Significant differences in access to tests and treatments for multiple myeloma between public and private systems in Latin America. Results of a Latin American survey. GELAMM (Grupo de Estudio Latino Americano de Mieloma Múltiple)

The incidence of multiple myeloma (MM) has increased in the last 20 years, particularly in middle and low-middle income countries. Access to diagnostic and prognostic tests and the availability of effective care is highly variable globally. Latin America represents 10% of the world population, distributed in countries of varied size, population, and socio-economic development. In the last decade, great improvements have been made in the diagnosis and treatment of MM. Applying these advances in real life is a challenge in our region. Local data regarding MM standards of care and outcomes are limited. A survey was carried out among hematologists from 15 Latin American countries to describe access to MM diagnostic and prognostic tests and the availability of effective care options. This study provides real-world data for MM in our region, highlighting striking differences between public and private access to essential analyses and therapeutic options.

ATRX Mutations in Pineal Parenchymal Tumors of Intermediate Differentiation

Pineal parenchymal tumors are rare neoplasms, ranging from WHO Grade I to IV. There are few studies characterizing the molecular profiles of these tumors. ATRX alterations are strongly associated with the presence of the alternative lengthening of telomeres (ALT) phenotype, and within the central nervous system they tend to occur in subsets of gliomas, including those with IDH, NF1, or histone (H3 K27M or G34) mutations. Here, we identified ATRX frameshift mutations by next generation sequencing associated with corresponding protein loss in 2 cases of pineal parenchymal tumors of intermediate differentiation (PPTID) developing in a 21-year-old woman and a 64-year-old man. In contrast, we identified partial ATRX loss in 1 pineoblastoma, among 14 pineal parenchymal tumors of various grades (6 pineoblastomas, 4 pineocytomas, and 4 PPTID) using tissue microarrays; ALT was absent in these cases. Evaluating the cBioPortal database, an ATRX mutation was identified in one (of 3 total) PPTIDs analyzed. Thus, ATRX mutations associated with protein loss and ALT develop in a small subset of pineal parenchymal tumors and may be limited to those with intermediate differentiation. The clinical significance of these alterations requires further study.

Highly sensitive and ultrafast read mapping for RNA-seq analysis

As sequencing technologies progress, the amount of data produced grows exponentially, shifting the bottleneck of discovery towards the data analysis phase. In particular, currently available mapping solutions for RNA-seq leave room for improvement in terms of sensitivity and performance, hindering an efficient analysis of transcriptomes by massive sequencing. Here, we present an innovative approach that combines re-engineering, optimization and parallelization. This solution results in a significant increase of mapping sensitivity over a wide range of read lengths and substantial shorter runtimes when compared with current RNA-seq mapping methods available.

Pro- and anti-inflammatory cytokine gene single-nucleotide polymorphisms in inflammatory bowel disease

Anti-inflammatory cytokines have an important role in disease, tumour and transplant processes. Alterations in the regulation of several cytokines have been implicated in a variety of inflammatory disorders, including IBD (inflammatory bowel disease) [Crohn's disease (CD) and ulcerative colitis (UC)]. Cytokine polymorphisms are also known to affect the level of gene expression. Thus, the aim of this study was to determine the relationship between cytokine polymorphisms and the IBD pathologies in a Spanish population. Polymorphisms analysis was performed using PCR-SSOP using a microbeads luminex assay. The following polymorphisms were determined: TNFα [-238G/A (rs361525) and -308G/A (rs1800629)], IFNγ [+874A/T (rs62559044)], TGFβ [+869C/T (rs1982073) and +915G/C (rs1800471)], IL10 [-1082A/A (rs1800896), -592A/C (rs1800872), -819C/T (rs1800871)], IL6 [-174C/G (rs1800795)], IL12p40 [3'UTR -1188A/C (rs3212227)], IL1α [-889C/T (rs1800587)], IL1β [-511C/T (rs1143634) and +3962C/T (rs1143633)], IL1R [Pst-1 1970C/T] and IL1RA [Mspa-1 11100C/T]. No statistical differences in TNFα, IFNγ, TGFβ, IL10, IL6, IL1α, IL1β, IL1R and IL1Ra genotypes and allele distributions between the IBD groups and healthy controls were found. However, we observed significant differences in the 3'UTR -1188A/C polymorphism of IL12p40. So -1188A allele was increased in patients with UC and the -1188C allele (high IL12p40 production) was increased in patients with CD with respect to controls. These data are in concordance with the fact that CD has been shown to be associated with a Th1 T-cell-mediated inflammation model and high IL12/IFNγ production at histological affected sites. These data suggest that cytokine polymorphisms in TNFα, IFNγ, TGFβ, IL10, IL6 and IL1α, IL1β, IL1R and IL1Ra cytokine gene do not seem to be relevant in IBD susceptibility and IL12p40 3'UTR -1188A/C polymorphism seems to be associated with a differential IBD development.

Cholera toxin expression by El Tor Vibrio cholerae in shallow culture growth conditions

Vibrio cholerae O1 classical, El Tor and O139 are the primary biotypes that cause epidemic cholera, and they also express cholera toxin (CT). Although classical V. cholerae produces CT in various settings, the El Tor and O139 strains require specific growth conditions for CT induction, such as the so-called AKI conditions, which consist of growth in static conditions followed by growth under aerobic shaking conditions. However, our group has demonstrated that CT production may also take place in shallow static cultures. How these type of cultures induce CT production has been unclear, but we now report that in shallow culture growth conditions, there is virtual depletion of dissolved oxygen after 2.5 h of growth. Concurrently, during the first three to 4 h, endogenous CO2 accumulates in the media and the pH decreases. These findings may explain CT expression at the molecular level because CT production relies on a regulatory cascade, in which the key regulator AphB may be activated by anaerobiosis and by low pH. AphB activation stimulates TcpP synthesis, which induces ToxT production, and ToxT directly stimulates ctxAB expression, which encodes CT. Importantly, ToxT activity is enhanced by bicarbonate. Therefore, we suggest that in shallow cultures, AphB is activated by initial decreases in oxygen and pH, and subsequently, ToxT is activated by intracellular bicarbonate that has been generated from endogenous CO2. This working model would explain CT production in shallow cultures and, possibly, also in other growth conditions.

Consecuencias de la resección de la cabeza radial sobre la articulación radiocubital distal

Nuestro objetivo ha sido la realización de un estudio clínico y radiológico de las secuelas en la articulación radiocubital distal en pacientes intervenidos de una extirpación aislada, total e inmediata, de cabeza radial, tras haber sufrido una fractura de tipo III y IV de Mason. Para ello hemos estudiado a 45 pacientes intervenidos en el Hospital Donostia entre los años 1988 y 2004, a los que se les ha realizado una entrevista clínica, una exploración física y radiológica del brazo intervenido, así como del contralateral para realizar el estudio comparativo. Hemos encontrado diferencias estadísticamente significativas en la medición de fuerza prensil, laterodigital y pulpar, y en la existencia de cambios degenerativos radiográficos. Observamos también disminución en los arcos de movilidad de la muñeca siendo los movimientos de supinación y extensión los más afectados (1,9º y 2,55º respectivamente de media respecto al contralateral). El valor medio de dolor en la muñeca intervenida en una escala analógica visual fue de 0,13 en reposo y 0,65 en actividad. No encontramos trastornos neurológicos, y los pacientes expresaron un alto grado de satisfacción con el resultado. Por to-do ello podemos concluir que aunque hay diferencia estadística, ésta no parece interferir en la realización de actividades de la vida diaria de nuestros pacientes ni por disminución de fuerza o movilidad ni por presencia de dolor.

Use of linezolid in critically ill patients admitted to intensive care units

All indications of linezolid (LZD) in Intensive Care Units (ICU) were included as cases in an observational, prospective and multicentre study. One hundred thirty-nine indications were analyzed. In most cases (92.7%), treatment for nosocomial infections was indicated. The most frequent infection was pneumonia (42.7%), followed by catheter-related bacteraemias (CRB). A total of 58.7% of the indications were empirical and in 45.7% of the cases the cultures confirmed infection by gram-positive cocci (GPC). In 43 cases (31.2%), the indication was made as a rescue measure (mainly due to clinical failure) in patients previously treated with glycopeptides. Of isolated GPC, 70.2% were methicillin-resistant. The cure rate of the population per intent-to-treat was 73.2%. Only one case of thrombocytopenia was recorded. Conclusions. LZD is used with a high degree of diagnostic safety. In the ICU, it is primarily indicated to treat pneumonias and CRB with good clinical and microbiological response. This antibiotic has acted as a good therapeutic resource against clinical failure in infections treated with glycopeptides.

Paclitaxel plus carboplatin (PC) in patients with metastatic melanoma (MM): Experience in a single institution

e20019

Background: The number of agents active in patients with metastatic melanoma is limited and cure is not an objective for treatment at this stage, so that clinical benefit in these patients is the most important. The aim of the study was to evaluate the efficacy and safety of combination regimen consisting of paclitaxel and carboplatin as second-line chemotherapy, in patients with MM. Based on reports of responses to PC, 17 patients with MM was treated at the National Cancer Institute of Mexico. Methods: We evaluated retrospectively the combination of PC in patients with MM. Data regarding patient characteristics and outcomes were abstracted from medical records of NCI of Mexico from 01/05 to 12/08. The regimen was weekly paclitaxel (at a dose of 80 mg/m2) received on days 1, 8, and 15 of a 21-day cycle and carboplatin (AUC 5) on day 1. Response evaluation was using RECIST and toxicity was according to National Cancer Institute Common Toxicity Criteria. This study was approved by the hospital ethics committee. Results: Seventeen patients with MM were treated with PC. All patients were previously treated (and failed) with dacarbazine (DTIC). Sixteen were assessable for response with three cycles of chemotherapy and seventeen for toxicity. One patient was deemed to be ineligible because they presented severe hypersensitivity reaction to paclitaxel at beginning. Objective partial response were obtained in 4 patients (25%); 8 stable disease (50%) at least four months. No patient had a complete response to therapy. Progression disease was in 4 patients (25%). In 12 (75%) we noted clinical benefit. The median time to disease progression for the entire group was 4.2 months (range, 1–11 mos), with a median overall survival of 8.1 months (range, 5.6–10.5 mos). The toxicity grade 3 reported was thrombocytopenic in 2 patients (11%) and anemia in one patient (6%). Additional patients had reversible toxicities grade 3 including alopecia, nausea and fatigue; 2 of them presented moderate hypersensitivity reactions to paclitaxel. No toxic death was noted. Conclusions: The PC combination appears to be safety and well tolerated in second line chemotherapy in MM, however we need more patients to demonstrate a true clinical benefit, we outcomes are according with other clinical reports.

No significant financial relationships to disclose.

Nutritional preferences of a group of Streptosporangium soil isolates

The nutritional preferences of twelve strains of genus Streptosporangium were studied as a first step in the design of production media to be used in a natural products screening program. The media ingredients included 20 alpha-amino acids, 35 carbon sources (monosaccharides, oligosaccharides, polysaccharides, polyalcohols and others), 22 complex sources (meals, peptones, yeast derivatives, etc.). The growth of these strains in the presence of these culture media ingredients and the production of inhibitory substances against Bacillus subtilis were analyzed in solid-phase cultures. The results show that the isolates studied did not exhibit a common trend in their preference of nutrient sources, either for to support their growth or the production of anti-B. subtilis substances.

Negative ion formation and motion in a mixture of CCl4 and Ar

This paper deals with the measurement of the mobility of negative ions in the mixtures of CCl4 with Ar with the CCl4 ratio up to 33.3%. The pulsed Townsend technique was employed to produce an integrated ionic avalanche over a range of the density-reduced electric field E/N for which ionization is either negligible or absent, and attachment processes are dominant, leading to the formation of mostly CCl-4. The E/N range of measurement was 1-50 Td (1 Td=10(-17) V cm(2)). Our measurements strongly suggest that attachment is the dominant process and only negative ions are formed.

Nutritional status of indigenous children at boarding schools in northern Mexico

OBJECTIVE

To assess the nutritional status of Tarahumara children at indigenous boarding schools.

DESIGN

Cross-sectional comprehensive nutritional survey.

SETTING

The schools sampled were located in indigenous municipalities of the northern Mexican state of Chihuahua.

SUBJECTS

The study was carried out in 2001 among 331 children aged 6-14 y from a sample of five schools. Anthropometric measurements, a thyroid exam and capillary haemoglobin levels were obtained from the children. Serum concentrations of ferritin, iron, total iron-binding capacity, vitamin B(12), folic acid and zinc were collected from a subsample of 100 children.

RESULTS

The prevalence of wasting and overweight (children 6-9 y) was 1.1 and 4.6%, respectively, and of underweight, risk of overweight and overweight (10-14 y) was 3.2, 5.1 and 0.6%, respectively. Stunting (6-12 y) was present in 22.3% of the children. The total goitre rate was 5.4%. The prevalence of anaemia was 13% (boys 11.4, girls 14.5%). Overall, 24.2% of the children were iron deficient (depletion 11.1%, deficient erythropoiesis 3%, iron deficiency anaemia 10.1%). No child had folic acid values <3 ng/ml, but 20.2% had low (<200 microg/dl) and 27.3% marginal (200-300 microg/dl) vitamin B(12) levels, and 80.2% had low zinc concentrations (<60 microg/dl).

CONCLUSIONS

Nutritional underweight and stunting were similar to those reported in rural localities at the national level, but overweight was less prevalent in children aged 10-14 y. Various micronutrient deficiencies was identified including zinc and vitamin B(12), but the prevalence of iron and folic acid deficiency was lower than expected. These results suggest that Tarahumara children attending boarding schools may be the better-off children from these extremely poor and marginalized areas.

SPONSORSHIP

Swedish Agency for Research Cooperation with Developing Countries and the Mexican Social Security Institute.

[Complications of endoscopic retrograde cholangiopancreatography]

INTRODUCTION

Endoscopic sphincterotomy (ES) is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated complications and mortality of endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

Between june 6, 1998 and june 6, 1999 553 ERCP were performed in our centers. Inclusion criteria for protocol were: ERCP indication, complete follow-up and informed consent. We prospectively studied complications of ECRP in consecutive patients treated at 2 institutions (San Martin Hospital, La Plata, Argentina and Hadassah University Hospital, Jerusalem, Israel). The follow-up was done during 365 days with a clinical examination, laboratory test and ultrasonography to determine the possible complications.

RESULTS

Of 553 ERCP, 43 had a complications; including pancreatitis in 16 cases, cholangitis in 12, hemorrhage in 5, perforation in 3 and miscellaneous in 7. 3-1) ES frequency: 241 patients (pts). 3-2) FOLLOW-UP: 365 days in 504 pts. 3-3) Sex and age: women 274 pts, men 230 pts. Age range 1 month to 90 year old. 3-4) Final diagnoses: choledocholitiasis (38.8%), strictures (18%), pancreatic cancer (4.3%), ampullary cancer (2.3%) and normal ERCP (24.4%).

CONCLUSIONS

The rate of complications after ES can vary in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique. Our percentage of complications (7.53%) coincide with consulted studies. Today, diagnostic ERCP has been challenged by magnetic resonance cholangiography (MRC). MRC provides images of the billary and pancreatic ducts that are nearly equal to those of ERCP without the procedural risk associated.

Iron deficiency anemia in Tarahumara women of reproductive-age in northern Mexico

OBJECTIVE

To determine the prevalence of iron deficiency anemia (IDA) among Tarahumara women of reproductive age.

MATERIAL AND METHODS

A cross-sectional survey was conducted in a representative sample of 481 women aged 12-49 years, residents of Guachochi Municipality, Chihuahua, from June to September 1998. The hemoglobin (Hb) level was measured in capillary blood using the Hemocue technique, and the serum ferritin level in capillary serum spotted on filter paper, in a sub-sample of women. Central tendency and dispersion measures were estimated; the Chi-squared test was used to test differences in proportions and ANOVA and Bonferroni's test for differences in means.

RESULTS

Prevalence of anemia (mean Hb +/- S.D.) was 16.1% (140 +/- 16 g/l) and 25.7% (129 +/- 12 g/l) for non-pregnant and pregnant women, respectively. Pregnant women in the 3rd trimester and those who were breast-feeding their children during the first 6 months after delivery had the highest prevalence of anemia (38.5% and 42.9%, respectively). Iron deficiency was responsible for most of the anemia found in this sample.

CONCLUSIONS

This study provides relevant information for the development of intervention programs to treat and prevent IDA in this ethnic group.

The impact of a clinical training unit on integrated child health care in Mexico

This study had two aims: to describe the activities of a clinical training unit set up for the integrated management of sick children, and to evaluate the impact of the unit after its first four years of operation. The training unit was set up in the outpatient ward of a government hospital and was staffed by a paediatrician, a family medicine physician, two nurses and a nutritionist. The staff kept a computerized database for all patients seen and they were supervised once a month. During the first three years, the demand for first-time medical consultation increased by 477% for acute respiratory infections (ARI) and 134% for acute diarrhoea (AD), with an average annual increase of demand for medical care of 125%. Eighty-nine per cent of mothers who took their child for consultation and 85% of mothers who lived in the catchment area and had a deceased child received training on how to recognize alarming signs in a sick child. Fifty-eight per cent of these mothers were evaluated as being properly trained. Eighty-five per cent of primary care physicians who worked for government institutions (n = 350) and 45% of private physicians (n = 90) were also trained in the recognition and proper management of AD and ARI. ARI mortality in children under 1 year of age in the catchment area (which included about 25,000 children under 5 years of age) decreased by 43.2% in three years, while mortality in children under 5 years of age decreased by 38.8%. The corresponding figures for AD mortality reduction were 36.3% and 33.6%. In this same period, 11 clinical research protocols were written. In summary, we learned that a clinical training unit for integrated child care management was an excellent way to offer in-service training for primary health care physicians.

Does being a woman make a difference in professional practice? A qualitative view to the practice of rheumatology

OBJECTIVE

To explore to what extent female rheumatologists perceived that gender had an influence on their professional practice or on their choice of specialty.

METHODS

We collected data from 29 female rheumatologists and used qualitative and quantitative methods to describe the findings.

RESULTS

Three groups of respondents were identified (cluster analysis). Most of these rheumatologists perceived that gender influenced the way they practiced, although the specific weights of the topics were different in the 3 groups. Gender also influenced these physicians' choice of specialty field.

CONCLUSION

The differences in practice style may have a potential effect on health systems as feminization of the medical profession increases.

Bilateral and simultaneous ischemic optic neuropathy following hip replacement surgery

Ischemic optic neuropathy, is an exceptional complication of surgery. Moreover, bilateral and simultaneous visual deficit in ischemic optic neuropathy is very rare. We describe two patients who suffered bilateral and simultaneous ischemic optic neuropathy after elective total hip replacement. Anemia and hypotension are the most likely risk factors.

Diagnostic value of tachypnoea in pneumonia defined radiologically

OBJECTIVE

To evaluate whether sensitivity and specificity of tachypnoea for the diagnosis of pneumonia change with age, nutritional status, or duration of disease.

METHODS

Diagnostic testing of 110 children with acute respiratory infection, 51 of whom presented with tachypnoea. The gold standard was a chest roentgenogram. Thirty five children had a radiological image of pneumonia; 75 were diagnosed as not having pneumonia. Sensitivity, specificity, and percentage of correct classification of tachypnoea, by itself or in combination with other clinical signs for all children, by age groups, nutritional status, and disease duration were calculated.

RESULTS

Tachypnoea as the sole clinical sign showed the highest sensitivity (74%) and a specificity of 67%; 69% of cases were classified correctly. Sensitivity was reduced when other clinical signs were combined with tachypnoea, and there was no significant increase in correct classification, although specificity increased to 84%. In children with a disease duration of less than three days, tachypnoea had a lower sensitivity and specificity (55% and 64%, respectively), and a lower percentage of correct classification (62%). In children with low weight for age (< 1 Z-score), tachypnoea had a sensitivity of 83%, a specificity of 48%, and 60% correct classification. Sensitivity and specificity did not vary with age groups.

CONCLUSIONS

Tachypnoea used as the only clinical sign is useful for identifying pneumonia in children, with no significant variations for age. In children with low weight for age, tachypnoea had higher sensitivity, but lower specificity. However, during the first three days of disease, the sensitivity, specificity, and percentage of correct classification were significantly lower.

[Prevalence of malnutrition in Tarahumara children under 5 years of age in the municipality of Guachochi, Chihuahua]

OBJECTIVE

To determine the prevalence of malnutrition among Tarahumara children under 5 years of age in the municipality of Guachochi, Chihuahua, Mexico.

MATERIAL AND METHODS

During the summer of 1996, we interviewed a representative sample of 450 children from 62 communities, stratified by size of population. The sample represents 12.2% of the total number of Tarahumaras in the municipality. For each of three anthropometric indices (weight-for-age, weight-for-height and height-for-age), we calculated the Z-score in reference to NCHS population values. Results are presented as means and standard deviations as well as prevalence of malnutrition at different cut-off-points, stratified by age, sex, and size of the community.

RESULTS

Prevalence figures of malnutrition (< -2Z) were: weight-for-age: 36.4% (mean SD +/- -1.66 +/- 1.1); weight-for-height: 3.5% (mean SD +/- -0.43 +/- 0.9); and height-for-age: 57.1% (mean SD +/- -2.15 +/- 1.3). Children aged 12-23 months were the most affected, both in weight-for-height and weight-for-age (10.3% and 52.6%, respectively). Children over one year of age presented prevalences of height-for-age < -2Z over 60%. Significant sex differences (p < 0.05) were observed, favoring girls.

CONCLUSIONS

Malnutrition among Tarahumara children reaches its peak during the second year of life (12-23 months old), affecting boys more than girls. This information may be useful for planning and targeting nutrition intervention programs for this underprivileged indigenous group.

[Acceptability of food supplements in pregnant or lactating women and children under 5 years of age]

OBJECTIVE

The present study explores the acceptance and consumption of nutritional supplements that form part of a governmental program to support nutritionally vulnerable groups.

MATERIAL AND METHODS

Pregnant and lactating women, and mothers of malnourished toddlers, infants and children were interviewed. Data were collected, after introduction with an interview guide with an open-ended format, through face-to-face interviews conducted at home. Interviews were taped with previous informed consent. Analysis included topics and subtopics approached by the interviewed women.

RESULTS

The studied population showed good acceptance to the supplement when offered as a drink. When considering benefits, pregnant women thought first of their baby's health than of their own and associated the possible advantages of the supplement to its "vitamin" contents. Acceptance of the flavors was largely influenced by previous contact to specific flavors. Children under 1 year of age preferred the liquid consistency and elderly children favored the puree. Most mothers considered that the offered amount was enough and there was the general impression that, as the time of the intervention elapsed, children showed greater appetite. The diet was not substituted by the supplement.

CONCLUSIONS

Acceptance of the supplement may be improved by messages focusing on the well-being and health of the child and insisting on the benefits for the pregnant mother. Community health providers should be involved in supporting the program, recommending consumption and acceptance of the supplement. The identification by mothers of "vitamins" as part of the supplement may be used to reinforce the concept of beneficial effects associated to micronutrient supplementation. Qualitative evaluations should be performed as part of the assessment of community-based programs.

A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico

In Tlaxcala State, Mexico, we determined that 80% of children who died from diarrhoea or acute respiratory infections (ARI) received medical care before death; in more than 70% of the cases this care was provided by a private physician. Several strategies have been developed to improve physicians' primary health care practices but private practitioners have only rarely been included. The objective of the present study was to evaluate the impact of in-service training on the case management of diarrhoea and ARI among under-5-year-olds provided by private and public primary physicians. The training consisted of a five-day course of in-service practice during which physicians diagnosed and treated sick children attending a centre and conducted clinical discussions of cases under guidance. Each training course was limited to six physicians. Clinical performance was evaluated by observation before and after the courses. The evaluation of diarrhoea case management covered assessment of dehydration, hydration therapy, prescription of antimicrobial and other drugs, advice on diet, and counselling for mothers; that of ARI case management covered diagnosis, decisions on antimicrobial therapy, use of symptomatic drugs, and counselling for mothers. In general the performance of public physicians both before and after the intervention was better than that of private doctors. Most aspects of the case management of children with diarrhoea improved among both groups of physicians after the course; the proportion of private physicians who had five or six correct elements out of six increased from 14% to 37%: for public physicians the corresponding increase was from 53% to 73%. In ARI case management, decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups; the proportion of private physicians with at least three correct elements out of four increased from 13% to 42%, while among public doctors the corresponding increase was from 43% to 78%. Hands-on training courses thus seemed to be effective in improving the practice of physicians in both the private and public sectors.

Seasonal diarrhoeal mortality among Mexican children

The study investigated the effects on diarrhoeal deaths among under-5-year-old Mexican children of the following variables: season (summer or winter), region (north versus south), age group, and place of death. Examination of death certificates indicated that the distribution of deaths in 1989-90 was bimodal, with one peak during the winter and a more pronounced one during the summer. In 1993-94, however, the winter peak was higher than that in the summer (odds ratio (OR) = 2.04). These findings were due mostly to deaths among children aged 1-23 months (OR = 1.86). Diarrhoeal mortality was highest among children aged 6-11 months (OR = 2.23). During the winter, there was a significant increase in the number of deaths that occurred in medical care units and among children who had been seen by a physician before they died, but deaths occurring at home showed no seasonal variation. In the northern states, the reduction in diarrhoeal mortality was less in winter than in summer (OR = 2.62). In the southern states, the proportional reduction during the winter was similar to that in the summer.

The quality of private and public primary health care management of children with diarrhoea and acute respiratory infections in Tlaxcala, Mexico

In Tlaxcala, Mexico, 80% of the children who died from diarrhoea or acute respiratory infections (ARI) in 1992-1993 received medical care; in more than 70% of cases it was provided by a private general practitioner (GP). The present study evaluated the quality of case management by private and public GPs to children under five years of age with diarrhoea and ARI. During the clinical observation, the treatment and counselling given to the mother were assessed with the WHO guidelines as reference standard. A total of 41 private and 40 public GPs were evaluated for the management of diarrhoea, and 59 private and 40 public GPs for the management of ARI. For diarrhoea, half of the private GPs gave inadequate rehydration therapy, 63% gave incorrect advice on diet, 66% and 49% made an incorrect correct decision in the prescription of antimicrobial and symptomatic drugs, respectively. Public GPs generally performed better in diarrhoea management: 7% gave inadequate rehydration therapy, 13% gave wrong advice on diet, 3% made a wrong decision in the prescription of symptomatic drugs and 28% gave a wrong decision in antimicrobial prescription. In the management of ARI, 66% and 58% of private GPs made a wrong decision in the prescription of antimicrobial and symptomatic drugs, respectively, compared to 30% and 20% of public GPs, respectively. Counselling to the mother given by both private and public GPs was considered inadequate in most cases of diarrhoea and ARI. These results clearly show that private doctors, as important providers of medical care, need to be included in the strategies to improve the quality of care of children with diarrhoea and ARI. Future research needs to address the determinants of the clinical practice of private doctors in countries like Mexico.

[Nutrition and development in the first semester of life]

OBJECTIVE

To study the psychomotor development of young infants from a poor and underfed rural community and to correlate this with the nutritional conditions of the mother during pregnancy and the child itself.

MATERIAL AND METHODS

We studied 82 mother-child pairs from the 5th month of pregnancy to the 6th month of life of the child as to anthropometry and food consumption. The neonatal Brazelton test and the Bayley test at 3 and 6 months were applied to the child.

RESULTS

Several of the neonatal psychomotor tests applied to the child correlate positively with the mother's weight and skin folds, as well as with the child's own previous weight and size. This was also true for maternal consumption of animal foods and fruits during pregnancy. A negative correlation was observed with the consumption of corn tortillas and beans. The correlation of several tests applied to the child at six months was positive with its complementary consumption, total energy and several foods, specially egg, milk and fruit around three months of age.

CONCLUSIONS

Small variations in nutrition of the mother-child pairs from the poor rural community studied had consequences on the psychomotor development of the infant. These findings point to the need for more applied nutrition programs.

Implementation of conditions of the inoculum stage for Streptosporangium cultures

Different factors concerning the inoculum stage of cultures classified within the genus Streptosporangium have been studied. These factors include a comparison among several inoculum media and sources, the influence of aeration and volume of medium in the growth of the cultures, and the effect of the inoculum size on the course of the production of two antibacterial substances. The results suggest that a slight variation in the status of the seed culture (age, biomass concentration, etc.) affect the course of the batch culture during its initial exponential phase (3-5 days), whereas, at longer times, the behavior of the culture does not depend greatly on the characteristics of the inoculum. The results obtained have allowed to define a set of conditions producing the maximum increase of biomass in the minimum time.

[Ethnography of acute respiratory infections in a rural zone of Mexican highlands]

OBJECTIVE

To identify the terms used by mothers to refer to diseases, signs and symptoms related to acute respiratory illnesses (ARI), alarming signs which should motivate them to seek medical attention, and to describe common home practices of disease care and treatment.

MATERIAL AND METHODS

An ethnographic study was performed in six rural communities of the Mexican central highlands. Interviews were collected from 12 key informers, six mothers of children who had died from ARI and 24 mothers of children younger than five years of age, with several ethnographic techniques to complement information ("triangulation").

RESULTS

The most commonly identified diseases were cold, sore throat, cough, bronchitis, pneumonia and "bronchopneumonia". Key signs to establish diagnosis included nasal discharge, sore throat, cough, head and body ache, fever. "bubbling" chest, general malaise and shortness of breath. Tachypnea was referred to as "strong breathing", "much breathing", "rapid breathing" or "sizzle"; intercostal depression as "the chest sinks", stridor as "chest moan or chest snore", sibilance as "chest snore" and cyanosis as "he turns purple". Home treatments include herbal teas, lemon, green or red tomato or potato applied to the throat externally, as well as creams applied to chest or back. Antibiotic prescription was not common, contrary to antipyretics. Most mothers recognized mild illnesses: severe illnesses were recognized less frequently. When faced with a severe ARI, mothers sought attention firstly at the project clinic, second in frequency with a private physician in the capital of the province and then at the Health Ministry of the district. The reasons to choose these possibilities were mainly proximity and lower costs.

CONCLUSIONS

This information can be useful to improve communication with mothers.

Dental implants in the oral rehabilitation of a teenager with hypohidrotic ectodermal dysplasia: report of a case

This report presents the case of a teenager affected by hypohidrotic ectodermal dysplasia and rehabilitated with a fixed maxillary partial prosthesis and mandibular overdenture supported by osseointegrated implants. Treatment had a major impact on patient's self-esteem, function, and esthetics.

[Superstitions around teeth]

Popular beliefs in magical medicines or manneuvers to cure dental pains, have been at every time subject of curiosity and even of credulity for common people. Writers and story-tellers describe medicines and habits used to relief or get rid of toothache, in interesting and humorous tales.

Impact of oral rehydration and selected public health interventions on reduction of mortality from childhood diarrhoeal diseases in Mexico

Reported are the results of an analysis of mortality trends from diarrhoeal diseases among under-5-year-olds in Mexico between 1978 and 1993 in relation to the impact of education, basic sanitation, and selected medical care practices. The study period was divided into three stages; the first pre-dated the widespread application of oral rehydration therapy (ORT); the second, covered the implementation of a nationwide programme promoting ORT; and the third included additional measures, such as immunization and improvements in basic sanitation. Mortality rates decreased progressively, at an average of 1.8% per year in the first stage, 6.4% in the second, and 17.8% in the third. The importance of literacy campaigns for women and the promotion of ORT was confirmed. Both of these measures reduced mortality; however, a greater reduction resulted from a massive immunization campaign against measles and improvements in sanitation (expansion of the drainage and piped water systems, improved water chlorination procedure, and effective prohibition of the use of sanitary sewage for vegetable irrigation).

[Fictions and stories]

A short and interesting work, where the author of "The secret tooth", exposes some opinions about fiction and story, words he considers should not be opposed, but really on the contrary, be harmonized to contribute with their alliance for personal joy of readers. Writers like Joyce, Caillois, Updike, and others, are quoted for renewing texts with reports referred to Dentistry.

[Anemia in women of reproductive age. The results of a national probability survey]

Iron deficiency is one of the most prevalent forms of malnutrition which is clinically known as anemia. Functional consequences of anemia include impairment of cardiovascular performance, limitation in productivity, higher incidence of low birth weight and premature delivery, and increased maternal mortality. This paper presents a descriptive analysis of anemia in women of reproductive age in Mexico. Data were collected by the Ministry of Health through a National Nutrition Survey in 1988, which draw a representative sample from four regions: North, Center, South and Federal District. Anemia was more prevalent in pregnant (18.17%) than in non-pregnant women (15.38%). Those women living in predominantly indigenous communities had higher prevalence of anemia (24.02%) than non-indigenous women (14.67%). Anemia was more prevalent in urban areas (15.54%) than in rural (13.56%). Mean +/- standard deviation values for hemoglobin were lower in pregnant women (12.5 +/- 1.6 g/dL) than in non-pregnant ones (13.7 +/- 1.6 g/dL). Consistently, the Northern and Southern regions were worse off than the Center and the Federal District. These data indicate that anemia is a public health problem in Mexico. The functional consequences of this deficiency justify interventions to treat and prevent it.

Changing physician prescribing patterns: evaluation of an educational strategy for acute diarrhea in Mexico City

This paper presents the results of an intervention strategy designed to decrease drug prescription and increase the use of oral rehydration therapy (ORT) in the treatment of acute diarrhea aimed at family medicine practitioners in two primary health care units of the Mexican Social Security Institute. The intervention consisted of six successive stages: 1) Baseline study of prescribing practices by all 69 physicians in both clinics; 2) Training workshop attended by 36 physicians, including a critical analysis of relevant up-to-date literature, review of results of stage I, discussion of a previously designed treatment algorithm for acute diarrhea, and modification of it according to participant's experience; 3) Post-workshop evaluation; 4) Establishment of a peer review committee to discuss the treatment behavior of participating physicians; 5) Mid-term evaluation for 2 months after the committee stopped functioning; 6) Long-term evaluation at 6, 12 and 18 months, of 20 physicians who received the complete intervention (study group) and 20 physicians who received none (control group). The treatment behaviors of the study and control groups were similar on baseline, but differed significantly (P < 0.01) in the post-workshop evaluation. The study group showed a reduction in the use of antibiotics (from 78.8% to 39.3%) and restrictive diets (47.3% to 12.4%), and increased the use of ORT (31.4% to 58.4%) for children younger than 5 years old with acute diarrhea. In the mid-term evaluation, the use of antibiotics by the study group decreased to 27.6%, prescription of restrictive diets decreased to 6.4%, and use of ORT increased to 73.8% (P < 0.01, in all cases). In the long-term evaluation, persistent positive prescribing behavior was still present in the study group, with a significant difference (P < 0.05) compared to the control group, where no modification was found in the prescribing behavior throughout the study. The average proportion of cases treated according to the algorithm by the study group increased in 29.2% (31.3 to 60.5%) after the workshop, and 45.2% (31.3 to 76.5%) after peer review committee. This behavior was maintained during 18 months after the intervention (74%). The control group showed no significant modification in the average proportion of cases treated according to the algorithm during the study (2 years 7 months). The active participation of physicians in the workshop and in the peer review committee was identified as the key to the short and long-term success of the educational strategy.