age or at hospital discharge if earlier (retest TSH) in infants with VLBW in the neonatal intensive care unit to determine the prevalence and factors associated with retest TSH ≥5 mU/L, a concentration requiring close follow-up for hypothyroidism. Utility of alternative cut-offs for NBS TSH also was assessed. RESULTS: A total of 398 infants, median gestational age 29 (range 22-36) weeks, birth weight 1138 (470-1498) g, were included in this study. Retest TSH was obtained at 49.5 (12-137) days after birth. Median retest TSH was 3.1 (0.5-27.9) mU/L. Seventy-three (18.3%) of the cohort had retest TSH ≥5 mU/L. Adjusting NBS cut-off to ≥15 or ≥10 mU/L identified <50% of infants with TSH ≥5 mU/L, resulting in 6% false positives and >70% false negatives. Multiple regression modeling indicated that 35% of variance in retest TSH value was explained by NBS TSH concentration, birth weight, and gestational age, all P < .01. CONCLUSIONS: Retesting for hypothyroidism at 36 weeks of corrected gestational age in infants with VLBL and normal NBS could identify infants who require ongoing surveillance until thyroid function has been definitively ascertained. Adjusting NBS TSH cutoffs is not a valid option for identifying potential hypothyroidism in infants with VLBW because of lack of sensitivity and unacceptable false-positive and false-negative rates.
Assuntos
Hipotireoidismo Congênito , Peso ao Nascer , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Triagem Neonatal/métodos , TireotropinaRESUMO
OBJECTIVES: Children's insurance coverage, through increased access and use of the healthcare system, may increase the likelihood that healthcare professionals (HCPs) will detect and report child maltreatment. We sought to estimate the association between insurance coverage for children and reporting of child maltreatment by HCPs. STUDY DESIGN: We conducted a cross-sectional study of US counties from 2008 to 2015 using data from the US Census Bureau's Small Area Health Insurance Estimates, National Center for Health Statistics, and National Child Abuse and Neglect Data System. The primary predictor was counties' percent of children insured. We controlled for counties' children living at ≤200% federal poverty level, race/ethnicity demographics, and urban-rural status. The primary outcome was the rate of maltreatment reporting from HCPs. Generalized linear mixed effects models with repeated measures across years tested associations. RESULTS: We included 5517 county-year observations involving 470â876â018 child-years. Counties' percent of children insured ranged from 74.6% to 99.2% with a median of 93.7% (IQR, 91.0-95.4). For every 1 percentage point increase in counties' percent of children insured, there was an associated 2% increase in child maltreatment reporting by HCPs (adjusted incidence rate ratio, 1.02; 95% CI, 1.02-1.03). If counties' percentage of insured children had been 1 percentage point greater in 2015, a predicted 5620 (95% CI, 5620-8089) additional reports would have been generated. CONCLUSIONS: Among its other benefits for children's well-being, insurance coverage may also contribute to child protection by increasing the reporting of maltreatment among HCPs.
Assuntos
Atitude do Pessoal de Saúde , Maus-Tratos Infantis/diagnóstico , Cobertura do Seguro , Notificação de Abuso , Criança , Estudos Transversais , Humanos , Cobertura do Seguro/estatística & dados numéricos , Estados UnidosRESUMO
OBJECTIVE: To determine if child physical abuse hospitalization rates vary across urban-rural regions overall and after accounting for race/ethnicity and poverty demographics. STUDY DESIGN: This was a retrospective cross-sectional study of black, Hispanic, and non-Hispanic white children <5 years of age living in all US counties. US counties were classified as central metro, fringe/small metro, and rural. Incidence rates were calculated using child physical abuse hospitalization counts from the 2012 Kids' Inpatient Database and population statistics from the 2012 American Community Survey. Counties' race/ethnicity demographics and percent of children living in poverty were used to adjust rates. RESULTS: We identified 3082 child physical abuse hospitalizations occurring among 18.2 million children. Neither crude nor adjusted overall rates of child physical abuse hospitalizations varied significantly across the urban-rural spectrum. When stratified by race/ethnicity, crude child physical abuse hospitalization rates decreased among black children 29.1% (P = .004) and increased among white children 25.6% (P = .001) from central metro to rural counties. After adjusting for poverty, only rates among black children continued to vary significantly, decreasing 34.8% (P = .001) from central metro to rural counties. Rates were disproportionately higher among black children compared with white children and their disproportionality increased with population density, even after poverty adjustment. Rates among Hispanic children were disproportionately lower compared with white children in nearly all urban-rural categories. CONCLUSIONS: Our results suggest that urban black children have unique exposures, outside of poverty, increasing their risk for child physical abuse hospitalization. Identifying and addressing these unique urban exposures may aid in reducing black-white disproportionalities in child physical abuse.
Assuntos
Maus-Tratos Infantis/etnologia , Etnicidade/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Abuso Físico/etnologia , População Rural , População Urbana , Maus-Tratos Infantis/estatística & dados numéricos , Pré-Escolar , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Incidência , Masculino , Abuso Físico/estatística & dados numéricos , Pobreza , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study. STUDY DESIGN: This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics. RESULTS: Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission. CONCLUSIONS: Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.
Assuntos
Asma/terapia , Criança Hospitalizada/estatística & dados numéricos , Procedimentos Clínicos/estatística & dados numéricos , Adolescente , Antibacterianos/uso terapêutico , Broncodilatadores/uso terapêutico , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Glucocorticoides/uso terapêutico , Custos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais Pediátricos , Humanos , Pacientes Internados , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Estudos RetrospectivosRESUMO
BACKGROUND: As the arboviral diseases dengue, chikungunya and Zika emerge in the Americas, so does the need for sustainable vector control policies. To successfully achieve mosquito control, joint efforts of both communities and governments are essential. This study investigates this important, but by-and-large neglected topic. METHODS: In June and July 2015, a cross-sectional mixed methods study applying a survey questionnaire (response rate of 82.5%; n = 339), in-depth interviews (n = 20) and focus group discussions (n = 7; 50 participants) was performed in Curaçao. The study was designed based on an integrated theoretical framework of the Health Belief Model and the Theory of Planned Behaviour. RESULTS: Participants showed a good knowledge of, and a high-level performance of mosquito breeding site control (MBSC) practices. Personal protection against mosquitoes (e.g. topical repellents) was perceived as relatively less effective thus practiced to lower extent compared to MBSC practices (i.e. larval source management). A lower intention to perform MBSC was independently associated with: (i) satisfaction on governmental MBSC (P = 0.012); (ii) barriers to perform MBSC practices, i.e. 'Government doesn't control other breeding sites' (P = 0.005), 'Don't know how to control breeding sites' (P = 0.041), and 'a mosquito does not transmit dengue' (P = 0.016), (iii) attitudes towards MBSC (P = 0.001) and self-efficacy (person's perceived ability to act) to perform MBSC (P = 0.002). Mixed-methods evidence highlights three possible ways of improving community participation in MBSC. First, it highlights the need for ongoing media coverage, targeting (i) communities' perceptions on transmission routes of dengue and chikungunya, and (ii) presence of car tires in yards. Secondly, it shows that promotion of governmental activities in MBSC can enhance MBSC of communities, if people develop a sense of responsibility to perform MBSC at their own properties. Thirdly, this study describes the presence of key persons in communities, who could be engaged in mosquito control policies to improve MBSC in neighbourhoods. CONCLUSION: This study reveals gaps between policy and communities' lived realities. These gaps might be overcome with the proposed interventions, resulting in a higher performance of MBSC in the community in Curaçao. Furthermore, this study shows how interdisciplinary mixed methods research can provide important, comprehensive, and in-depth insights to inform mosquito control policies.
Assuntos
Aedes/fisiologia , Participação da Comunidade , Conhecimentos, Atitudes e Prática em Saúde , Controle de Mosquitos/métodos , Adolescente , Adulto , Animais , Cruzamento , Febre de Chikungunya/prevenção & controle , Febre de Chikungunya/transmissão , Estudos Transversais , Curaçao , Dengue/prevenção & controle , Dengue/transmissão , Feminino , Grupos Focais , Humanos , Mordeduras e Picadas de Insetos/prevenção & controle , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Projetos de Pesquisa , Inquéritos e Questionários , Adulto Jovem , Infecção por Zika virus/prevenção & controle , Infecção por Zika virus/transmissãoRESUMO
Background: Beyond the acute illness phase, chikungunya constitutes a public health problem given its chronic disease phase, which may include long-term arthralgia, arthritis, fatigue, and depression. Currently, there is no consensus on how to define chikungunya chronicity. Methods: A comprehensive cross-sectional survey was performed in Curaçao in June and July 2015 to evaluate 304 adult laboratory-confirmed chikungunya patients 3-16 months after diagnosis. We developed a novel tool, the Curaçao Long-Term Chikungunya Sequelae (CLTCS) score, to classify chronic chikungunya disease and estimate its burden regarding disease duration, clinical presentation, and impact on quality of life. Results: Disease persistence was estimated to be 79% one month after symptom onset and 64% after 400 days. Chikungunya persistence was characterized by higher proportions of arthralgia, weakness, myalgia, and age 41-60 years. Individuals were classified as "highly affected," "mildly affected," and "recovered." "Highly affected" disease status was associated with clinical complaints (arthralgia, weakness, loss of vitality, and being diabetic) and major decreases in quality-of-life scores. Conclusions: In the Caribbean, a high proportion of chikungunya patients remains chronically affected. We propose the CLTCS as a suitable score to easily and rapidly classify the severity of chikungunya chronic disease and to assess the need for symptom-alleviating treatment.
Assuntos
Febre de Chikungunya/diagnóstico , Febre de Chikungunya/epidemiologia , Surtos de Doenças , Adolescente , Adulto , Região do Caribe/epidemiologia , Febre de Chikungunya/classificação , Vírus Chikungunya/isolamento & purificação , Vírus Chikungunya/metabolismo , Doença Crônica , Efeitos Psicossociais da Doença , Estudos Transversais , Feminino , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Fatores de Risco , Fatores Socioeconômicos , Inquéritos e Questionários , Adulto JovemRESUMO
OBJECTIVES: The 2009-2010 influenza A (H1N1pdm09) pandemic caused substantial morbidity and mortality among young patients; however, mortality estimates have been confounded by regional differences in eligibility criteria and inclusion of selected populations. In 2013-2014, H1N1pdm09 became North America's dominant seasonal influenza strain. Our objective was to compare the baseline characteristics, resources, and treatments with outcomes among critically ill patients with influenza A (H1N1pdm09) in Mexican and Canadian hospitals in 2014 using consistent eligibility criteria. DESIGN: Observational study and a survey of available healthcare setting resources. SETTING: Twenty-one hospitals, 13 in Mexico and eight in Canada. PATIENTS: Critically ill patients with confirmed H1N1pdm09 during 2013-2014 influenza season. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were 90-day mortality and independent predictors of mortality. Among 165 adult patients with H1N1pdm09-related critical illness between September 2013 and March 2014, mean age was 48.3 years, 64% were males, and nearly all influenza was community acquired. Patients were severely hypoxic (median PaO2-to-FIO2 ratio, 83 mm Hg), 97% received mechanical ventilation, with mean positive end-expiratory pressure of 14 cm H2O at the onset of critical illness and 26.7% received rescue oxygenation therapy with prone ventilation, extracorporeal life support, high-frequency oscillatory ventilation, or inhaled nitric oxide. At 90 days, mortality was 34.6% (13.9% in Canada vs 50.5% in Mexico, p < 0.0001). Independent predictors of mortality included lower presenting PaO2-to-FIO2 ratio (odds ratio, 0.89 per 10-point increase [95% CI, 0.80-0.99]), age (odds ratio, 1.49 per 10 yr increment [95% CI, 1.10-2.02]), and requiring critical care in Mexico (odds ratio, 7.76 [95% CI, 2.02-27.35]). ICUs in Canada generally had more beds, ventilators, healthcare personnel, and rescue oxygenation therapies. CONCLUSIONS: Influenza A (H1N1pdm09)-related critical illness still predominantly affects relatively young to middle-aged patients and is associated with severe hypoxemic respiratory failure. The local critical care system and available resources may be influential determinants of patient outcome.
Assuntos
Estado Terminal/terapia , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/fisiopatologia , Influenza Humana/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Corticosteroides/economia , Corticosteroides/uso terapêutico , Adulto , Idoso , Antivirais/economia , Antivirais/uso terapêutico , Canadá/epidemiologia , Estado Terminal/epidemiologia , Oxigenação por Membrana Extracorpórea/economia , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Gastos em Saúde , Humanos , Influenza Humana/economia , Influenza Humana/epidemiologia , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Respiração Artificial/economia , Respiração Artificial/métodos , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapiaRESUMO
After decades of unawareness about Lynch syndrome, the medical community in South America is increasingly interested and informed. The visits and support of mentors like H. T. Lynch had been crucial to this awakening. Several countries have at least one registry with skilled personnel in genetic counseling and research. However, this only represents a very restricted resource for the region. According to the GETH, there are 27 hereditary cancer care centers in South America (21 in Brazil, 3 in Argentina, 1 in Uruguay, 1 in Chile and 1 in Peru). These registries differ in fundamental aspects of function, capabilities and funding, but are able to conduct high quality clinical, research and educational activities due to the dedication and personal effort of their members, and organizational support. More support from the governments as well as the participation of the community would boost the initiatives of people leading these groups. Meantime, the collaboration among the South American registries and the involvement of registries and leaders from developed countries will allow to maximize the efficiency in caring for affected patients and their families. The aim of this article is to describe how the knowledge of LS began to be spread in South America, how the first registries were organized and to summarize the current state of progress. In addition, we will provide an update of the clinical and molecular findings in the region.
Assuntos
Neoplasias Colorretais Hereditárias sem Polipose/genética , Aconselhamento Genético/estatística & dados numéricos , Aconselhamento Genético/tendências , Predisposição Genética para Doença , Testes Genéticos , Sistema de Registros/estatística & dados numéricos , Neoplasias Colorretais Hereditárias sem Polipose/diagnóstico , Neoplasias Colorretais Hereditárias sem Polipose/epidemiologia , Mutação em Linhagem Germinativa , América do Sul/epidemiologiaRESUMO
BACKGROUND: Soybean [Glycine max (L.) Merrill] is one of the most important legumes cultivated worldwide, and Brazil is one of the main producers of this crop. Since the sequencing of its reference genome, interest in structural and allelic variations of cultivated and wild soybean germplasm has grown. To investigate the genetics of the Brazilian soybean germplasm, we selected soybean cultivars based on the year of commercialization, geographical region and maturity group and resequenced their genomes. RESULTS: We resequenced the genomes of 28 Brazilian soybean cultivars with an average genome coverage of 14.8X. A total of 5,835,185 single nucleotide polymorphisms (SNPs) and 1,329,844 InDels were identified across the 20 soybean chromosomes, with 541,762 SNPs, 98,922 InDels and 1,093 CNVs that were exclusive to the 28 Brazilian cultivars. In addition, 668 allelic variations of 327 genes were shared among all of the Brazilian cultivars, including genes related to DNA-dependent transcription-elongation, photosynthesis, ATP synthesis-coupled electron transport, cellular respiration, and precursors of metabolite generation and energy. A very homogeneous structure was also observed for the Brazilian soybean germplasm, and we observed 41 regions putatively influenced by positive selection. Finally, we detected 3,880 regions with copy-number variations (CNVs) that could help to explain the divergence among the accessions evaluated. CONCLUSIONS: The large number of allelic and structural variations identified in this study can be used in marker-assisted selection programs to detect unique SNPs for cultivar fingerprinting. The results presented here suggest that despite the diversification of modern Brazilian cultivars, the soybean germplasm remains very narrow because of the large number of genome regions that exhibit low diversity. These results emphasize the need to introduce new alleles to increase the genetic diversity of the Brazilian germplasm.
Assuntos
Variação Genética , Genoma de Planta , Genômica , Glycine max/genética , Sequenciamento de Nucleotídeos em Larga Escala , Alelos , Brasil , Análise por Conglomerados , Variações do Número de Cópias de DNA , Genômica/métodos , Mutação INDEL , Filogenia , Polimorfismo de Nucleotídeo Único , Seleção Genética , Glycine max/classificaçãoRESUMO
OBJECTIVES: To compare the duration of opioid treatment and length of stay among infants treated for neonatal abstinence syndrome (NAS) by using a pilot buprenorphine vs conventional methadone treatment protocol. STUDY DESIGN: This retrospective cohort analysis evaluated infants who received pharmacotherapy for NAS at 6 hospitals in Southwest Ohio from January 2012 through August 2014. A single neonatology provider group used a standardized methadone protocol across all 6 hospitals. However, at one of the sites, infants were managed with a buprenorphine protocol unless they had experienced chronic in utero exposure to methadone. Linear mixed models were used to calculate adjusted mean duration of opioid treatment and length of inpatient hospitalization with 95% CIs in infants treated with oral methadone compared with sublingual buprenorphine. The use of adjunct therapy was examined as a secondary outcome. RESULTS: A total of 201 infants with NAS were treated with either buprenorphine (n = 38) or methadone (n = 163) after intrauterine exposure to short-acting opioids or buprenorphine. Buprenorphine therapy was associated with a shorter course of opioid treatment of 9.4 (CI 7.1-11.7) vs 14.0 (12.6-15.4) days (P < .001) and decreased hospital stay of 16.3 (13.7-18.9) vs 20.7 (19.1-22.2) days (P < .001) compared with methadone therapy. No difference was detected in the use of adjunct therapy (23.7% vs 25.8%, P = .79) between treatment groups. CONCLUSION: The choice of pharmacotherapeutic agent is an important determinant of hospital outcomes in infants with NAS. Sublingual buprenorphine may be superior to methadone for management of NAS in infants with select intrauterine opioid exposures.
Assuntos
Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Metadona/uso terapêutico , Síndrome de Abstinência Neonatal/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adulto , Analgésicos Opioides/efeitos adversos , Protocolos Clínicos , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Modelos Lineares , Masculino , Síndrome de Abstinência Neonatal/etiologia , Ohio , Transtornos Relacionados ao Uso de Opioides/etiologia , Estudos RetrospectivosRESUMO
Melioidosis is a bacterial infection caused by Burkholderia pseudomallei, a gram-negative saprophytic bacillus. Cases occur sporadically in the Americas with an increasing number of cases observed among people with no travel history to endemic countries. To better understand the incidence of the disease in the Americas, we reviewed the literature, including unpublished cases reported to the Centers for Disease Control and Prevention. Of 120 identified human cases, occurring between 1947 and June 2015, 95 cases (79%) were likely acquired in the Americas; the mortality rate was 39%. Burkholderia pseudomallei appears to be widespread in South, Central, and North America.
Assuntos
Melioidose/epidemiologia , Burkholderia pseudomallei , Região do Caribe/epidemiologia , América Central/epidemiologia , Humanos , Incidência , América do Norte/epidemiologia , América do Sul/epidemiologiaRESUMO
PROBLEM/CONDITION: Melioidosis is an infection caused by the Gram-negative bacillus Burkholderia pseudomallei, which is naturally found in water and soil in areas endemic for melioidosis. Infection can be severe and sometimes fatal. The federal select agent program designates B. pseudomallei as a Tier 1 overlap select agent, which can affect both humans and animals. Identification of B. pseudomallei and all occupational exposures must be reported to the Federal Select Agent Program immediately (i.e., within 24 hours), whereas states are not required to notify CDC's Bacterial Special Pathogens Branch (BSPB) of human infections. PERIOD COVERED: 2008-2013. DESCRIPTION OF SYSTEM: The passive surveillance system includes reports of suspected (human and animal) melioidosis cases and reports of incidents of possible occupational exposures. Reporting of suspected cases to BSPB is voluntary. BSPB receives reports of occupational exposure in the context of a request for technical consultation (so that the system does not include the full complement of the mandatory and confidential reporting to the Federal Select Agent Program). Reporting sources include state health departments, medical facilities, microbiologic laboratories, or research facilities. Melioidosis cases are classified using the standard case definition adopted by the Council of State and Territorial Epidemiologists in 2011. In follow up to reports of occupational exposures, CDC often provides technical assistance to state health departments to identify all persons with possible exposures, define level of risk, and provide recommendations for postexposure prophylaxis and health monitoring of exposed persons. RESULTS: During 2008-2013, BSPB provided technical assistance to 20 U.S. states and Puerto Rico involving 37 confirmed cases of melioidosis (34 human cases and three animal cases). Among those with documented travel history, the majority of reported cases (64%) occurred among persons with a documented travel history to areas endemic for melioidosis. Two persons did not report any travel outside of the United States. Separately, six incidents of possible occupational exposure involving research activities also were reported to BSPB, for which two incidents involved occupational exposures and no human infections occurred. Technical assistance was not required for these incidents because of risk-level (low or none) and appropriate onsite occupational safety response. Of the 261 persons at risk for occupational exposure to B. pseudomallei while performing laboratory diagnostics, 43 (16%) persons had high-risk exposures, 130 (50%) persons had low-risk exposures, and 88 (34%) persons were classified as having undetermined or unknown risk. INTERPRETATION: A small number of U.S. cases of melioidosis have been reported among persons with no travel history outside of the United States, whereas the majority of cases have occurred in persons with a travel history to areas endemic for melioidosis. If the number of travelers continues to increase in countries where the disease is endemic, the likelihood of identifying imported melioidosis cases in the United States might also increase. PUBLIC HEALTH ACTIONS: Reporting of melioidosis cases can improve the ability to monitor the incidence and prevalence of the disease in the United States. To improve prevention and control of melioidosis, CDC recommends that (1) physicians consider melioidosis in the differential diagnosis of patients with acute febrile illnesses, risk factors for melioidosis, and compatible travel or exposure history; (2) personnel at risk for occupational exposure (e.g., laboratory workers or researchers) follow proper safety practices, which includes using appropriate personal protective equipment when working with unknown pathogens; and (3) all possible occupational exposures to B. pseudomallei be reported voluntarily to BSPB.
Assuntos
Burkholderia pseudomallei/isolamento & purificação , Melioidose/epidemiologia , Melioidose/veterinária , Doenças Profissionais/epidemiologia , Exposição Ocupacional/estatística & dados numéricos , Vigilância da População , Pesquisadores , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Centers for Disease Control and Prevention, U.S. , Criança , Feminino , Humanos , Iguanas/microbiologia , Macaca/microbiologia , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Porto Rico/epidemiologia , Pesquisadores/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Viagem , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Melioidosis results from infection with Burkholderia pseudomallei and is associated with case-fatality rates up to 40%. Early diagnosis and treatment with appropriate antimicrobials can improve survival rates. Fatal and nonfatal melioidosis cases were identified in Puerto Rico in 2010 and 2012, respectively, which prompted contact investigations to identify risk factors for infection and evaluate endemicity. METHODS: Questionnaires were administered and serum specimens were collected from coworkers, neighborhood contacts within 250 m of both patients' residences, and injection drug user (IDU) contacts of the 2012 patient. Serum specimens were tested for evidence of prior exposure to B. pseudomallei by indirect hemagglutination assay. Neighborhood seropositivity results guided soil sampling to isolate B. pseudomallei. RESULTS: Serum specimens were collected from contacts of the 2010 (n = 51) and 2012 (n = 60) patients, respectively. No coworkers had detectable anti-B. pseudomallei antibody, whereas seropositive results among neighborhood contacts was 5% (n = 2) for the 2010 patient and 23% (n = 12) for the 2012 patient, as well as 2 of 3 IDU contacts for the 2012 case. Factors significantly associated with seropositivity were having skin wounds, sores, or ulcers (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.2-17.8) and IDU (OR, 18.0; 95% CI, 1.6-194.0). Burkholderia pseudomallei was isolated from soil collected in the neighborhood of the 2012 patient. CONCLUSIONS: Taken together, isolation of B. pseudomallei from a soil sample and high seropositivity among patient contacts suggest at least regional endemicity of melioidosis in Puerto Rico. Increased awareness of melioidosis is needed to enable early case identification and early initiation of appropriate antimicrobial therapy.
Assuntos
Burkholderia pseudomallei/imunologia , Burkholderia pseudomallei/isolamento & purificação , Busca de Comunicante , Doenças Endêmicas , Melioidose/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Antibacterianos/sangue , Criança , Pré-Escolar , Feminino , Testes de Hemaglutinação , Humanos , Masculino , Pessoa de Meia-Idade , Porto Rico/epidemiologia , Fatores de Risco , Microbiologia do Solo , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Pregnant female patients with vaginal bleeding in the first trimester are seen commonly in the Emergency Department (ED) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. The protocol for the management of these patients requires that they have a sonographic evaluation performed for the purpose of localizing the pregnancy where possible, to assist with determining the risk for an ectopic pregnancy. The ultrasound examinations are performed in the radiology department. OBJECTIVE: This retrospective study was conducted to evaluate how long patients wait for a pelvic ultrasound. We also sought to establish how many patients had ultrasound findings that would have allowed safe discharge home. METHODS: The records of 150 patients seen in the six-month period from January 1 to July 30, 2008 were examined. Data were extracted pertaining to age, time to see an emergency room doctor, time taken for ultrasound examination to be obtained from the radiology department and the ultrasound findings. RESULT: Fifty-four per cent presented to the Emergency Department with a complaint of vaginal bleeding and abdominal pain, 29% with bleeding only, 16% with abdominal pain only and one with syncope. One hundred and sixteen of the patients enrolled had an ultrasound performed at UHWI. The average waiting time for an ultrasound was 3.8 ± 2.5 hours. The majority (66/116) of the patients had an intrauterine pregnancy (IUP) demonstrated on ultrasound. Twenty-nine had no IUP, free fluid or adnexal mass. These 95 patients would likely have been discharged home. Ten patients had an adnexal mass with or without free fluid, and ten had free fluid only on ultrasound. One patient was found to have a definite ectopic pregnancy. These 21 patients would have been referred for evaluation by the obstetrician on call for further management. CONCLUSION: The majority of patients had sonographic findings that would have allowed safe and timely discharge from the Emergency Department had ultrasound been available at the point of care.
RESUMO
INTRODUCTION: A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC). METHODS: To determine the outcome of STC in this high-risk group, we retrospectively reviewed the histopathology reports and case records of all subtotal colectomies performed for LGIB over a 8-year period. RESULTS: Fifty-eight patients (mean age: 71 years; male to female ratio, 1 : 1) underwent emergency surgery for unlocalised LGIB, 45% of which were massive on admission, and unresponsive to resuscitation. The remainder had persistent or recurrent bleeding during the index hospitalisation. The hospitalisation for colectomy represented the first for LGIB for 56% of the study group, while 38% were on at least their third such admission. All but three patients underwent preoperative rigid proctosigmoidoscopy. Fifty-five of the 58 patients were treated with STC and primary ileorectal anastomosis. The major causes of bleeding were diverticular disease only (68%), angiodysplasia only (12%) and both diseases (12%). Overall mortality was 17%, with the main contributor being sepsis resulting from anastomotic leak. Non-fatal complications occurred in 20%, resulting in a mean postoperative length of stay of 13 days. All patients were doing well on their first follow-up visit with a mean number of four stools per day after 1 month. CONCLUSION: While emergency STC is an effective and definitive method of treating unlocalised massive LGIB, its associated morbidity and mortality may limit its usefulness.
Assuntos
Colectomia/métodos , Doenças do Colo/cirurgia , Hemorragia Gastrointestinal/cirurgia , Idoso , Anastomose Cirúrgica , Angiodisplasia/complicações , Colectomia/estatística & dados numéricos , Doenças do Colo/etiologia , Divertículo do Colo/complicações , Emergências , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Íleo , Tempo de Internação , Masculino , Reto/cirurgia , Estudos RetrospectivosRESUMO
OBJECTIVES: To compare the spectrum, concentration, and activity of host defense proteins (HDPs) on the skin surface of newborns and adults, to assess variation in HDP concentrations in different anatomic regions in newborns, and to examine alteration in HDP concentrations with care practices. STUDY DESIGN: Proteins recovered from tape discs applied to stratum corneum of 25 term newborns (forehead and posterior trunk) and 20 adults (forehead) were analyzed by Western analysis for 5 HDPs and for muramidase activity. Protein concentrations were compared in samples obtained after delivery, after the first bath, and at 24 hours of age. RESULTS: Total protein was 2.8-fold higher in adults compared with newborns. Lysozyme and lactoferrin were detected in all samples. In contrast to total protein, lysozyme concentrations and muramidase activity were 5-fold higher in newborns relative to adults and were not altered after bathing. Lysozyme concentrations were significantly higher over the trunk compared with the forehead in newborns. CONCLUSIONS: The newborn skin surface is replete with prototypical HDPs, lysozyme, and lactoferrin. Bathing does not significantly diminish concentrations. These factors are likely to contribute importantly to the newborn infants' defense against invasive bacterial infections.
Assuntos
Imunidade Inata , Lactoferrina/análise , Lactoferrina/imunologia , Muramidase/análise , Muramidase/imunologia , Pele/imunologia , Adulto , Fatores Etários , Feminino , Humanos , Recém-Nascido , Masculino , Pele/químicaRESUMO
PURPOSE: The first Argentine experience with epidemiologic, molecular, and genetic counseling data is reported. METHODS: We analyzed 43 families fulfilling Amsterdam criteria identified from a prospective database with data from 779 relatives. RESULTS: Eleven families (25.6 percent) presented as Lynch I, 29 (67.4 percent) as Lynch II, and 3 (7 percent) as Muir-Torre syndrome. Among the 306 affected members, 197 cases of colorectal cancer were identified (mean age at diagnosis, 52.1 (range, 21-90) years). The most frequent extracolonic tumors were gastric adenocarcinoma in males and endometrium adenocarcinoma in females. A high incidence of breast cancer was observed (16 cases among 155 females, crude rate: 11,594.20/100,000). Twenty-seven patients (8.8 percent) developed more than one tumor. These patients were younger than those with only one tumor (45 vs. 51 years; P = 0.001). In 5 of 11 patients who underwent molecular sequencing, a pathologic mutation was found. A novel C deletion at 1910 nucleotide, codon 637, exon 12 of MSH2 gene was identified in a family with a strong aggregation of breast cancer with lack of MSH2 immunohistochemical staining. For 78.2 percent of counseled individuals, this session represented the first time they received information, and 73.9 percent stated that their physicians were unaware of their family background. CONCLUSIONS: Argentine families presented a high incidence of stomach cancer. The elevated incidence of breast cancer and its association with a novel hMSH2 mutation bring to consideration the inclusion of this malignancy as part of the syndrome. A lack of awareness by both physicians and persons at risk was observed.