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Background: Secondary immune thrombocytopenia (ITP) is a heterogeneous and unpredictable disease associated with various underlying conditions., Objective: The objective of the study was to investigate clinical evolution and chronicity predictors in secondary ITP., Methods: Patients treated at an academic medical center during 2008-2019 were stratified by age as children <16 years and adults <16 years. Responses to steroids, intravenous immunoglobulin G (IVIG), rituximab, and eltrombopag were classified as response (R) and complete response (CR). Risk factors for chronic ITP were determined by multiple regression with uni- and multi-variate analysis., Results: Eighty-three patients were included, 37 children and 46 adults. The most frequent associated conditions were infections 53%, systemic lupus erythematosus (SLE) 24%, thyroid disease 9.6%, and Evans syndrome 3.6%. Response to first-line treatment in the whole cohort was 94%; CR 45.7%; and R 50.6%. Initial response to steroids alone was 91.3% (n = 21/23), rituximab plus high-dose dexamethasone (HDD) 93.3% (n = 14/15); children receiving IVIG alone 100% (n=12/12); and eltrombopag in adults 100% (n = 3/3). Relapse was documented in 19.4% of children and 34% of adults, at a median time of 15 and 2 months, respectively; 30.4% of adults (15.2% from the miscellaneous group, 10.9% SLE-associated, and 4.3% infection-associated) and 18.9% of children followed a chronic course; age ≥10 years and platelets ≥20 × 109/L were risk factors for chronic ITP in children., Conclusion: Evolution was heterogeneous: a better and more sustained response was documented in the infections group compared to SLE or the miscellaneous group.

Coccidioidomycosis is an endemic disease of arid regions in the Western hemisphere. Its clinical presentation varies from asymptomatic nodules on chest x-rays to disseminated disease. We present the case of a 48-year-old man with a hard and heterogeneous tumor in the posterior aspect of the right testis. Color flow doppler testicular ultrasonography was performed and two nodular masses in the tail of the right epididymis were identified. An epididymectomy was performed and histopathological examination revealed coccidioidomycosis. After diagnosis, the patient was successfully treated with fluconazol.

We present the case of a 25-year-old man with progressive limb weakness. His electrocardiogram showed prominent U waves which made us consider hypokalemia. The final diagnosis was toluene intoxication with severe hypokalemia and metabolic acidosis. Intravenous potassium administration and hydration effectively corrected the electrolyte and acid-base alterations; weakness resolved and the patient was discharged. The approach to a patient with acute weakness can be challenging. This case reminds us that the electrocardiogram can be a valuable tool in the evaluation and differential diagnosis of patients presenting to the emergency department with these conditions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To report the design, methodology and initial results of the National Socioeconomic Survey of Access to Health of the EsSalud Insured., Results: There were interviews in 25,000 homes, surveying 79,874 people, of which 62,659 were affiliated to EsSalud. The insured people are mainly males (50.6%) with a higher technical education level (39.7%). The insured population has mostly independent (95.0%) and own (68.1%) home. Only 34.5% of the insured practice some sport or physical exercise; 14.0% of the population suffers from a chronic disease; 3.5% have diabetes; and 7.1%, arterial hypertension. In the last three months, 35.4% of the members needed medical attention; of these, only 73.1% received health care and the remaining 10.9% were treated in pharmacies or non-formal health care services., Results: The 25,000 homes were interviewed, surveying 79,874 people, of which 62,659 were affiliated to EsSalud. The insured people are mainly males (50.6%) with a higher technical education level (39.7%). The insured population has mostly independent (95.0%) and own (68.1%) home. Only 34.5% of the insured practice some sport or physical exercise; 14.0% of the population suffers from a chronic disease; 3.5% have diabetes; and 7.1%, arterial hypertension. In the last three months, 35.4% of the members needed medical attention; of these, only 73.1% received health care and the remaining 10.9% were treated in pharmacies or non-formal health care services., Conclusions: This survey is the first performed in the population of EsSalud affiliates, applied at the national level, and has socio-economic and demographic data of the insured, their distribution, risk factors of health, prevalence of health problems and the degree of access to health services.

Lyme disease is the most common tick-borne illness in North America. A 23-year-old female presented to our emergency department with a chief complaint of sudden dyspnea and chest pain. An electrocardiogram revealed a third degree heart block. She was a resident of the Northeast region of Mexico and referred a recent travel to an endemic area for Borrelia burgdorferi in the center of Mexico in the past weeks. Lyme carditis was diagnosed after enzyme linked immunosorbent assay for IgM antibodies against B. burgdorferi was reported positive and corroborated by a confirmatory immunoblot analysis. Persistent AV block was the only manifestation in our patient, a presentation scarcely reported in literature., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We present the case of a human immunodeficiency virus (HIV)-infected patient who arrived at our emergency department with fever, headache and exertional dyspnea. Throughout their stay, a chest x-ray was taken and a rounded opacity in his left lung was observed. CT images showed same abnormality and also ground glass opacities were seen. Symptoms and images strongly suggested a pulmonary infection due to pneumocystis jirovecii, however a presence of a round lesion should always lead to neoplasia being suspected. We empirically started treatment based on trimethoprim and sulfamethoxazole. Once available, flexible bronchoscopy and bronchoalveolar lavage was performed and stained preparations from his respiratory specimens confirmed the diagnosis of pulmonary pneumocystis infection. Finally, after 4 days of antibiotic therapy, an important clinical improvement was documented; a new chest x-ray was performed and the previous rounded opacity was absent. This finding strongly suggested a case of round pneumonia., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To compare the performance of the corrected count increment (CCI) and three other formulas to assess 24-hour posttransfusion platelet survival in hematology patients., Methods: Twenty-four-hour posttransfusion platelet counts were analyzed after apheresis platelet transfusion. Platelet increment (PI), percent platelet recovery (PPR), and percentage platelet increment (PPI) were compared with CCI by receiver operating characteristic analysis. Clinical factors that influence platelet survival were assessed by logistic regression., Results: In total, 142 apheresis platelet transfusions in 85 hematology patients were studied. Mean (SD) CCI at 24 hours was 11,869 (10,125). Compared with CCI, the sensitivity of other formulas ranged from 89.4% to 95.7% and specificity from 94.7% to 100%. Cutoff values were 15.7 × 103/µL for PI, 11.4% for PPR, and 17% for PPI. For ABO-compatible vs incompatible transfusions, CCI was 14,070/µL vs 9,176/µL (P = .007). Negative factors for all formulas were sepsis, hypotension, and amphotericin B., Conclusions: PI, PPR, and PPI are comparable to CCI for assessing 24-hour platelet survival., (© American Society for Clinical Pathology, 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objective: Cytospin conventional cytomorphology (CCC) is the standard method for detecting lymphoblasts in cerebrospinal fluid (CSF) of patients with acute lymphoblastic leukemia (ALL) and for guiding treatment decisions. We evaluated flow cytometry immunophenotyping (FCI) performance for improving detection of central nervous system (CNS) involvement in ALL., Methods: This prospective study included analysis of consecutive CSF samples of patients of all ages with ALL at 3 clinical stages: new diagnosis, relapse suspicion, and after relapse treatment. Manual, cytospin, automated, and FCI methods were compared and their performance statistically assessed. Using FCI as the reference method, optimal CSF cutoff cell count that better correlated with presence of lymphoblasts was established by receiver operating characteristic (ROC) curve analysis., Results: Seventy-seven CSF samples were investigated, 35 (45.4%) from newly diagnosed cases, 30 (39%) suspicion of relapse, and 12 (15.6%) after treatment for relapse. Median manual WBC count in patients with CNS involvement detected by FCI was 3.75 cells/μL (0.0-1280), and this was also the count that best correlated with CNS infiltration (sensitivity, 50.0%; specificity, 82.2%). Compared with FCI, CCC sensitivity and specificity were 28.6% and 100%. Automated CSF WBC count in patients with CNS involvement detected by FCI was 5 (0.0-1578). For automated count, optimal WBC cutoff was 4.5 cells/μL (sensitivity, 62.5%; specificity, 70.5%)., Conclusion: Flow cytometry immunophenotyping complements conventional cytospin analysis for detection of lymphoblasts in the CSF of ALL patients at any clinical stage., (© 2017 John Wiley & Sons Ltd.)

Objective: Relapse is the major cause of treatment failure in acute lymphoblastic leukemia (ALL) of childhood; it is more frequent among high-risk patients from low-middle income than from high-income countries. The frequency, sites and outcome of relapsed ALL in children of northeast Mexico over a decade was documented., Methods: A retrospective analysis of 246 children belonging to a low-income group <16 years with de novo ALL during 2004-2015 was performed. Five-year overall survival (OS) and event-free survival was estimated by Kaplan-Meier analysis. Data on time, site, response to therapy and final outcome of relapse were analyzed. Hazard ratios (HRs) of relapse and death were estimated by the Cox regression model. Very early relapse was defined as that occurring in <18 months, early relapse between 18 and 36 months, and late relapse >36 months from diagnosis, respectively., Results: Eighty-seven (35.4%) children relapsed. Five-year OS was 82.6% in children without relapse vs. 42% for relapsed patients. Bone marrow (BM) was the most frequent site of relapse (51.72%). Isolated central nervous system (CNS) relapses occurred in 29.9%. Five-year OS was 11.2% for BM and 15.5% for early relapse. HR of relapse for organomegaly was 3.683, 2.247 for an initial white blood cell count >50 000 × 10 9 /l and 1.169 for positive minimal residual disease status., Conclusion: A high rate of very early, CNS, and BM relapse with a considerably low 5-year OS requiring reassessment of therapy was documented. Organomegaly at diagnosis was a highly significant clinical predictor for relapse.

Introducción: La segunda causa de muerte infantil es el cáncer, del cual las leucemias y los tumores del sistema nervioso central son las presentaciones más frecuentes; de los últimos, los astrocitomas representan 40 %., Objetivo: Identificar los factores asociados con la supervivencia a cinco años en niños con astrocitoma cerebral., Método: Estudio de casos y controles anidado en una cohorte retrospectiva en pacientes con diagnóstico de astrocitoma cerebral que recibieron tratamiento de diciembre de 2006 a enero de 2010. Se realizó estadística descriptiva y prueba de chi cuadrado; para evaluar la supervivencia se utilizó el método de Kaplan-Meier., Resultados: Se incluyeron 21 pacientes con diagnóstico de astrocitoma cerebral; la supervivencia fue de 76 % a cinco años, el astrocitoma pilocítico fue el más frecuente (61 %), con una edad media de siete años; predominó el sexo masculino, la edad al fallecimiento osciló entre los ocho y 12 años (p = 0.022); 80 % de los pacientes fallecidos tuvo tumor con localización infratentorial d (RM = 17.3, IC 95 % = 1-622, p = 0.01). No hubo diferencia en la supervivencia atribuible al tratamiento., Conclusión: La supervivencia a cinco años fue de 76 %; el factor de riesgo significativo que la limita es la localización infratentorial del tumor., Introduction: The second cause of children’s death is cancer, with leukemia and central nervous system tumors being the most common, among which astrocytomas account for 40%., Objective: To find out the factors associated with 5-year survival in children with cerebral astrocytoma., Method: Case-control study nested in a retrospective cohort of patients diagnosed with cerebral astrocytoma who received treatment from December 2006 to January 2010. Descriptive statistics and the chi-square test were carried out; the Kaplan-Meier method was used to assess survival., Results: Twenty-one patients diagnosed with cerebral astrocytoma were included; survival was 76% at 5 years; with pilocytic astrocytoma being the most common (61%); mean age was 7 years, and male gender was predominant; age at death ranged from 8 to 12 years (p = 0.022), with 80% of deceased patients having infratentorial localization (OR = 17.3; 95% CI = 1-622; p = 0.01). There was no treatment-attributable survival difference., Conclusions: Five-year survival was 76%; the limiting risk factor is tumor infratentorial localization., (Copyright: © 2018 SecretarÍa de Salud.)

Background: Acute lymphoblastic leukemia (ALL) is one of the main and most expensive and prolonged causes of hospitalization for childhood cancer. We describe the hospitalization rate and its costs for an open population with ALL in a low-middle income country., Procedure: We retrospectively analyzed 449 hospital admissions for 101 pediatric patients with ALL over 8 years. Clinical files and electronic databases were scrutinized to document causes, duration, readmission rate, costs, and outcome of each admission. Hospitalizations were divided into two categories: general pediatric ward and pediatric intensive care unit (PICU). Hospitalization rates and its costs per patient were estimated considering person-time at risk., Results: Patients had an admission rate of 2.09 hospitalizations per patient-year and median length of stay per admission was 5 days. Most admissions occurred during the first 2 years from diagnosis. Mean cost per day was 239 US dollars (USD) and mean cost per stay was 2,246 USD versus 1,016 and 19,004 USD (P = 0.001) in the PICU, respectively. Total hospitalization cost per patient per year (PPPY) was 5,991 USD for high-risk patients and 3,038 USD for standard-risk patients. Patients between ages 1 and 9 years had a PPPY cost of $4,057; while for children younger than 1 year or older than 9 years, it was 7,463 USD. The popular medical insurance program covered 70% of hospitalizations and 63% of its total cost; patients contributed 2%, with the hospital absorbing 35%., Conclusions: Hospitalizations for children with ALL were less expensive than in high-income countries but had a significant cost to low-income families and to the healthcare system., (© 2017 Wiley Periodicals, Inc.)

Objective: To identify possible differences in the level of externalizing behavior problems among children with and without hearing impairment and determine whether any relationship exists between this type of problem and parenting practices., Methods: The Behavior Assessment System for Children was used to evaluate externalizing variables in a sample of 118 boys and girls divided into two matched groups: 59 with hearing disorders and 59 normal-hearing controls., Results: Significant between-group differences were found in hyperactivity, behavioral problems, and externalizing problems, but not in aggression. Significant differences were also found in various aspects of parenting styles. A model for predicting externalizing behavior problems was constructed, achieving a predicted explained variance of 50%., Conclusion: Significant differences do exist between adaptation levels in children with and without hearing impairment. Parenting style also plays an important role.

Background: Advances in automated cell separators have improved the efficiency of plateletpheresis and the possibility of obtaining double products (DP). We assessed cell processor accuracy of predicted platelet (PLT) yields with the goal of a better prediction of DP collections., Study Design and Methods: This retrospective proof-of-concept study included 302 plateletpheresis procedures performed on a Trima Accel v6.0 at the apheresis unit of a hematology department. Donor variables, software predicted yield and actual PLT yield were statistically evaluated. Software prediction was optimized by linear regression analysis and its optimal cut-off to obtain a DP assessed by receiver operating characteristic curve (ROC) modeling., Results: Three hundred and two plateletpheresis procedures were performed; in 271 (89.7%) occasions, donors were men and in 31 (10.3%) women. Pre-donation PLT count had the best direct correlation with actual PLT yield (r = 0.486. P < .001). Means of software machine-derived values differed significantly from actual PLT yield, 4.72 × 10 11 vs.6.12 × 10 11 , respectively, (P < .001). The following equation was developed to adjust these values: actual PLT yield= 0.221 + (1.254 × theoretical platelet yield). ROC curve model showed an optimal apheresis device software prediction cut-off of 4.65 × 10 11 to obtain a DP, with a sensitivity of 82.2%, specificity of 93.3%, and an area under the curve (AUC) of 0.909., Conclusion: Trima Accel v6.0 software consistently underestimated PLT yields. Simple correction derived from linear regression analysis accurately corrected this underestimation and ROC analysis identified a precise cut-off to reliably predict a DP., (© 2016 Wiley Periodicals, Inc.)

Background: Reports dealing with clinical outcomes of classical Hodgkin's lymphoma in low- to middle-income countries are scarce and response to therapy is poorly documented. This report describes the characteristics and clinical outcomes of patients with classical Hodgkin's lymphoma from a single institution in Latin America., Method: A retrospective study was conducted over ten years of patients with classical Hodgkin's lymphoma treated at a referral center. Progression-free and overall survival rates were estimated by Kaplan-Meier analysis. The univariate Cox regression model was used to estimate associations between important variables and clinical outcomes., Main Results: One hundred and twenty-eight patients were analyzed. The mean age was 28.5 years. The five-year progression-free and overall survival were 37.3% and 78.9%, respectively. Of the whole group, 55 (43%) were primary refractory cases. Only 39/83 (47%) patients with advanced disease vs. 34/45 (75.6%) in early stages (p-value=0.002) achieved complete remission. Those with advanced disease had a five-year overall survival of 68.7% vs. 91.8% for early disease (p-value=0.132). Thirty-one patients relapsed (24.2%) and 20 (64.5%) received a transplant. The hazard ratio for progression with bone marrow infiltration was 2.628 (p-value=0.037). For death, an International Prognostic Score ≥4 had a hazard ratio of 3.355 (p-value=0.050) in univariate analysis. Two-thirds of classical Hodgkin's lymphoma patients diagnosed at advanced stages had a low progression-free survival but an overall survival similar to high-income countries., Conclusion: Patients diagnosed with classical Hodgkin's lymphoma in Northeastern Mexico had a significantly low progression-free survival rate and presented with advanced disease, underscoring the need for earlier diagnosis and improved contemporary therapeutic strategies in these mainly young productive-age Hodgkin's lymphoma patients., (Copyright © 2017. Published by Elsevier Editora Ltda.)

Background: Survival for acute lymphoblastic leukemia (ALL) decreases with age. Patients across all age groups from a homogeneous ethnic and socioeconomic background were studied to document age effect., Material and Methods: Patients diagnosed from 2005 to 2015 at a university hospital in Northeast Mexico were divided into 4 age groups: infants (< 1), children (≥ 1 to < 16), adolescents (≥ 16 to ≤ 20), and adults (> 20 years). Correlation between age at diagnosis and relapse-free (RFS) and overall survival (OS) was investigated., Results: A total of 377 patients were included. Five-year RFS and OS for children were 55.6% and 66.9%; for adolescents, 36.0% and 48.3%; for adults, 19.5% and 24.1%, respectively. Differences in RFS and OS between age groups were significant (P < .001, P < .001). In the Cox regression model, all age groups reached statistical significance in univariate analysis of mortality., Conclusion: Age plays a decisive role in clinical evolution of ALL and strongly influences outcome. Age older than 20 represents a progressive high-risk factor for death., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: There is a paucity of the studies of adolescents with acute lymphoblastic leukemia (ALL). This is more noticeable in low- and middle-income countries. The international 5-year event-free survival (EFS) and overall survival (OS) for this age group is around 80%, with pediatric-inspired protocols offering better results., Methods: A retrospective analysis of adolescents aged 16-20 diagnosed with ALL during the period 2004-2015 treated with a high-risk pediatric protocol at an academic center from a middle-income country was performed. Five-year OS and EFS were estimated by the Kaplan-Meier analysis. Hazard ratios of relapse and death were estimated by the Cox regression model., Results: Five-year EFS and OS for 57 adolescents were 23.3% and 48.9%, respectively. From the 41 patients who achieved complete remission, 24 (58.5%) relapsed. Bone marrow and central nervous system were the most frequent sites of relapse. Hazard ratio of treatment failure and death for patients with organomegaly at diagnosis was 2.026 and 2.970, respectively. Treatment-related toxicity developed in 31 (54.4%) patients and febrile neutropenia was the most frequent in 14 (24.6%) cases. Twelve patients (21.1%) had poor adherence to treatment., Conclusions: High relapse rate and low 5-year EFS compared with international standards, was documented. Use of intensified pediatric regimens, adherence to proven effective medications, improved supportive care, and prevention of abandonment are necessary to improve survival rates in these patients., (© 2016 Wiley Periodicals, Inc.)

There is scarce information regarding the concentration of cytokines in cerebrospinal fluid (CSF) of children with acute lymphoblastic leukemia (ALL) and their clinical association with CNS status. A prospective analysis of 40 patients <18years with newly diagnosed ALL was performed. Human cytokine magnetic bead panel assay values of IL-2, IL-4, IL-6, IL-8, IL-10, MCP-1, TNF-α in CSF at diagnosis, end of induction to remission, and 6months after diagnosis were determined. IL-6 and MCP-1 values showed a significant increment at the end of induction. From the whole group 4 (10.0%), patients relapsed to the CNS at a median of 11.48months. A significantly higher value of TNF-α at third determination in these CNS-relapsed patients was documented, 7.48 vs. 2.86pg/mL in 36 children without relapse (p=0.024). TNF-α concentration increased at a median 5.48months before CNS relapse. By receiver-operating characteristic curve (ROC) analysis, the best cut-off point of TNF-α concentration that better predicted CNS relapse was ≥1.79pg/mL. In conclusion an increase in TNF-α concentration on CSF preceded CNS relapse in children with ALL. An increase in MCP-1 and IL-6 was not associated to CNS relapse and appears to result from an inflammatory response after IT injection of chemotherapy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The therapeutic progress for adults with acute lymphoblastic leukemia (ALL) has been slow, with a 5-year survival of 30% to 45% in developed countries. Scarce information is available regarding the treatment and survival rates from nonindustrialized populations. In the present study, the characteristics of adults with ALL at a single institution were documented., Patients and Methods: The clinical files of patients aged ≥ 18 years who had been diagnosed with ALL from 2005 to 2015 at a reference center in Mexico were scrutinized. Overall survival (OS) and event-free survival (EFS) were determined using the Kaplan-Meier method. The hazard ratios for death and relapse were estimated using Cox regression analysis., Results: A total of 94 adults were included. Their median age was 33 years; 69 (73.4%) had high-risk and 25 (26.6%) had standard-risk ALL. Of the 94 patients, 67 (71.3%) achieved complete remission (CR), 20 (21.3%) experienced disease resistance, and 7 (7.4%) died early during induction to remission, mainly of sepsis. The 5-year EFS and OS was 23.4% and 31.1% for the whole group and 24.9% and 38.9% for patients who achieved CR, respectively. Of the 94 patients, 50 (43.9%) died of sepsis or disease progression. Relapse developed in 43 patients (45.7%). The median survival after relapse was 6.93 months. Bone marrow was the most frequent site of relapse (21 patients [48.8%]) and conferred a significantly lower 5-year OS of 16.4%., Conclusion: Adults with ALL in Mexico had high-risk characteristics and an increased relapse rate; however, the OS after CR was similar to the greatest achieved in developed countries, suggesting that a threshold for curing adult ALL with current therapeutic strategies has been reached., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Aims: In high-income countries, treatment protocols for acute lymphoblastic leukemia (ALL) in children lead to a 5-year overall survival (OS) approaching 90%. There is scarce information on protocols and results of therapy from low-middle income countries (LMIC). We documented the results of treating children with ALL with two protocols in consecutive 5-year periods at a reference center in northeast Mexico., Patients and Methods: Children ≤16 years of age diagnosed with ALL treated with two protocols were studied. Each protocol was used for 5 years; 246 children, 112 in protocol 1 and 134 in protocol 2, were included. Protocols were BFM-inspired and adapted from several regimens; protocol 2 was intended to decrease toxicity and need for hospitalization. Event-free survival (EFS) and overall survival (OS) were determined using the Kaplan-Meier method., Results: In protocol 1, 103 patients (91.96%) achieved complete remission compared to 106 (79.10%) in protocol 2 (p = 0.001). The 5-year OS was 67.1% for protocol 1 vs. 55.5% for protocol 2, whereas EFS was 58.2% vs. 36.9%, respectively. Relapse occurred in 45 patients (40.17%) in protocol 1 vs. 42 (31.34%) in protocol 2 (p = 0.181). OS 1 year after relapse was 52.4% vs. 57.1%, respectively. No difference in relapse rate was documented., Conclusions: No improvement in survival rates of children with ALL from a low-income group living in a LMIC was achieved over a decade. Implementation of contemporary protocols with a high success rate is mandatory., (Copyright © 2017 IMSS. Published by Elsevier Inc. All rights reserved.)

Background: Infective endocarditis is a serious infection, often resulting from injection drug use. Inpatient treatment regularly focuses on management of infection without attention to the underlying addiction. We aimed to determine the addiction interventions done in patients hospitalized with injection drug use-associated infective endocarditis., Methods: This is a retrospective review of patients hospitalized with injection drug use-associated infective endocarditis from January, 2004 through August, 2014 at a large academic tertiary care center in Boston, Massachusetts. For the initial and subsequent admissions, data were collected regarding addiction interventions, including consultation by social work, addiction clinical nurse and psychiatry, documentation of addiction in the discharge summary plan, plan for medication-assisted treatment and naloxone provision., Results: There were 102 patients admitted with injection drug use-associated infective endocarditis, 50 patients (49.0%) were readmitted and 28 (27.5%) patients had ongoing injection drug use at readmission. At initial admission, 86.4% of patients had social work consultation, 23.7% had addiction consultation, and 24.0% had psychiatry consultation. Addiction was mentioned in 55.9% of discharge summary plans, 7.8% of patients had a plan for medication-assisted treatment, and naloxone was never prescribed. Of 102 patients, 26 (25.5%) are deceased. The median age at death was 40.9 years (interquartile range 28.7-48.7)., Conclusions: We found that patients hospitalized with injection drug use-associated infective endocarditis had high rates of readmission, recurrent infective endocarditis and death. Despite this, addiction interventions were suboptimal. Improved addiction interventions are imperative in the treatment of injection drug use-associated infective endocarditis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To correlate the angles between the acetabulum and the proximal femur in symptomatic patients with femoroacetabular impingement (FAI), using computed tomography (CT)., Methods: We retrospectively evaluated 103 hips from 103 patients, using multislice CT to measure the acetabular age, acetabular version (in its supraequatorial portion and in its middle third), femoral neck version, cervical-diaphyseal and alpha angles and the acetabular depth. For the statistical analysis, we used the Pearson correlation coefficient., Results: There were inverse correlations between the following angles: (1) acetabular coverage versus alpha angle (p = 0.019); (2) acetabular version (supraequatorial) versus alpha angle (p = 0.049). For patients with femoral anteversion lower than 15 degrees: (1) acetabular version (supraequatorial) versus alpha angle (p = 0.026); (2) acetabular version (middle third) versus alpha angle (p = 0.02). For patients with acetabular version (supraequatorial) lower than 10 degrees: (1) acetabular version (supraequatorial) versus alpha angle (p = 0.004); (2) acetabular version (middle third) versus alpha angle (p = 0.009)., Conclusion: There was a statistically significant inverse correlation between the acetabular version and alpha angles (the smaller the acetabular anteversion angle was, the larger the alpha angle was) in symptomatic patients, thus supporting the hypothesis that FAI occurs when cam and pincer findings due to acetabular retroversion are seen simultaneously, and that the latter alone does not cause FAI, which leads to overdiagnosis in these cases.

Acidophilic organisms, such as Acidithiobacillus ferrooxidans, possess high-level resistance to copper and other metals. A. ferrooxidans contains canonical copper resistance determinants present in other bacteria, such as CopA ATPases and RND efflux pumps, but these components do not entirely explain its high metal tolerance. The aim of this study was to find other possible copper resistance determinants in this bacterium. Transcriptional expression of A. ferrooxidans genes coding for a cytoplasmic CopZ-like copper-binding chaperone and the periplasmic copper-binding proteins rusticyanin and AcoP, which form part of an iron-oxidizing supercomplex, was found to increase when the microorganism was grown in the presence of copper. All of these proteins conferred more resistance to copper when expressed heterologously in a copper-sensitive Escherichia coli strain. This effect was absent when site-directed-mutation mutants of these proteins with altered copper-binding sites were used in this metal sensitivity assay. These results strongly suggest that the three copper-binding proteins analyzed here are copper resistance determinants in this extremophile and contribute to the high-level metal resistance of this industrially important biomining bacterium., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Throughout evolution, organisms have created numerous mechanisms to sense and respond to their environment. One such highly conserved mechanism involves regulation by heterotrimeric G-protein complex comprised of alpha (Gα), beta (Gβ) and gamma (Gγ) subunits. In plants, these proteins play important roles in signal transduction pathways related to growth and development including response to biotic and abiotic stresses and consequently affect yield. In this work, we have identified and characterized the complete heterotrimeric G-protein repertoire in the Capsicum annuum (Capsicum) genome which consists of one Gα, one Gβ and three Gγ genes. We have also identified one RGS gene in the Capsicum genome that acts as a regulator of the G-protein signaling. Biochemical activities of the proteins were confirmed by assessing the GTP-binding and GTPase activity of the recombinant Gα protein and its regulation by the GTPase acceleration activity of the RGS protein. Interaction between different subunits was established using yeast- and plant-based analyses. Gene and protein expression profiles of specific G-protein components revealed interesting spatial and temporal regulation patterns, especially during root development and during fruit development and maturation. This research thus details the characterization of the first heterotrimeric G-protein family from a domesticated, commercially important vegetable crop., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Interpreting an electroencephalogram (EEG) is a subjective process which involves various obstacles to reach an agreement. If the interobserver agreement of a diagnostic process is poor, that process cannot be considered accurate. The aim of this study was to evaluate the intra and interobserver agreement of the EEG reading in pediatric patients., Methods: 108 EEGs of children under 16 years of age were included. EEGs were interpreted by two pediatric neurologists. Observer number one performed three readings on three different moments to assess intraobserver agreement, while the third reading was blind for the diagnosis. Interobserver agreement was assessed with a single blind reading for the diagnosis of the two observers. Agreement was measured with the kappa index., Results: Intraobserver agreement to differentiate if the EEG was normal or abnormal was substantial when the three readings were compared (kappa index: 0.66-0.78). The highest agreement rate corresponded to the readings of those who had knowledge of the diagnosis. The interobserver agreement assessing between abnormal or normal EEG was slight (k = 0.12)., Conclusions: Since the EEG is a subjective interpreter dependent study, it is necessary to establish a consensus to standardize the criteria for its interpretation in order to increase the interobserver agreement.

Prenatal assessment of a fetus with D-transposition of the great arteries demonstrated an absence of mixing between systemic and pulmonary circulations, and predicted lethal postnatal hypoxemia. A multidisciplinary meeting evaluated therapeutic options. After cesarean delivery, veno-venous extracorporeal membrane oxygenation was instituted in preparation for open atrial septectomy. The infant subsequently underwent an arterial switch procedure. Prenatal delineation of pulmonary and systemic circulations in the fetus with D-transposition of the great arteries influences postnatal management. Multidisciplinary planning enhanced the perinatal outcome.

Mimicry between rewarding and non-rewarding flowers within individuals has been accepted as a strategy favored by selection to deceive pollinators. It has been proposed that this mechanism relies on the exploitation of pollinator's sensory biases, but field evidence is still scarce. In this study, we describe the mechanism of deceit pollination in the monoecious herb Begonia gracilis, a species with exposed rewarding structures (pollen) and intersexual mimicry. Specifically, we test the role of mimicry and exploitation of sensory biases on the reproductive success of male (pollination visitation) and female flowers (probability of setting fruits). We show that pollinators' perception of the amount of reward provided by male flowers is influenced by the independent variation in the sizes of the androecium and the perianth. Large rewarding structures and small perianths were preferred by pollinators, suggesting a central role of the relative size of the rewarding structure on pollinators' foraging decisions. Hence, rewarding male flowers cheat pollinators by exploiting their sensory biases, a strategy followed by non-rewarding female flowers. We suggest that intersexual mimicry operates through the functional resemblance of male flowers' deceit strategy. Artificial manipulation of the flowers supports our findings in natural conditions. Overall, we propose that the continuous and independent variation in the size of the perianth and the reproductive organs among male and female flowers could itself be adaptive.

Epilepsy is a disease characterized by unprovoked epileptic seizures resulting from a bioelectrical brain dysfunction. Antiepileptic treatment controls 75% of all epileptic patients; the other 25% continue to have epileptic seizures in spite of a combination of multiple antiepileptic drugs. The purpose of this work was to evaluate the use of methylprednisolone in the treatment of children with refractory epilepsy. Fourteen children with refractory epilepsy at the Hospital de Especialidades No. 25 of the Instituto Mexicano del Seguro Social in Monterrey, Northeast Mexico were included. For five consecutively days, each patient received methylprednisolone by intravenous administration at a dosage of 15 mg/kg/day each 8 h, once a month for 3 months. The frequency of epileptic seizures and possible related side effects were evaluated every month during the three months before, during, and after administration of methylprednisolone. The frequency of epileptic seizures was reduced by more than 50% in 12/14 patients during methylprednisolone treatment. The median number of seizures before treatment with methylprednisolone was 8, 8, and 7; during the treatment: 1, 1, and 1; and after treatment: 2, 2, and 3 (p=0.000). We conclude that methylprednisolone reduces the frequency of epileptic seizures in children with refractory epilepsy., (Copyright Georg Thieme Verlag KG Stuttgart New York.)

Background: This paper presents the ongoing results of an effort to achieve the integration of a navigated cooperative robotic arm into computer-assisted orthopaedic surgery. A seamless integration requires the system acting in direct cooperation with the surgeon instead of replacing him., Methods: Two technical issues are discussed to improve the haptic operating modes for interactive robot guidance. The concept of virtual fixtures is used to restrict the range of motion of the robot according to pre-operatively defined constraints, and methodologies to assure a robust and accurate motion through singular arm configurations are investigated., Results: A new method for handling singularities is proposed, which is superior to the commonly used damped-least-squares method. It produces no deviations of the end-effector in relation to the virtually constrained path., Conclusions: A solution to assure a good performance of a hands-on robotic arm at singularity configurations is proposed., ((c) 2007 John Wiley & Sons, Ltd.)

Computer-assisted design/computer-assisted manufacturing (CAD/CAM) has been used successfully in commercial industry for several decades and is only now becoming more common for use within the clinical setting. This presentation will outline how CAD/CAM frameworks present numerous advantages over conventional castings when used to treat edentulous and partially edentulous patients in such areas as strength, biocompatibility, and precision machining. Recent advancements in CAD/CAM technology have decreased the costs associated with the fabrication of implant- and tooth-borne frameworks.

In gynodioecious populations, the frequency of females is expected to have a strong influence on the contemporary genetic structure of populations. Historical patterns of range contraction and expansion are also known to influence the genetic diversity of plant populations. We explore the influence of male sterility and colonization history on the genetic diversity in populations of Kallstroemia grandiflora along the Pacific of México. Both the overall population Fis and Fis values of hermaphrodites showed a negative association with female frequency. Genetic diversity declined with latitude. Our results provide evidence that females have a significant effect on the genetic structure as predicted by theoretical models and provide support for the hypothesis that historical processes have modified the genetic structure of K. grandiflora.

Cervical cancer constitutes a major health problem in Mexico and other developing countries. The purpose of our study was to assess the experience of a comprehensive national oncological reference center on pelvic exenteration for post-radiotherapy recurrent or persistent cervical cancer, describing the prognostic value of time to recurrence, procedure complications, and survival. Medical records from 42 patients with post-radiotherapy recurrent or persistent cervical cancer who underwent a pelvic exenteration with curative purposes from 1984 to 1989 were retrospectively reviewed. Histological diagnoses were squamous cell carcinoma (32 patients), adenosquamous carcinoma (9 patients), and adenocarcinoma (1 patient). Average follow up was of 56.3 mo after the procedure and global survival at 5 yr was 65.8%. Survival for patients with early recurrence was 56.9% vs 78% for patients with late recurrence (p = 0.05). Complications were observed in 65.3% of the cases with a surgical mortality of 4.8%. Pelvic exenteration is a surgical procedure with high morbidity in spite of the recent medical advances. Pelvic exenteration should not be indicated with palliative purposes owing to the high rate of complications. Patients with tumor persistence or early recurrence have a worse prognosis. In well-selected cases, exenteration may provide a survival benefit.

The interest to know the Internal Mammary Chain (IMC) Involvement , is that it is a lymphatic filter as primary as the axilla. Anatomic-surgical fundaments, were presented for their exploration. Fifty (50) pectus-sternal, analizing the number of nodes (average 9,7 per specimen), located preferably in the three first intercostal spaces, were studied. In the second phase IMC with a staging criterion and extrapleural way, resecting 1 or 2 costal cartilages, were explored. In 78 patients, pathological-anatomy correlation between IMC and the axilla, we observed 6% positive IMC with negative axilla. More recently in the era of the setinel node, we have explored IMC in 44 patients through intercostal spaces and without cartilages resection. In 28 patients we performed through radioisotopic way and gamma probe and in the remaining 16, through anatomic search if the tumor was either upper mid or lower. The most frequent spaces explored were in the 2nd and 3rd; 2,27 nodes average per patient. The pathological-anatomy between IMC and the axilla revealed the following results: axilla (-) IM (-): 59%; axilla (+) MI (-): 25%; axilla (+) IM (+): 11% and axilla (-)IM (+): 5%. We concluded that this is a non-aggressive method, with an excellent tolerance that allows the evaluation of another filter as primary as the axilla and that together they represent the best systemic disease prognostics. We believe that its exploration is justified in those cases in which the histological result , correlated with the axilla, allows a therapeutic approach change.

Late blight caused by the oomycete Phytophthora infestans is the economically most important and destructive disease in potato cultivation. Quantitative resistance to late blight available in tetraploid cultivars is correlated with late maturity in temperate climates, which is an undesirable characteristic. A total of 30 DNA-based markers known to be linked to loci for pathogen resistance in diploid potato were selected and tested as polymerase chain reaction-based markers for linkage with quantitative trait loci (QTL) for late blight resistance and plant maturity in two half-sib families of tetraploid potatoes. Most markers originated from within or were physically closely linked to candidate genes for quantitative resistance factors. The families were repeatedly evaluated in the field for quantitative resistance to late blight and maturity. Resistance was corrected for the maturity effect. Nine of eleven different map segments tagged by the markers harbored QTL affecting maturity-corrected resistance. Interactions were found between unlinked resistance QTL, providing testable strategies for marker-assisted selection in tetraploid potato. Based on the linkage observed between QTL for resistance and plant maturity and based on the genetic interactions observed between candidate genes tagging resistance QTL, we discuss models for the molecular basis of quantitative resistance and maturity.

In clinical experience, guided tissue regeneration has been associated with complications, which include membrane exposure. The maintenance of a stable blood clot under the membrane is key to a successful regenerative outcome. This requires adequate membrane stabilization, tension-free suturing, and maintenance of a good vascular supply to the defect. Careful selection of defects after a thorough periodontal evaluation and modification of surgical techniques from those used for conventional resective procedures can lead to predictable outcomes for guided tissue regeneration.

Objective: Our purpose was to compare third-trimester fetal biophysical activities in normal and well-controlled insulin-dependent diabetic pregnancies., Study Design: We performed serial bimonthly fetal biophysical studies from 30 to 38 weeks in 18 normal and 18 well-controlled insulin-dependent diabetic pregnancies (White classes B through D). Each study contained 60 minutes of simultaneous ultrasonographic recordings of fetal breathing movements and rates, baseline heart rate, and body movements. Mean daily blood glucose levels of diabetic patients were determined from home monitors; HbA1c was determined every 6 weeks and ultrasonographic fetal growth rates every 3 weeks. Data were compared with t tests, analysis of variance with repeated measures, and chi 2 tests., Results: Women in the diabetic group maintained good glycemic control and were delivered of normal infants of weights similar to those of nondiabetic gravidas. Their fetuses had higher mean incidences of fetal breathing movement, fetal heart rates, and fetal breathing rates but lower fetal movements and fetal heart rate acceleration counts than did controls throughout the study. Neither short- nor long-term maternal glycemic levels correlated well with fetal biophysical performance., Conclusions: In spite of good maternal glycemic control fetuses of diabetic women behaved differently from those of nondiabetic women. Modulation of their biophysical activities may be affected by maternal glycemic status before the last trimester. Different standards might need to be applied to interpret their tests.

The synthesis of (3S,6R)-3-hydroxy-1,7-dioxaspiro[5.5]undecane (8) and its (4R)-4-hydroxy isomer (11) from (3R,4S,6R)-3,4-dihydroxy-1,7-dioxaspiro[5.5]undecane (1), obtained from D-fructose, has been accomplished by regioselective deoxygenation at C-4 and C-3, respectively, of the appropriately protected derivatives.

The synthesis of the title compound13 has been carried out through the preparation of its precursor, (3R,4R,5S,6R)-3,4,5-trihydroxy-1,7-dioxaspiro[5.5]undecane (6), obtained fromD-fructose using Wittig's methodology, reduction, and spiroketalation. Compound6 was transformed into13 by a Barton deoxygenation at C-5 followed by a Corey dideoxygenation at C-3,4 of the appropriately protected derivatives.

To determine the values of individual and combined biophysical fetal surveillance tests in a general high-risk population, we examined 1000 consecutive pregnancies complicated by either postdatism, hypertension, intrauterine growth retardation, or diabetes mellitus. Nonstress tests, amniotic fluid pocket measurements, and umbilical artery Doppler velocimetry were performed on each patient; each test was rated against gestational age-adjusted standards. Clinical end points included perinatal mortality, intrapartum fetal distress, 5-minute Apgar score less than 7, and neonatal acidosis in pregnancies without major anomalies or extreme prematurity (age at birth greater than 32 weeks), delivered within 72 hours of final tests. Each testing method had specificity greater than 90%. Sensitivities ranged from 69% (nonstress test) to 21% (Doppler velocimetry). Negative predictive values of each method exceeded 85%; positive predictive values ranged from 81% (nonstress test) to 42% (amniotic fluid measurements). The positive predictive value for any abnormal test was 54% and increased to 100% when all tests were abnormal; this latter condition occurred in only 2% of the total population. Amniotic fluid measurements or Doppler velocimetry, when compared with the nonstress test, appeared to be less powerful "stand-alone" screening tests. The performance of all tests in a single session confers little improvement in detection of fetal compromise if the nonstress test is normal; however, this approach may aid decision-making in the management of pregnancies when fetal maturity is not established.

To study the effects of L-tryptophan and glucose on fetal breathing activity, we examined 40 women with normal term pregnancies, randomly assigned to four equal groups who either continued fasting (group C), received 1 gm of oral tryptophan (group T), received 100 gm of oral glucose (group G), or received both substrates (group T + G). Studies lasted 210 minutes, during which fetal breathing movements were observed with real-time ultrasonography and entered and analyzed for incidence, rate, and variability on a microcomputer. Plasma glucose and tryptophan levels were determined every 30 minutes. The incidence of fetal breathing movements declined in group C and rose significantly in the other groups. Breathing rates were unchanged in groups C and T but rose significantly in groups G and T + G during peak breathing intervals. Breath interval variability did not change significantly in any study group. Maternal administration of tryptophan is associated with an alteration in fetal breathing activity but to a lesser degree than that observed after maternal glucose loading.

A computer-assisted biophysical assessment was performed in a woman with chronic alcoholism at 37 weeks' gestation. She was first seen in a state of acute alcohol intoxication (322 mg/dl). Although fetal breathing movement incidence was normal (30%), fetal tachypnea (67 breaths per minute) and decreased fetal body movements (0.11%) were seen. Because these findings differ from those previously reported with regard to normal pregnancies exposed to lower levels of alcohol, their implications are discussed.

Central pontine myelinolysis, also known as osmotic demyelination syndrome, is an uncommon disorder associated with rapid correction of severe hyponatremia. We present the case of a healthy young pregnant woman with hyperemesis gravidarum who developed severe hyponatremia (serum sodium 103 mEq/L). After rapid correction of her serum sodium within 12-15 hours with a 0.9% saline solution, the patient became comatose and died of sepsis and respiratory failure. Examination of the brain showed extensive demyelination in both pontine and extrapontine areas.

Use of a pediatric stainless steel microaggregate screen filter to filter whole blood, gravity-sedimented packed cells, and centrifuged packed cells (cPC) from 20 healthy adults resulted in excessive levels of hemolysis (to 1477.9 mg/dl plasma hemoglobin with 5-day-old cPC) and unacceptable frequency of occlusion (10 to 40 percent).