Factors associated with mechanical ventilation longer than 24 h after liver transplantation in patients at risk for bleeding

BACKGROUND

This risk analysis aimed to explore all modifiable factors associated with prolonged mechanical ventilation (lasting > 24 h) after liver transplantation, based on prospectively collected data from a clinical trial.

METHODS

We evaluated 306 candidates. Ninety-three patients were excluded for low risk for transfusion (preoperative haemoglobin > 130 g.l-1), and 31 patients were excluded for anticoagulation therapy, bleeding disorders, familial polyneuropathy, or emergency status. Risk factors were initially identified with a log-binomial regression model. Relative risk was then calculated and adjusted for age, sex, and disease severity (Model for End-Stage Liver Disease [MELD] score).

RESULTS

Early tracheal extubation was performed in 149 patients (84.7%), and 27 patients (15.3%) required prolonged mechanical ventilation. Reoperations were required for 6.04% of the early extubated patients and 44% of patients who underwent prolonged ventilation (p = 0.001). A MELD score > 23 was the main risk factor for prolonged ventilation. Once modifiable risk factors were adjusted for MELD score, sex, and age, three factors were significantly associated with prolonged ventilation: tranexamic acid (p = 0.007) and red blood cell (p = 0.001) infusion and the occurrence of postreperfusion syndrome (p = 0.004). The median (IQR) ICU stay was 3 (2-4) days in the early extubation group vs. 5 (3-10) days in the prolonged ventilation group (p = 0.001). The median hospital stay was also significantly shorter after early extubation, at 14 (10-24) days, vs. 25 (14-55) days in the prolonged ventilation group (p = 0.001). Eight patients in the early-extubation group (5.52%) were readmitted to the ICU, nearly all for reoperations, with no between-group differences in ICU readmissions (prolonged ventilation group, 3.7%).

CONCLUSION

We conclude that bleeding and postreperfusion syndrome are the main modifiable factors associated with prolonged mechanical ventilation and length of ICU stay, suggesting that trials should explore vasopressor support strategies and other interventions prior to graft reperfusion that might prevent potential fibrinolysis.

TRIAL REGISTRATION

European Clinical Trials Database (EudraCT 2018-002510-13,) and on ClinicalTrials.gov (NCT01539057).

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Blood component requirements in liver transplantation: effect of 2 thromboelastometry-guided strategies for bolus fibrinogen infusion-the TROMBOFIB randomized trial

BACKGROUND

A low plasma fibrinogen level influences blood component transfusion. Thromboelastometry provides clinical guidance for fibrinogen replacement in liver transplantation (LT).

OBJECTIVES

We hypothesized that infusions of fibrinogen concentrate to reach an A10_FibTem value of 11 mm during LT could reduce red blood cell (RBC) and other component and fluid requirements in comparison to standard care.

METHODS

This randomized, blinded, multicenter trial in 3 hospitals enrolled 189 LT-scheduled patients allocated to an intervention target (A10_FibTem, 11 mm) or a standard target (A10_FibTem, 8 mm); 176 patients underwent LT with fibrinogen replacement. Data were analyzed by intention-to-treat (intervention group, 91; control group, 85). Blood was extracted, and fibrinogen kits were prepared to bring each patient's fibrinogen level to the assigned target at the start of LT, after portal vein clamping, and after graft reperfusion. The main outcome was the proportion of patients requiring RBC transfusion during LT or within 24 hours.

RESULTS

The proportion of patients requiring RBCs did not differ between the groups: intervention, 74.7% (95% CI, 65.5%-83.3%); control, 72.9% (95% CI, 62.2%-82.0%); absolute difference, 1.8% (95% CI, -11.1% to 14.78%) (P = .922). Thrombotic events occurred in 4% of the patients in both groups; reoperation and retransplantation rates and mortality did not differ. Nearly 70% of the patients in both groups required fibrinogen concentrate to reach the target. Using an 11-mm A10_FibTem target increased the maximum clot firmness without affecting safety. However, this change provided no clinical benefits.

CONCLUSION

The similar low plasma fibrinogen concentrations could explain the lack of significant between-group outcomes.

P-616 Systematic review and meta-analysis of efficacy and safety of r-FSH biosimilars EMA-approved compared to reference r-FSH (follitropin alfa)

Study question

Are recombinant FSH biosimilars approved by the European Medicines Agency (EMA) comparable in efficacy and safety to the originator follitropin alfa?

Summary answer

Pooled analysis from studies comparing EMA-approved biosimilars with the reference product did not detect differences in efficacy or safety between these two gonadotropins.

What is known already

A biosimilar is, according to EMA, a biological medicine highly similar to another already approved (‘reference’), and are approved according to the same standards of quality, safety and efficacy. Their development and approval opens a window of opportunity to make IVF treatments more affordable for the general population. Two previous meta-analysis of phase III non-inferiority randomized controlled trials (RCT) including non EMA-approved rFSH biosimilars (Chua et al., 2021 and Budani et a., 2021) have suggested that pregnancy and live births are lower with biosimilars compared to follitropin alfa.

Study design, size, duration

Systematic review with meta-analysis following PRISMA guidelines.

Participants/materials, setting, methods

Databases searched from inception to november 2021 were: PubMed-MEDLINE, WOS, The Cochrane Library, ClinicalTrials.gov, EudraCT and Google Scholar using these keywords: ‘biosimilars’, ‘follitropin alfa’, `originator’ and ‘ovarian stimulation’. RCTs and non-randomized comparative studies were included. Risk of bias was assessed with ROB-2 tool and Newcastle-Ottawa Scale studies. Pooled Odds Ratios (OR) and mean differences (MD) when applicable, with a 95% confidence interval (CI), were calculated. PROSPERO protocol registration has been requested.

Main results and the role of chance

After the systematic search,five studies were included in the meta-analysis: two phase-III RCT (Strawitzki, 2016 and Rettenbacher, 2015) and three non-randomized comparative studies, one of them prospective (Kaplan 2021) and the other two retrospective (Sprem Goldstajn, 2021 and Van den Haute, 2021) involving 2173 IVF cycles. Risk of bias was low for the two RCT and moderate for the observational studies. The OR of clinical pregnancy was 0.89 (95% CI = 0.74,1.07; I2=0%) and the OR of live birth was 0.86 (95% CI = 0.71,1.04; I2=0%). No differences were observed in the cumulative birth rate either (OR = 0.86; 95% CI = 0.68, 1.09; I2 0%). The total number of oocytes retrieved was similar (MD = 0.25; 95%CI,-0.93, 1.43; I2 79%); as it was the total dose of gonadotropins employed (MD=-19.56; 95% CI, -57.88, 18.76; I2 0%) and the length of the stimulation (MD = 0.12; 95% CI,-0.23, 0.47; I2 80%). The risk of Ovarian Hyperstimulation Syndrome was similar in both cases (OR = 1.36; 95% CI, 0.63, 2.91; I2 21%).

Limitations, reasons for caution

Main limitations of this meta-analysis include the fact that three of the five included studies are not randomized studies and two of them are retrospective, which can bias the results.

Wider implications of the findings

This is the first meta-analysis including only results from studies with biosimilars EMA-approved. The results show that there are no differences between the biosimilars and the reference in terms of efficacy or safety. Larger RCTs including patients with different patterns of ovarian response are needed to confirm these findings.

Trial registration number

Not applicable

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality

BACKGROUND

Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).

METHODS

591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.

RESULTS

447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.

CONCLUSIONS

cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

Autoantibody screening in Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute inflammatory neuropathy with a heterogeneous presentation. Although some evidences support the role of autoantibodies in its pathogenesis, the target antigens remain unknown in a substantial proportion of GBS patients. The objective of this study is to screen for autoantibodies targeting peripheral nerve components in Guillain-Barré syndrome.

METHODS

Autoantibody screening was performed in serum samples from all GBS patients included in the International GBS Outcome study by 11 different Spanish centres. The screening included testing for anti-ganglioside antibodies, anti-nodo/paranodal antibodies, immunocytochemistry on neuroblastoma-derived human motor neurons and murine dorsal root ganglia (DRG) neurons, and immunohistochemistry on monkey peripheral nerve sections. We analysed the staining patterns of patients and controls. The prognostic value of anti-ganglioside antibodies was also analysed.

RESULTS

None of the GBS patients (n = 100) reacted against the nodo/paranodal proteins tested, and 61 (61%) were positive for, at least, one anti-ganglioside antibody. GBS sera reacted strongly against DRG neurons more frequently than controls both with IgG (6% vs 0%; p = 0.03) and IgM (11% vs 2.2%; p = 0.02) immunodetection. No differences were observed in the proportion of patients reacting against neuroblastoma-derived human motor neurons. Reactivity against monkey nerve tissue was frequently detected both in patients and controls, but specific patterns were only detected in GBS patients: IgG from 13 (13%) patients reacted strongly against Schwann cells. Finally, we confirmed that IgG anti-GM1 antibodies are associated with poorer outcomes independently of other known prognostic factors.

CONCLUSION

Our study confirms that (1) GBS patients display a heterogeneous repertoire of autoantibodies targeting nerve cells and structures; (2) gangliosides are the most frequent antigens in GBS patients and have a prognostic value; (3) further antigen-discovery experiments may elucidate other potential antigens in GBS.

Baseline haemoglobin and thromboelastometry are predictive of red blood cell requirements and one-year mortality in liver transplantation

BACKGROUND

To determine the predictive capacity of baseline haemoglobin and maxim clot firmness (MCF) EXTEM thromboelastometry for intraoperative red blood cell (RBC) requirements and its influence on mortality.

METHODS

591 adult liver transplant (LT) recipients from ten Spanish centres were reviewed. The main outcomes were the percentage of patients who received RBC and massive transfusion (≥ 6 RBC units), RBC units transfused, and mortality.

RESULTS

76 % received a donor after brain death graft and 24 % a controlled donor after circulatory death graft. Median (interquartile ranges) RBC transfusion was 2 (0-4) units, and 63 % of patients were transfused. Comparing transfused and non-transfused patients, mean (standard deviation) for baseline haemoglobin was 10.4 (2.1) vs. 13.0 (1.9) g/dl (p = 0.001), EXTEM MCF was 51(11) vs. 55(9) mm (p = 0.001). Haemoglobin and EXTEM MCF were inversely associated with the need of transfusion odds ratio (OR) of 0.558 (95 % CI 0.497-0.627, p < 0.001) and OR 0.966 (95 % CI0.945-0.987, p = 0.002), respectively. Pre-operative baseline haemoglobin ≤ 10 g/dL predicted RBC transfusion, sensitivity of 93 % and specificity of 47 %. Massive transfusion (MT) was received by 19 % of patients. Haemoglobin ≤10 g/dL predicted MT with sensitivity 73 % and specificity of 52 %. One-year patient and graft survival were significantly lower in patients who required MT (78 % and 76 %, respectively) vs. those who did not (94 % and 93 %, respectively).

DISCUSSION

whereas EXTEM MCF is less dreterminant predicting RBC requirements, efforts are required to improve preoperative haemoglobin up to 10 g/dl in patients awaiting LT.

P–682 Serum progesterone level as prognostic factor in frozen-thawed embryo transfer cycles: effect of selected threshold on gestational results. Systematic review, stratified meta-analysis and meta-regression

Study question

Is there an optimum progesterone threshold level below which gestational results are significantly worse in frozen embryo transfer cycles (FET) with hormone replacement therapy (HRT)?

Summary answer

Low serum progesterone during luteal phase of HRT-FET cycles impairs substantially its gestational outcomes, regardless of threshold level, origin of oocytes and euploidy of embryos.

What is known already

HRT for endometrial preparation in FET or oocyte donation cycles is widely used. Oestrogen doses are usually patient-tailored varying upon endometrial thickness, whereas the optimal level of progesterone exposure has not been defined. Various studies have found a negative association between serum progesterone levels measured during luteal phase and FET results in terms of pregnancy and miscarriage rates. Most likely there is an optimal level below which results are worse but a standard threshold level is yet to be established, as in almost every study a different threshold has been found.

Study design, size, duration

Systematic review and stratified meta-analysis with meta-regression following PRISMA guidelines. An electronic search of MEDLINE, EMBASE, Web of Science, Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials and ClinicalTrials.gov was conducted from inception to January 2021. The aim was to identify prospective or retrospective cohort studies measuring serum progesterone levels around frozen embryo transfer date in HRT cycles. A combination of the following key search terms was used: “progesterone”, “serum”, “frozen embryo”, “transfer”, “frozen-thawed”.

Participants/materials, setting, methods

Studies analyzing association of luteal serum progesterone with FET-HRT outcomes were included. Risk of bias within studies was assessed using the Newcastle-Ottawa Scale (NOS). Clinical/ongoing pregnancy and miscarriage rates (C/OPR,MR) were considered as primary and secondary outcomes respectively. Odds Ratios with 95% Confidence Interval (OR,95%CI) were calculated applying a random effects model meta-analysis. Heterogeneity was assessed using the I2 statistic. A meta-regression was conducted to examine the association of the effect with the threshold level.

Main results and the role of chance

The systematic search retrieved 792 studies, 494 after duplicates removal of which 343 were screened and 51 assessed for eligibility. 12 studies, reporting 14 threshold levels, were included in the meta-analysis involving 5009 HRT-FET cycles. Two of them were prospective cohort studies while the rest were retrospective. 10 of them have been published in peer review journals and two were conference abstracts. Quality of studies assessed with NOS varied between 5 and 9. The progesterone threshold ranged from 5.0 to 21.94 ng/ml. Low progesterone levels were associated with less C/OPR (OR: 0.52; 95% CI: 0.40 to 0.66; 11 studies, 5009 cycles). Low progesterone was also associated with high MR (OR: 2.01; 95% CI: 1.57 to 2.58; 9 studies, 2560 pregnancies). These effects showed remarkable consistency in specific sub-analyses considering separately studies with progesterone thresholds up to or above 10 mg/mL, and studies carried out in cycles using oocyte donation, autologous oocytes and embryo aneuploidies screening. Meta-regression did not identify significant association between size effect and progesterone threshold, regarding neither C/OPR (regression coefficient: 0.02; CI 95%: –0.02 to 0.06; p: 0.28) nor MR (regression coefficient: 0.11; CI 95%: –0.13 to 0.36; p: 0.32).

Limitations, reasons for caution

High degree of clinical and statistical heterogeneity was found due to different routes and doses of progesterone administration, date of progesterone analyses and variety of thresholds as well as high diversity of embryo origin. Despite sensibility analysis by embryo origin any of these sources of heterogeneity can preclude the results.

Wider implications of the findings: Despite low progesterone levels are significantly associated to lower gestational results, and a threshold of 10 ng/ml constitutes the median value of our distribution, high quality prospective studies are needed to validate the prognostic value of progesterone levels and to establish an standardised threshold level for clinical application.

Trial registration number

not required

Impact of switching to raltegravir and/or adding losartan in lymphoid tissue fibrosis and inflammation in people living with HIV. A randomized clinical trial

BACKGROUND

Persistent inflammation and immune activation are associated with lymph node fibrosis and end-organ diseases in treatment-suppressed people living with HIV (PLWH). We investigated the effect of switching to raltegravir and/or adding losartan on lymphoid tissue fibrosis and on the inflammatory/immune-activation mediators in treated HIV patients.

METHODS

Chronic HIV-infected patients treated with two nucleoside reverse transcriptase inhibitors (2NRTI) and one non-NRTI (NNRTI) or protease inhibitor (PI) during at least 48 weeks were randomized to four groups (n = 48): 2NRTI + efavirenz (EFV), 2NRTI + EFV + losartan, 2NRTI + raltegravir and 2NRTI + raltegravir + losartan for 48 weeks. Tonsillar biopsy and peripheral blood markers of CD4 and CD8 T-lymphocyte activation and senescence, monocyte activation and soluble markers of inflammation were determined at baseline and at week 48 and compared between groups.

RESULTS

No changes in lymphoid tissue architecture were observed. Adding losartan had no impact on lymphocyte subsets. Conversely, patients who switched to raltegravir showed a higher decrease in all activated [CD4+CD38+HLA-DR+, -0.3 vs. 0.48 (P = 0.033); CD8+CD38+ HLA-DR+, -1.6 vs. 1.3 (P = 0.02)] and senescent [CD4+CD28-CD57+, -0.3 vs. 0.26 (P = 0.04); CD8+CD28-CD57+, -6.1 vs. 3.8 (P = 0.002)] T lymphocytes. In addition, the median CD4/CD8 ratio increased by 0.35 in patients in the raltegravir group vs. 0.03 in the other arms (P = 0.002). Differences between groups in monocyte subpopulations or soluble inflammation markers were not observed.

CONCLUSIONS

Losartan had no effect on lymphoid fibrosis or immune activation/inflammation. Conversely, switching to a regimen with raltegravir significantly decreased activated and senescent T-lymphocyte subpopulations and increased CD4/CD8 ratio in successfully treated PLWH.

Gender-related beliefs and attitudes about tobacco use and smoking cessation in Mexico

BACKGROUND

While overall trends in tobacco use among men are declining, tobacco use continues to rise significantly among women in developing countries. This study aimed to explore the gender-related beliefs and attitudes about tobacco use and smoking cessation in Mexico, one of the top five Latin America countries with the highest prevalence of tobacco consumption.

MATERIALS AND METHODS

This study was conducted using an explanatory qualitative methods design. Semi-structured interviews were conducted with 14 adults smokers (8 women & 6 men) who visited primary healthcare clinics in Mexico City. Two researchers independently coded the interviews and applied the final codes upon consensus. Inter-rater reliability was assessed for four groups of codewords (92% agreement), based on an ecological model on socio-cultural factors.

FINDINGS

Initiation to smoking in women begins out of curiosity, and in men by imitation. Also, women start using tobacco at an older age compared to men. During maintenance of smoking, women report experiencing loneliness and anxiety about multiple responsibilities, e.g. women reveal that they feel guilty when they smoke due to their maternal role as caregivers. Additionally, some women report that smoking is a symbol of freedom, recalling the media messages associated with promoting tobacco products. Among men, the results show that they smoke for pleasure and to socialize, and consider that women smoke to imitate men and feel powerful. Regarding cessation, women are ambivalent about quitting smoking or not, and men mention not needing professional support. For organizational barriers, women mention the cost of treatment and men, the distance to clinics.

CONCLUSION

Smoking cessation interventions should be proposed from an approach that involves changes in social norms, seeking a more equitable relationship between men and women. Therefore, there must be broad engagement from different sectors and not just at the health sector level.

"El nen s'ha menjat una aranya": The development of narratives in Catalan speaking children

The production of a well-constructed narrative is the culmination of several years of language acquisition and is an important milestone in children's development. There is no current description of narrative development for Catalan speaking children. This study collected elicited narratives in Catalan from 118 children aged 4;0-10;11. Narratives were scored for macrostructure and microstructure. Narrative scores improved with age with maximum performance for macrostructure by 9 years. Children's ability to use micro-structural components of Catalan is variable with some developments continuing beyond 9 years. The results are discussed in relation to theoretical arguments about universal and specific features of narrative development. We conclude by highlighting the usefulness of the new test for future language assessment of children acquiring Catalan.

Estudio morfométrico de pezuñas en genotipos bovinos criados en los humedales del Ñeembucú Paraguay

Se evaluó la morfometría de pezuñas en bovinos criados en los humedales del Ñeembucú y áreas de influencia. Participaron 80 hembras adultas agrupadas por genotipos en Criollo Ñeembucú; Criollo Pilcomayo; Nelore; Brahman y Brangus, analizándose Longitud muralla (LM); Altura pezuña (AP); Longitud talón (LT); Longitud pezuña (LP); Diagonal pezuña (DP); Grosor pezuña (GP). El análisis con el software R incluyó varianza paramétrica y no paramétrica, y en las pezuñas anterior medial y posterior lateral, Análisis de Componentes Principales, Discriminante Canónico y Clúster por el método de Ward. El Criollo Ñeembucú mostró mayores LM y AP, el Nelore las menores; la LT, reveló estabilidad longitudinal en nativos, no así en el Nelore. La LP fue mayor en Criollos, Nelore y Brangus. La DP mostró adecuado reparto de las cargas. El GP, mayor en el Nelore y Brangus, fue menor en el Brahman, con talones bajos y menores DP y LP. El ACP explicó más del 70% de la variación. El CP1 se asoció positivamente a DP, LP, LM, LT y AP; el CP2 fue vinculado a GP. El ADC explicó mejor la variabilidad entre genotipos, con valores elevados de GP en el Nelore y bajos en el Brahman. El método de Ward conformó grupos con la mayoría de los genotipos, revelando poca diferencia entre individuos; no obstante, algunos clústeres concentraron en grupos diferentes a la mayoría de los animales Nelore y Brahman.

Ultraviolet radiation in the Atacama Desert

The world's highest levels of surface ultraviolet (UV) irradiance have been measured in the Atacama Desert. This area is characterized by its high altitude, prevalent cloudless conditions, and a relatively low total ozone column. In this paper, we provide estimates of the surface UV (monthly UV index at noon and annual doses of UV-B and UV-A) for all sky conditions in the Atacama Desert. We found that the UV index at noon during the austral summer is expected to be greater than 11 in the whole desert. The annual UV-B (UV-A) doses were found to range from about 3.5 kWh/m² (130 kWh/m²) in coastal areas to 5 kWh/m² (160 kWh/m²) on the Andean plateau. Our results confirm significant interhemispherical differences. Typical annual UV-B doses in the Atacama Desert are about 40% greater than typical annual UV-B doses in northern Africa. Mostly due to seasonal changes in the ozone, the differences between the Atacama Desert and northern Africa are expected to be about 60% in the case of peak UV-B levels (i.e. the UV-B irradiances at noon close to the summer solstice in each hemisphere). Interhemispherical differences in the UV-A are significantly lower since the effect of the ozone in this part of the spectrum is minor.

Decision-making Process by Users and Providers of Health Care Services During the AH1N1 Epidemic Influenza in Mexico: Lessons Learned and Challenges Ahead

OBJECTIVE

The aim of the study was to analyze, using a decision analysis approach, the probability of severity of illness due to delayed utilization of health services and inappropriate hospital medical treatment during the 2009 AH1N1 influenza epidemic in Mexico.

METHODS

Patients with influenza AH1N1 confirmed by the polymerase chain reaction (PCR) test from two hospitals in Mexico City, were included. Path methodology based upon literature and validated by clinical experts was followed. The probability for severe illness originated from delayed utilization of health services, delayed prescription of neuraminidase inhibitors (NAIs) and inappropriate use of antibiotics was assessed.

FINDINGS

Ninety-nine patients were analyzed, and 16% developed severe illness. Most patients received NAIs and 85.9% received antibiotics. Inappropriate use of antibiotics was observed in 70.7% of cases. Early utilization of services increased the likelihood of non-severe illness (cumulative probability CP = 0.56). The major cumulative probability for severe illness was observed when prescription of NAIs was delayed (CP = 0.19).

CONCLUSION

Delayed prescription of NAIs and irrational use of antibiotics are critical decisions for unfavorable outcomes in patients suffering influenza AH1N1.

Fumar entre adolescentes: análisis cuantitativo y cualitativo de factores psicosociales asociados con la decisión de fumar en escolares mexicanos

Objetivo. Analizar factores psicosociales asociados con la decisión de fumar en estudiantes de entre 13 y 15 años de edad en la Ciudad de México. Material y métodos. Se utilizaron modelos de regresión logística de la Encuesta de Tabaquismo en Jóvenes (n=945) y cuatro grupos focales (GF) en dos escuelas secundarias, realizada en 2011 y 2012. Resultados. Factores asociados a fumar: a) creer que es seguro (RM=2.4, IC95% 1.28-4.7), GF: capacidad de control sobre consumo y daños a largo plazo; b) tener al menos un padre fumador (RM=1.6, IC95% 1.1-2.3), GF: influyen para iniciar/mantener consumo; c) tener amigos fumadores (RM=5.0, IC95% 1.9-13.6), GF: influyen para experimentación/ repetición, escuelas sin normas sobre prohibición y tener acceso a cigarros (RM=2.1, IC95% 0.9-4.1). Factores pro­tectores: a) creer que es dañino (RM=0.3, IC95% 0.14-0.65), GF: rechazo a convivencia con fumadores; b) comunicación con familia (RM=0.5, IC95% 0.36-0.91), GF: apelar al auto-cuidado; c) Considerarse joven para fumar (RM=0.2, IC95% 0.12-0.43), GF: conocimientos sobre daños y percepción de riesgo. Conclusión. Se deben fortalecer destrezas psicosociales positivas y el cumplimiento de legislación de protección a jóvenes.

The Solar Spectrum in the Atacama Desert

The Atacama Desert has been pointed out as one of the places on earth where the highest surface irradiance may occur. This area is characterized by its high altitude, prevalent cloudless conditions and relatively low columns of ozone and water vapor. Aimed at the characterization of the solar spectrum in the Atacama Desert, we carried out in February-March 2015 ground-based measurements of the spectral irradiance (from the ultraviolet to the near infrared) at seven locations that ranged from the city of Antofagasta (on the southern pacific coastline) to the Chajnantor Plateau (5,100 m altitude). Our spectral measurements allowed us to retrieve the total ozone column, the precipitable water, and the aerosol properties at each location. We found that changes in these parameters, as well as the shorter optical path length at high-altitude locations, lead to significant increases in the surface irradiance with the altitude. Our measurements show that, in the range 0–5100 m altitude, surface irradiance increases with the altitude by about 27% in the infrared range, 6% in the visible range, and 20% in the ultraviolet range. Spectral measurements carried out at the Izaña Observatory (Tenerife, Spain), in Hannover (Germany) and in Santiago (Chile), were used for further comparisons.

Impact of anaemia on health-related quality of life and cardiac remodelling in patients with lower risk myelodysplastic syndromes. Results of GlobQoL study

The aim of this study was to analyse the eventual changes in health-related quality of life (HRQoL) and left ventricular function (LVF) over a 1-year follow-up period in a cohort of patients with lower risk myelodysplastic syndromes (MDS) receiving standard supportive treatment, in order to identify potential clues for early clinical intervention, as well as to analyse how they relate to haemoglobin levels and other aspects of the disease. A total of 39 adult anaemic patients with lower risk MDS were included in a prospective, observational, multi-centre study. Changes in performance status, functional capacity and HRQoL were collected by using standardised measures (ECOG scale; SPPB, Short Physical Performance Battery; SF-36, Short-Form 36 questionnaire; QLQ-C30, Quality of Life Core Questionnaire; FACT-An, Functional Assessment of Cancer Therapy-Anaemia scale questionnaires respectively). Need for transfusion (Linear Analogue Scale Assessment), as perceived independently by the patient and the haematologist, was also recorded. No changes in HRQoL (or LVF) were found, except for slight reductions in SF-36 physical function (P = 0.034), SPPB gait speed (P = 0.038) and FACT-An score (P = 0.029), all without apparent immediate clinical relevance for HRQoL, that were unrelated to changes in haemoglobin level. Periodical evaluation of gait speed may assist the clinician in early detection of patient's occult functional decline before it becomes clinically relevant.

Allelic variation at the rpv1 locus controls partial resistance to Plum pox virus infection in Arabidopsis thaliana

BACKGROUND

Sharka is caused by Plum pox virus (PPV) in stone fruit trees. In orchards, the virus is transmitted by aphids and by grafting. In Arabidopsis, PPV is transferred by mechanical inoculation, by biolistics and by agroinoculation with infectious cDNA clones. Partial resistance to PPV has been observed in the Cvi-1 and Col-0 Arabidopsis accessions and is characterized by a tendency to escape systemic infection. Indeed, only one third of the plants are infected following inoculation, in comparison with the susceptible Ler accession.

RESULTS

Genetic analysis showed this partial resistance to be monogenic or digenic depending on the allelic configuration and recessive. It is detected when inoculating mechanically but is overcome when using biolistic or agroinoculation. A genome-wide association analysis was performed using multiparental lines and 147 Arabidopsis accessions. It identified a major genomic region, rpv1. Fine mapping led to the positioning of rpv1 to a 200 kb interval on the long arm of chromosome 1. A candidate gene approach identified the chloroplast phosphoglycerate kinase (cPGK2) as a potential gene underlying the resistance. A virus-induced gene silencing strategy was used to knock-down cPGK2 expression, resulting in drastically reduced PPV accumulation.

CONCLUSION

These results indicate that rpv1 resistance to PPV carried by the Cvi-1 and Col-0 accessions is linked to allelic variations at the Arabidopsis cPGK2 locus, leading to incomplete, compatible interaction with the virus.

Salud mental de migrantes centroamericanos indocumentados en tránsito por la frontera sur de México

Objetivo. Conocer las necesidades percibidas de salud mental de migrantes centroamericanos indocumentados en tránsito por la ciudad de Tapachula, Chiapas. Material  y métodos. Estudio cualitativo realizado en Casa de Migrantes de Tapachula, Chiapas. Se realizaron 20 entrevistas semiestructuradas a diez mujeres y diez hombres migrantes. Se exploró el estado de salud mental y las expectativas de atención. Se retomaron nociones teórico-metodológicas de la fenomenología sociológica. Resultados. Los migrantes presentaban signos y síntomas de daños en su salud mental relacionados con experiencias vividas en el lugar de origen y en el tránsito por México. La percepción sobre su salud mental es influida por el modelo biomédico hegemónico. Las expectativas de servicios se relacionaron con la satisfacción de necesidades básicas. Conclusiones. Es necesario fortalecer la respuesta del sistema de atención en salud mental a partir de estrategias de cooperación y emprender acciones que promuevan la superación de una construcción biomédica de salud mental que estigmatiza, medicaliza, segrega y dificulta el acceso a servicios.

[Mental health of undocumented migrants in transit at the southern border of Mexico]

OBJECTIVE

To identify the perception and needs in mental health of Central American migrants in transit through Tapachula, Chiapas.

MATERIALS AND METHODS

Qualitative study in a migrant shelter in Tapachula, Chiapas. In 20 semi-structured interviews with migrant men and women, we explored their perceptions on mental health and expectations on care. We used basic notions of phenomenology to guide the analysis.

RESULTS

Migrants had several mental health problems related to the conditions at their country of origin and due to their initial transit through Mexico.Their perception on mental health problems was heavily influenced by the biomedical health paradigm. The expectations they had on the provision of services were related to the satisfaction of basic needs.

CONCLUSIONS

It is necessary to strengthen the governmental response to mental health needs through collaborative strategies. Also, actions are needed to further the understanding of mental health in order to transcend the biomedical notions that stigmatize, segregate and create a barrier to accessing services.

[Factors influencing Central America's civil society organization's capacity to provide AIDS related care]

OBJECTIVE

To analyze the capacities of Central American civil society organizations (CSOs) to implement HIV prevention and care strategies in mobile groups within the HIV Mesoamerican Project.

MATERIALS AND METHODS

During the year 2008, 14 key actors of nine Central American civil society organizations participating in the Mesoamerican Project were interviewed. The information collected was systematized using Atlas-TI software, and content analysis was performed according to its categories and dimensions.

RESULTS

These items were a contribution to capacity: the previous work of CSOs allowed the sensibilization of population and authorities to STD-HIV and to the implemented program; the coordination with government and other involved actors.

LIMITATIONS

a good but informal coordination with the government; the worsening economic situation reduced available resources; attended communities are isolated and unsecure.

CONCLUSION

To improve the capacities of CSOs in developing this type of project, it is recommended: that an initial community diagnosis be performed in order to better adapt the proposed interventions; to improve administrative efficiency; to formalize collaborative links with the government; and to seek counseling in the development of HIV prevention strategies that consider population mobility.

[Central American migrants' sexual experiences and rights in their transit to the USA]

OBJECTIVES

To explore the causes and circumstances that determine the way in which migrants experience their sexuality and how this impacts their sexual rights.

MATERIALS AND METHODS

Qualitative study conducted between April 2009 and July 2010 in Chiapas, Oaxaca, San Luis Potosí, and Tamaulipas. We conducted 22 in-depth interviews to migrants in transit and to ten different key actors. For the analysis we used elements of grounded theory.

RESULTS

Migrants know and identify the risks they may encounter in their transit but have scarce access to services to effectively exercise their sexual and reproductive rights. Their vulnerability makes them internalize and accept the violence enacted on them as part of their destiny and as what they must suffer in order to reach the USA.

CONCLUSIONS

Violence, including sexual violence, determines much of the experiences of their transit through Mexico. Differences between groups and between male and female migrants are determined by gender inequalities and power.

Contexto de las organizaciones civiles centroamericanas en la atención al sida en poblaciones móviles

Objetivo. Analizar los factores contextuales que influyen en la capacidad de las organizaciones de la sociedad civil (OSC) centroamericanas en acciones de prevención y atención al síndrome de inmunodeficiencia adquirida (sida) en poblaciones móviles (PM). Material y métodos. En 2008 se realizaron 14 entrevistas a directivos y operativos de nueve OSC centroamericanas que participaron en el Proyecto Mesoamericano. La información se sistematizó con el software Atlas-TI, y el tipo de análisis fue de contenido de acuerdo con categorías y dimensiones. Resultados. Contribuyeron a la capacidad: el trabajo previo de las OSC, que consiguió la sensibilización de población y autoridades acerca de las infecciones de transmisión sexual y del virus de inmunodeficiencia humana (ITS-VIH). Contribuyeron con el programa: la coordinación con el Gobierno y con otros actores. Como limitantes se encontraron que la relación con el Gobierno es buena pero informal, que el deterioro económico ha limitado recursos y que las comunidades atendidas son aisladas e inseguras. Conclusiones. Para mejorar la capacidad de las OSC se recomienda realizar un diagnóstico inicial de las comunidades; mayor eficiencia administrativa para mejorar el uso de sus recursos; ampliar las acciones de sensibilización hacia los gobiernos en la importancia de trabajar en la prevención del VIH en PM y formalizar los vínculos de colaboración con los mismos.

Sexualidad del migrante: experiencias y derechos sexuales de centroamericanos en tránsito a los Estados Unidos

Objetivos. Ahondar sobre las causas y circunstancias particulares en que ocurren las experiencias sexuales de los migrantes centroamericanos en su tránsito por México e identificar cómo afecta esto al ejercicio de sus derechos sexuales. Material y métodos. Estudio cualitativo (2009-2010). Se realizaron 22 entrevistas semiestructuradas a migrantes centroamericanos en tránsito por México y 10 a diversos actores clave. La sistematización, procesamiento y análisis de los datos se realizó a partir de algunos de los elementos de la teoría fundamentada. Resultados. Las experiencias sexuales de los migrantes en tránsito por México están vinculadas con aspectos de coerción, abuso, inequidad y violencia sexual. Los migrantes identifican riesgos a los que se enfrentan en el tránsito y tienen escaso acceso a servicios que les permitan hacer efectivos sus derechos, incluidos los sexuales. Su vulnerabilidad los hace asumir la violencia y las agresiones sexuales como parte ineludible del trayecto y de su destino como personas. Conclusiones. El tránsito de migrantes está relacionado con la violencia, incluida la sexual. Las diferencias entre migrantes y otros grupos, así como entre hombres y mujeres, son determinadas por las relaciones inequitativas de género y poder.

[Doctors and nurses' training for the early detection of the breast cancer in Mexico]

OBJECTIVE

Analyzing formal knowledge about breast cancer (BC) issues that medical and nursing students receive from different syllabuses and courses during their undergraduate studies.

MATERIALS AND METHODS

This exploratory study was conducted in 2009; it was based on semi-structured interviews applied to key stakeholders and complemented by an analysis of their undergraduate courses. The study population consisted of 199 Faculties and Schools of Medicine and 108 Schools and Colleges of Nursing and the unit of analysis consisted of the syllabuses for the undergraduate courses.

RESULTS

16.8% of the medical courses and 6.3% of the nursing courses had specific information about BC. Medical students predominantly received their training in biomedical and clinical areas and the socio-medical area to a lesser extent. The issues in nursing courses was mainly focused (in community areas) on promoting health and preventing disease (healthy lifestyles and recognition of women at high risk regarding BC).

DISCUSSION

Little evidence was found that medicine and nursing syllabuses contain issues related to BC. Medical and nursing curricula should be strengthened to improve professional skills and abilities related to BC to solve the affected population's problems and health needs, particularly regarding primary and secondary prevention.

[Exercising sexual and reproductive rights: a qualitative study of heterosexual people with HIV in Mexico]

OBJECTIVE

To analyze experiences of heterosexual Mexican people living with HIV (PLWHA) related to the exercise of their sexual and reproductive rights.

MATERIAL AND METHODS

Qualitative study based on 40 in-depth interviews with PLWHA in four Mexican States.

RESULTS

Lack of support and counseling limits the exercise of sexual and reproductive rights by PLWHA, especially women. Principal limitations include feelings of frustration and confusion, fear of re-infection, scanty information, lack of power to negotiate condom use, social stigma and discrimination, and limited access to services and adequate technologies.

CONCLUSION

To increase awareness and exercise of rights by PLWHA it is necessary to: improve sexual education; promote processes of cultural change to combat gender inequality and stigma and discrimination; and provide timely and scientific information about HIV prevention.

Activation of the EGFR/ERK pathway in high-grade mucoepidermoid carcinomas of the salivary glands

Background:

Mucoepidermoid carcinoma (MEC) shows differences in biological behaviour depending mainly on its histological grade. High-grade tumours usually have an aggressive biological course and they require additional oncological treatment after surgery.

Methods:

In a series of 43 MECs of the salivary glands, we studied the epidermal growth factor receptor (EGFR) gene by using dual-colour chromogenic in situ hybridisation (CISH). Moreover, we assessed the protein expressions of the EGFR and the activated extracellular signal-regulated kinases (pERK1/2) by using immunohistochemistry. These results were correlated with the histological grade of the tumours and the outcome of the patients.

Results:

The CISH study demonstrated a high-EGFR gene copy number, with balanced chromosome 7 polysomy, in 8 out of 11 high-grade MECs (72.7%), whereas 27 low-grade and 15 intermediate-grade tumours had a normal EGFR gene copy number (P<0.001). The EGFR gene gains correlated with disease-free interval (P=0.003) and overall survival of the patients (P=0.019). The EGFR protein expression had a significant correlation with the histological grade of the tumours but not with the outcome of the patients. The pERK1/2 expression correlated with histological grade of tumours (P<0.001), disease-free interval (P=0.004) and overall survival (P=0.001).

Conclusions:

The EGFR/ERK pathway is activated in high-grade MECs with aggressive behaviour. Patients with these tumours who require oncological treatment in addition to surgery could benefit from EGFR and mitogen-activated protein kinase pathway inhibitors.

Actual proportion of patients (pts) receiving chemotherapy or cetuximab for head and neck squamous carcinoma (HNSC)

e17058

Background: With the new indications of chemotherapy or cetuximab in HNSC, the rate of pts receiving these therapies nowadays is unclear. Methods: This retrospective study identified all consecutive pts with HNSC from January 1, 2006, to December 31, 2007, presented in a multidisciplinary team to decide further treatment in a single institution. ASCO guidelines for larynx preservation were followed to select surgery or chemoradiotherapy (ChRt). We classified the intention-to-treat as palliative, adjuvant or induction therapy. In the last case, always with concomitant radiotherapy (Rt) or prior to concomitant ChRt. Cetuximab was indicated with Rt as induction therapy for pts with problems to receive platin-based chemotherapy. Results: : A total of 350 pts were identified, 320 were male (91%), and 30 female (9%), with mean age 60.4 (range 41–90). Primary tumor was located in glottis (41%), supraglottis (19%), hypopharynx (11%), oropharynx (20%), or mouth (9%). Staging was I (27%), II (22%), III (16%), or IV (35%). Surgery alone was performed in 136 pts (39%) and chemotherapy or cetuximab in 214 other pts (61%). The intention-to-treat was palliative in 69 (32%), adjuvant in 51 (24%), or induction 94(44%) of the pts respectively. Rt plus cetuximab was administered to 31/97 (33%) and Rt plus chemotherapy in 63/97 (67%) pts as induction therapy. During this 2-year period, some pts received both induction/adjuvant and palliative chemotherapy. Conclusions: Chemotherapy or cetuximab is indicated as part of treatment in more than a half of pts with HNSC. Induction therapy is the most frequent indication.

No significant financial relationships to disclose.

[Access barriers in early diagnosis of breast cancer in the Federal District and Oaxaca]

OBJECTIVE

To identify social, cultural and health service barriers that prevent timely access to early detection of breast cancer in two regions: Mexico City Federal District and the state of Oaxaca.

MATERIAL AND METHODS

An exploratory cross-sectional qualitative study was carried out in 2008 among women under 25 years of age without pathology, with pathological diagnosis, their male partners and managers of several public and private institutions. Information was collected by focus groups and through interviews that were recorded and transcribed after having received informed consent.

RESULTS

Initial exploration allowed the identification of access barriers in three main areas: a) the availability of information for the general population, b) training of first-contact general practitioners and gynecologists, and c) fears among couples and families.

CONCLUSIONS

Barriers in the three levels identified are relevant as they reveal important deficiencies in the dissemination of information both to the general population and to health providers.