[Right-to-health litigation in three Latin American countries: a systematic literature review]

OBJECTIVE

Identify and evaluate studies that analyzed characteristics of right-to-health litigation in Brazil, Colombia, and Costa Rica.

METHODS

Studies were evaluated that analyzed characteristics of right-to-health litigation identified through a search of PubMed, LILACS, Cochrane Library, and Scirus (April 2012). Two reviewers evaluated the studies. Variables collected were, among others, grounds for litigation, proportion of lawsuits for benefits covered by the health system, and lawsuits on high-cost technologies.

RESULTS

Thirty studies were identified (Brazil 19, Colombia 10, and Costa Rica 1). Judgments were frequently in favor of plaintiffs: Colombia (75%-87%), Costa Rica (89.7%), and Brazil (70%-100%). In Colombia, lawsuits were filed for benefits included in the Compulsory Health Plan (range: 41%-69.9%). In Brazil there was considerable variation in the amount of lawsuits between the Exceptional Circumstance Drug Dispensing Program (13%-31%) and basic medicines in the Unified Health System (approximately 50%). Lawsuits on drugs varied as a percentage of all lawsuits (Colombia 11.9%-35.6%, Costa Rica 30.2%, and Brazil 49.6%). A study in Brazil found a statistically significant difference when comparing lawsuits on exceptional drugs versus all other drugs, by social class; and in another study, according to lawsuits from municipalities with better socioeconomic indicators. A concentration of lawsuits on drug prescribing by a limited group of physicians was reported. Prescribing was not always supported by scientific evidence. Another study found that in half of the cases, the cost of legal proceedings was higher than the cost of the services being claimed.

CONCLUSIONS

There are similarities in the grounds, nature, and impact of litigation in the context of the countries studied. The studies included show weaknesses of health systems to ensure access to different services as well as in the introduction of new health technologies.

A compact high-performance low-field NMR apparatus for measurements on fluids at very high pressures and temperatures

We discuss an innovative new high-performance apparatus for performing low-field Nuclear Magnetic Resonance (NMR) relaxation times and diffusion measurements on fluids at very high pressures and high temperatures. The apparatus sensor design and electronics specifications allow for dual deployment either in a fluid sampling well logging tool or in a laboratory. The sensor and electronics were designed to function in both environments. This paper discusses the use of the apparatus in a laboratory environment. The operating temperature and pressure limits, and the signal-to-noise ratio (SNR) of the new system exceed by a very wide margin what is currently possible. This major breakthrough was made possible by a revolutionary new sensor design that breaks many of the rules of conventional high pressure NMR sensor design. A metallic sample holder capable of operating at high pressures and temperatures is provided to contain the fluid under study. The sample holder has been successfully tested for operation up to 36 Kpsi. A solenoid coil wound on a slotted titanium frame sits inside the metallic sample holder and serves as an antenna to transmit RF pulses and receive NMR signals. The metal sample holder is sandwiched between a pair of gradient coils which provide a linear field gradient for pulsed field gradient diffusion measurements. The assembly sits in the bore of a low-gradient permanent magnet. The system can operate over a wide frequency range without the need for tuning the antenna to the Larmor frequency. The SNR measured on a water sample at room temperature is more than 15 times greater than that of the commercial low-field system in our laboratory. Thus, the new system provides for data acquisition more than 200 times faster than was previously possible. Laboratory NMR measurements of relaxations times and diffusion coefficients performed at pressures up to 25 Kpsi and at temperatures up to 175 °C with crude oils enlivened with dissolved hydrocarbon gases (referred to as "live oils") are shown. This is the first time low-field NMR measurements have been performed at such high temperatures and pressures on live crude oil samples. We discuss the details of the apparatus design, tuning, calibration, and operation. NMR data acquired at multiple temperatures and pressures on a live oil sample are discussed.

First Report of Monilinia fructicola Causing Brown Rot on Stored Japanese Plum Fruit in Chile

In autumn 2013, fruit of Japanese plum (Prunus salicina) cvs. Angelino and Black Kat developed an unusual brown and soft rot after 2 months in cold storage (0°C) on nearly 1% of the fruit. Fruit showed small, circular, light brown spots that eventually destroyed the entire fruit. Small sporodochia appeared on the fruit surface. Fruit was harvested from orchards located near San Francisco de Mostazal (33°59' S, 70°41' W), Chile. Small pieces of diseased tissue were selected from margins of lesions of surface disinfected (96% ethanol) fruit (n = 7) and placed on acidified potato dextrose agar (PDA) plates for 5 days at 20°C. Light brown colonies with even margins and concentric rings of spores were obtained. The conidia of five isolates were one-celled, hyaline, lemon-shaped, (min. 10.7) 14.9 ± 1.5 (max. 18.6) × (min. 8.1) 9.4 ± 0.8 (max. 10.8) μm (n = 30), and borne in branched monilioid chains. This fungus was identified as Monilinia fructicola (G. Winter) Honey (1). Identification was confirmed by amplifying and sequencing the ribosomal ITS1-5.8S-ITS2 region using ITS1 and ITS4 primers (3). BLAST analysis of Chilean plum isolates (GenBank Accession Nos. KF148610 and KF148611) were 99 to 100% identical to isolates of M. fructicola originating from the United States (DQ314727 and HQ846966, respectively) and 100% identical to the first Chilean isolate (JN001480) found in nectarines originating from California at the supermarkets in Santiago in June 2009. Koch's postulates were fulfilled by reproducing brown rot symptoms on mature wounded Japanese plums cv. Angelino (n = 8) inoculated with 10 μl of a conidial suspension (10⁵ conidia/ml) or with a mycelium plug (5-mm diameter). After 2 days in humid chambers (>80% relative humidity) at 25°C, all inoculated fruit developed brown rot symptoms with necrotic lesion means of 15.8 and 21.5 mm in diameter in fruit inoculated with conidia and mycelium, respectively. Non-inoculated control fruit remained healthy. Re-isolations were performed on PDA and the presence of M. fructicola was morphologically confirmed in 100% of the symptomatic fruits. To our knowledge, this is the first report demonstrating the presence of M. fructicola causing brown rot in stored Japanese plums in Chile after its first interception in 2009 in Chile, suggesting that this pathogen has been established in the field. Currently, M. fructicola is a quarantine organism under official control, restricted to Prunus orchards between Santiago and Nancagua in central Chile (2). References: (1) EPPO. EPPO Bull. 39:337, 2009. (2) Servicio Agrícola y Ganadero, SAG, Ministerio de Agricultura, Gobierno de Chile. www.sag.cl , accessed 15 November 2013. (3) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, NY, 1990.

[Priorities for health policy and systems research focused on human resources in health]

OBJECTIVE

Identify priorities for health policy and systems research related to human resources in Latin America and Caribbean countries.

METHODS

An online survey was designed based on a search in PubMed, Cochrane Library, and LILACS that contributed previously prioritized research questions. Respondents, mainly researchers and decision-makers, were identified through various sources. The first round, directed at researchers, aimed at refining and adding research questions and prioritizing questions that researchers regarded as relevant or very relevant. The second round was directed at researchers and decision-makers. A question was considered a priority when 50% (or more) of respondents described it as "relevant" or "very relevant."

RESULTS

The first round included 20 questions on human resources and 33/66 researchers responded. Questions suggested by the researchers were added, resulting in 26 questions for the second round, which were sent to 121 researchers and decision-makers. Respondent representation by country was uniform in both rounds. In the second round, 14/26 (54%) questions were described as very relevant. Priority issues related to regulation of the market, integration of education and health care needs, and distribution of human resources. The response rate was 50% in the first round (33/66), and 34% in the second round (41/121).

CONCLUSIONS

The results of this exercise provide a starting point for mobilization of resources for health policy and systems research. Identification of health systems research priorities is an effective and efficient strategy for reorienting political, financial, management, and social organization efforts for attaining universal health coverage.

[Bone mineral density and adequacy of dietary pattern of patients with chronic kidney disease in hemodialysis]

BACKGROUND

In chronic kidney disease (CKD) patients, malnutrition is common with loss of muscle mass and decreased bone mineral density (BMD), increasing the risk of morbidity.

OBJECTIVE

To compare body composition, bone mineral density (BMD) and bone mineral content (BMC) between CKD patients and healthy subjects, and relate these parameters with energy, macronutrients and micronutrients intake.

METHODS

Body composition was assessed 30 haemodialysis patients and compared with 28 healthy volunteers with DEXA. In patients, three 24 hours records of dietary intake were filled.

RESULTS

A significantly lower BMD (p < 0.01) and BMC (p < 0.0) were found in CKD patients. There was a trend for patients to have lower fat free mass (FFM) than controls (p = 0.06). In men, differences in BMD and BMC lost significance when adjusting for fat mass FM (%) and FFM (kg). In CKD, 34.5% and 27.6% of patients had an adequate intake of energy and protein, respectively. However, it was observed a deficit of energy and protein intake in 31.0% and 44.8% of patients, respectively. No significant correlation was found in CKD patients between macronutrient and calcium intake and BMD or BMC.

CONCLUSIONS

CKD have lower BMD and BMC than healthy volunteers. These differences lost significance in men, after adjusting for body composition parameters. A poor dietary adequacy was found in most patients with CKD, but no association was observed between these variables and body composition or bone mineral density.

Human mesenchymal stem cell-replicative senescence and oxidative stress are closely linked to aneuploidy

In most clinical trials, human mesenchymal stem cells (hMSCs) are expanded in vitro before implantation. The genetic stability of human stem cells is critical for their clinical use. However, the relationship between stem-cell expansion and genetic stability is poorly understood. Here, we demonstrate that within the normal expansion period, hMSC cultures show a high percentage of aneuploid cells that progressively increases until senescence. Despite this accumulation, we show that in a heterogeneous culture the senescence-prone hMSC subpopulation has a lower proliferation potential and a higher incidence of aneuploidy than the non-senescent subpopulation. We further show that senescence is linked to a novel transcriptional signature that includes a set of genes implicated in ploidy control. Overexpression of the telomerase catalytic subunit (human telomerase reverse transcriptase, hTERT) inhibited senescence, markedly reducing the levels of aneuploidy and preventing the dysregulation of ploidy-controlling genes. hMSC-replicative senescence was accompanied by an increase in oxygen consumption rate (OCR) and oxidative stress, but in long-term cultures that overexpress hTERT, these parameters were maintained at basal levels, comparable to unmodified hMSCs at initial passages. We therefore propose that hTERT contributes to genetic stability through its classical telomere maintenance function and also by reducing the levels of oxidative stress, possibly, by controlling mitochondrial physiology. Finally, we propose that aneuploidy is a relevant factor in the induction of senescence and should be assessed in hMSCs before their clinical use.

[Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures]

OBJECTIVE

The purpose of this study is to evaluate the results and complications of hip arthroplasty with conventional stem performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture.

MATERIAL AND METHODS

Between 1997 and 2011, 17 patients with a mean age of 76 years were treated with hip arthroplasty for failed treatment of intertrochanteric hip fracture. In all cases a conventional stem was used. The mean follow-up was 6 years (range 1-14 years). Pain, range of motion (Merle d'Aubigné) and functional results (Barthel), as well as implant fixation (Harris and Engh), were evaluated during the follow-up.

RESULTS

Except for one case of death (6%) and one case of infection (Girdlestone arthroplasty), all patients were able to walk independently at 6 months. The majority of the patients (87%) had no or mild pain. After 2 surgeries (osteosynthesis and hip arthroplasty) the mean Barthel Score had decreased from 81 to 66 points. Just one case (6%) of stem loosening has been observed.

DISCUSSION

In older patients, prosthetic replacement after failed proximal femoral fixation is a reliable salvage option. Most patients have good pain relief and functional improvement, although the rate of perioperative medical complications is high. Surgery is less demanding and the operating time is shorter when conventional femoral stems are used.

Switching to lopinavir/ritonavir with or without abacavir/lamivudine in lipoatrophic patients treated with zidovudine/abacavir/lamivudine

BACKGROUND

Discontinuation of thymidine nucleoside reverse transcriptase inhibitors (tNRTIs) is the only proven strategy for improving lipoatrophy. It is unclear whether switching to NRTI-sparing or to non-thymidine NRTI-containing therapy has differential effects on body fat recovery.

METHODS

This was a 96 week, open-label, randomized study in suppressed patients with moderate/severe lipoatrophy and no prior virological failure while receiving a protease inhibitor and who had their triple NRTI regimen (zidovudine/lamivudine/abacavir) switched to lopinavir/ritonavir plus abacavir/lamivudine for a 1 month run-in period and then randomized to lopinavir/ritonavir plus abacavir/lamivudine versus lopinavir/ritonavir monotherapy. The KRETA trial is registered with ClinicalTrials.gov (number NCT00865007).

RESULTS

Of 95 patients included, 88 were randomized to lopinavir/ritonavir plus abacavir/lamivudine (n = 44) or lopinavir/ritonavir monotherapy (n = 44). Median (IQR) baseline limb fat was 2.5 (1.6-3.7) kg in the lopinavir/ritonavir plus abacavir/lamivudine group and 2.5 (2.0-5.4) kg in the lopinavir/ritonavir monotherapy group. Six patients in the triple therapy group and 13 in the monotherapy group had discontinued study drugs by week 96. Although there were limb fat gains in each group at weeks 48/96 (+324/+358 g in lopinavir/ritonavir plus abacavir/lamivudine, P = 0.09/0.07, versus +215/+416 g in the lopinavir/ritonavir monotherapy group, P = 0.28/0.16), differences between groups were not significant [difference +109 g (95% CI -442, +660)/-57 g (95% CI -740, +625)].

CONCLUSIONS

In lipoatrophic patients treated with zidovudine/lamivudine/abacavir, switching to lopinavir/ritonavir monotherapy had no additional benefit in limb fat recovery relative to switching to lopinavir/ritonavir with abacavir/lamivudine. These data suggest that non-thymidine nucleosides such as abacavir/lamivudine are not an obstacle to limb fat recovery.

Use of GFP-tagged strains of Penicillium digitatum and Penicillium expansum to study host-pathogen interactions in oranges and apples

Penicillium digitatum and Penicillium expansum are responsible for green and blue molds in citrus and pome fruits, respectively, which result in major monetary losses worldwide. In order to study their infection process in fruits, we successfully introduced a green fluorescent protein (GFP) encoding gene into wild type P. digitatum and P. expansum isolates, using Agrobacterium tumefaciens-mediated transformation (ATMT), with hygromycin B resistance as the selectable marker. To our knowledge, this is the first report describing the transformation of these two important postharvest pathogens with GFP and the use of transformed strains to study compatible and non-host pathogen interactions. Transformation did not affect the pathogenicity or the ecophysiology of either species compared to their respective wild type strains. The GFP-tagged strains were used for in situ analysis of compatible and non-host pathogen interactions on oranges and apples. Knowledge of the infection process of apples and oranges by these pathogens will facilitate the design of novel strategies to control these postharvest diseases and the use of the GFP-tagged strains will help to determine the response of P. digitatum and P. expansum on/in plant surface and tissues to different postharvest treatments.

First Report of Diaporthe australafricana Associated with Stem Canker on Blueberry in Chile

Stem cankers of blueberry (Vaccinium corymbosum L.) have been observed on as much as 15% of the plants in plantations in central and southern Chile since 2006. Symptoms consisted of apical necrosis of the shoots and brown-to-reddish necrotic lesions on the stems. Internally, a brown-to-reddish discoloration of the vascular tissue can be observed. Twenty, single-plant samples were collected in 12 blueberry plantings (approximately 33°27' to 40°53'S). Isolations from the margins of the necrotic lesions on the stems were made by plating small pieces (5 mm) on potato dextrose agar acidified with 0.5 μl/ml of 92% lactic acid (APDA). The plates were incubated at 20°C for 5 to 7 days, and hyphal tips of white colonies with septate and hyaline mycelium were transferred to APDA. Colonies were then transferred to autoclaved Pinus radiata needles on 2% water agar and incubated for 20 days at 20°C. Twelve isolates producing black pycnidia and alpha conidia were tentatively identified as a Phomopsis sp. (teleomoph Diaporthe Nitschke). Other fungi, including Botryosphaeriaceae spp. and Pestalotiopsis spp., were also isolated. Alpha conidia were smooth, unicellular, hyaline, fusoid, biguttulate, and 6.4 to 7.9 × 2.3 to 3.3 μm (n = 20). Beta conidia were not observed. The internal transcribed spacer (ITS) region of the rDNA was amplified using primers ITS1 and ITS2 (4) and sequenced. BLASTn analysis of the 473-bp fragment (GenBank Accession No. JQ045712) showed 100% identity to Diaporthe australafricana Crous & J.M. van Niekerk from Vitis vinifera (3). The pathogenicity of D. australafricana was studied on blueberry cv. O'Neal using detached stems (n = 4) in the laboratory, on 2-year-old potted plants (n = 4) in a greenhouse, and on attached stems of mature plants (n = 4) established in the ground. Inoculations were done by placing mycelial plugs taken from 7-day-old APDA cultures in a 7-mm long incision made on the stems. Inoculations with sterile mycelium plugs served as negative controls. Inoculation sites were wrapped with Parafilm to avoid rapid dehydration. Dark brown, necrotic lesions on the internal tissues were obtained on all inoculated stems 15 days after inoculation. Mean lesion lengths were 18.0 ± 7.4 mm on detached stems, 7.8 ± 6.9 mm on stems of 2-year-old plants, and 7.3 ± 2.5 mm on mature plants in the field. No symptoms developed on control stems. Reisolations were successful in 100% of the inoculated stems and D. australafricana was confirmed by the presence of pycnidia and alpha conidia. To our knowledge, this is the first report of D. australafricana causing stem canker in V. corymbosum. Previously, this pathogen has been reported to be affecting Vitis vinifera in Australia and South Africa (3). These results do not exclude that other plant-pathogenic fungi may be involved in this syndrome (1,2). References: (1) J. G. Espinoza et al. Plant Dis 92:1407, 2008. (2) J. G. Espinoza et al. Plant Dis. 93:1187, 2009. (3) J. M. van Niekerk et al. Australas. Plant Pathol. 34:27, 2005. (4) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, NY, 1990.

Formulation development of the biocontrol agent Bacillus subtilis strain CPA-8 by spray-drying

AIMS

To prepare commercially acceptable formulations of Bacillus subtilis CPA-8 by spray-drying with long storage life and retained efficacy to control peach and nectarine brown rot caused by Monilinia spp.

METHODS AND RESULTS

CPA-8 24-h- and 72-h-old cultures were spray dried using 10% skimmed milk, 10% skimmed milk plus 10% MgSO(4) , 10% MgSO(4) and 20% MgSO(4) as carriers/protectants. All carriers/protectants gave good percentages of powder recovery (28-38%) and moisture content (7-13%). CPA-8 survival varied considerably among spray-dried 24-h- and 72-h-old cultures. Seventy-two hours culture spray dried formulations showed the highest survival (28-32%) with final concentration products of 1·6-3·3 × 10(9) CFU g(-1) , while viability of 24-h-old formulations was lower than 1%. Spray-dried 72-h-old formulations were selected to subsequent evaluation. Rehydration of cells with water provided a good recovery of CPA-8 dried cells, similar to other complex rehydration media tested. Spray-dried formulations stored at 4 ± 1 and 20 ± 1°C showed good shelf life during 6 months, and viability was maintained or slightly decreased by 0·2-0·3-log. CPA-8 formulations after 4- and 6 months storage were effective in controlling brown rot caused by Monilinia spp. on nectarines and peaches resulting in a 90-100% reduction in disease incidence.

CONCLUSIONS

Stable and effective formulations of biocontrol agent B. subtilis CPA-8 could be obtained by spray-drying.

SIGNIFICANCE AND IMPACT OF THE STUDY

New shelf-stable and effective formulations of a biocontrol agent have been obtained by spray-drying to control brown rot on peach.

Antimicrobial treatment of invasive non-perinatal human listeriosis and the impact of the underlying disease on prognosis

Listeriosis is a resurgent foodborne disease in European countries. Benefits of combined β-lactam-aminoglycoside treatment remain controversial and the impact of the underlying disease on prognosis has not been fully assessed. We conducted a retrospective review of cases of sporadic listeriosis in adults from 1995 to 2008 at two university-affiliated hospitals serving a population of 600,000 people in Madrid, Spain. The primary end-point was the associated in-hospital mortality. Sixty-four patients were studied. Estimated incidence of listeriosis was 0.76/100.000 persons/year. Seventy-four per cent had chronic underlying diseases; cirrhosis of the liver and haematological and solid neoplasias were the most common comorbidities. Primary bacteraemia (58%) and meningitis (42%) were the most frequent manifestations. Focal infections were seen in ten cases. In-hospital mortality was 31%. Patients treated with ampicillin or with an ampicillin-gentamicin combination did not differ in age, severity of underlying disease or type of presentation. Differences in mortality were not seen between patients treated with monotherapy and those given combined treatment (28% vs 35%; p 0.634). Ten patients were treated with trimethoprim-sulfamethozaxole alone and only one died. All patients without comorbidities survived infection but mortality of patients with cirrhosis of the liver was 21% and that of patients with haematological or solid neoplasias was 66%. Only haematological neoplasia (OR 6.67; 95% CI 1.71-26.04; p 0.006) was significantly associated with an increased risk of mortality (R(2) (Cox-Snell) = 0.262). Mortality of listeriosis mainly depended on the severity of the underlying disease. Combined ampicillin-gentamicin therapy did not improved survival. Trimethoprim-sulfamethozaxole may be an effective alternative therapy for listerial infections.