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Background: Malaria is highly heterogeneous: its changing malaria microepidemiology needs to be addressed to support malaria elimination efforts at the regional level., Methods: A 3-year, population-based cohort study in 2 settings in the Peruvian Amazon (Lupuna, Cahuide) followed participants by passive and active case detection from January 2013 to December 2015. Incidence and prevalence rates were estimated using microscopy and polymerase chain reaction (PCR)., Results: Lupuna registered 1828 infections (1708 Plasmodium vivax, 120 Plasmodium falciparum; incidence was 80.7 infections/100 person-years (95% confidence interval [CI] , 77.1-84.5). Cahuide detected 1046 infections (1024 P vivax, 20 P falciparum, 2 mixed); incidence was 40.2 infections/100 person-years (95% CI, 37.9-42.7). Recurrent P vivax infections predominated onwards from 2013. According to PCR data, submicroscopic predominated over microscopic infections, especially in periods of low transmission. The integration of parasitological, entomological, and environmental observations evidenced an intense and seasonal transmission resilient to standard control measures in Lupuna and a persistent residual transmission after severe outbreaks were intensively handled in Cahuide., Conclusions: In 2 exemplars of complex local malaria transmission, standard control strategies failed to eliminate submicroscopic and hypnozoite reservoirs, enabling persistent transmission., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Osteoarthritis (OA) is the most common joint disorder in the USA, and knee OA has the highest prevalence. Inflammation and decrease in vascularization are key factors in the degeneration of articular cartilage and the associated pain and decrease in function. To combat this process, the use of biologics including umbilical cord-derived Wharton's Jelly (UC-derived WJ) has grown. UC-derived WJ contains large quantities of regenerative factors, including growth factors (GFs), cytokines (CKs), hyaluronic acid (HA), and extracellular vesicles (EVs). The proposed study evaluates the safety and efficacy of intraarticular injection of UC-derived WJ for treatment of knee OA symptoms., Methods and Analysis: This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular UC-derived WJ in patients suffering from grade II/III OA will be assessed. Twelve patients with grade II/III OA who meet the inclusion and exclusion criteria will be recruited for this study which will be conducted at up to two sites within the USA. The participants will be followed for 1 s. Participants will be assessed using the Numeric Pain Rating Scale (NPRS), Knee Injury and Osteoarthritis Outcome Score (KOOS), 36-item short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, satisfaction, function, and cartilage regeneration., Discussion: This prospective study will contribute to the limited amount of data on UC-derived WJ, particularly with regard to its safety and efficacy. The outcomes from this study will also lay the groundwork for a large placebo-controlled trial of intraarticular UC-derived WJ for symptomatic knee OA., Trial Registration: ClinicalTrials.gov NCT04719793 . Registered on 22 January 2021.

The COVID-19 pandemic has placed an unprecedented burden on health care systems and economies around the globe. Clinical evidences demonstrate that SARS-CoV-2 infection produces detrimental levels of pro-inflammatory cytokines and chemokines that can lead to acute respiratory distress syndrome (ARDS) and significant systemic organ damage. Currently, there is no definitive therapy for COVID-19 or associated complications, and with the hope of a safe and effective vaccine in the distant future, the search for an answer is paramount. Mesenchymal stem cells (MSCs) provide a viable option due to their immunomodulatory effects and tissue repair and regeneration abilities. Studies have demonstrated that compassionate use of MSCs can reduce symptoms associated with SARS-CoV-2 infection, eliminate fluid buildup, and act as a regenerative technique for alveolar damage; all in a safe and effective way. With multiple autologous sources available for MSCs, each with their own respective limitations, allogenic umbilical cord (UC) and/or UC-derived Wharton's jelly (WJ) seem to be best positioned source to harvest MSCs to treat COVID-19 and associated symptoms. As an allogenic source, UC is readily available, easily obtainable, and is rich in immunomodulatory and regenerative factors. In this manuscript, we reviewed the current evidences and explored the potential therapeutic use of allogenic UC and/or WJ-derived MSCs for the treatment of COVID-19. Although, preliminary preclinical and clinical studies indicate that their use is safe and potentially effective, more multi-center, randomized, controlled trials are needed to adequately assess the safety and efficacy of UC and/or WJ-derived MSCs for the treatment of COVID-19.

Stem cells for regenerative medicine purposes offer therapeutic benefits, but disadvantages are still ill defined. The benefit of stem cells may be attributed to their secretion of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs), including exosomes. We present a novel cell-free stem cell-derived extract (CCM), formulated from human progenitor endothelial stem cells (hPESCs), characterized for biologically active factors using ELISA, nanoparticle tracking analysis and single particle interferometric reflectance imaging sensing. The effect on fibroblast proliferation and ability to induce stem cell migration was analyzed using Alamar Blue proliferation and Transwell migration assays, respectively. GFs including IGFBP 1, 2, 3, and 6, insulin, growth hormone, PDGF-AA, TGF-α, TGF-β1, VEGF, and the anti-inflammatory cytokine, IL-1RA were detected. Membrane enclosed particles within exosome size range and expressing exosome tetraspanins CD81 and CD9 were identified. CCM significantly increased cell proliferation and induced stem cell migration. Analysis of CCM revealed presence of GFs, CKs, and EVs, including exosomes. The presence of multiple factors including exosomes within one formulation, the ability to promote cell proliferation and induce stem cell migration may reduce inflammation and pain, and augment tissue repair.

Background: Musculoskeletal injuries and conditions affect millions of individuals. These ailments are typically managed by immobilization, physiotherapy, or activity modification. Regenerative medicine has experienced tremendous growth in the past decades, especially in musculoskeletal medicine. Umbilical cord-derived Wharton's jelly is an exciting new option for such therapies. Wharton's jelly is a connective tissue located within the umbilical cord largely composed of mesenchymal stem cells and extracellular matrix components, including collagen, chondroitin sulfate, hyaluronic acid, and sulfated proteoglycans. Wharton's jelly is a promising and applicable biologic source for orthopedic regenerative application., Methods: A systematic search will be conducted in PubMed, ScienceDirect, and Google Scholar databases of English, Italian, French, Spanish, and Portuguese language articles published to date. References will be screened and assessed for eligibility by two independent reviewers as per PRISMA guidelines. Articles will be considered without exclusion to sex, activity, or age. Studies will be included if they used culture-expanded, mesenchymal stem/stromal cells of mesenchymal stem cells and/or connective tissue obtained from Wharton's jelly. Studies will be excluded if Wharton's jelly is not the sole experimental examined cell type. Placebos, conventional non-operative therapies including steroid injections, exercise, and NSAIDs will be compared. The study selection process will be performed independently by two reviewers using a reference software. Data synthesis and meta-analysis will be performed separately for clinical and pre-clinical studies., Discussion: The results will be published in relevant peer-reviewed scientific journals. Investigators will present results at national or international conferences., Trial Registration: The protocol was registered on PROSPERO international prospective register of systematic reviews prior to commencement, CRD42020182487 .

Aims: In elderly patients with osteoarthritis and protrusio who require arthroplasty, dislocation of the hip is difficult due to migration of the femoral head. Traditionally, neck osteotomy is performed in situ, so this is not always achieved. Therefore, the purpose of this study is to describe a partial resection of the posterior wall in severe protrusio., Methods: This is a descriptive observational study, which describes the surgical technique of the partial resection of the posterior wall during hip arthroplasty in patients with severe acetabular protrusio operated on between January 2007 and February 2017., Results: In all, 49 hip arthroplasties were performed. The average age of patients was 60 years, and idiopathic was the most frequent aetiology of protrusio. All patients were treated with femoral head autograft and no intra- or postoperative complications were reported. No patients required revision surgery., Conclusion: Partial resection of the posterior wall demonstrated to be a safe surgical technique with 100% survival in a follow-up to ten years in total hip arthroplasty due to severe acetabular protrusio.Cite this article: Bone Joint Open 2020;1-7:431-437., Competing Interests: ICMJE COI statement: The authors have no financial or competing interests to disclose., (© 2020 Author(s) et al.)

The Peruvian Ministry of Health reports a near absence of malaria cases in the Amazon region during the COVID-19 pandemic. However, the rapid increase in SARS-CoV-2 infections has overwhelmed the Peruvian health system, leading to national panic and closure of public medical facilities, casting doubt on how accurately malaria cases' numbers reflect reality. In the Amazon region of Loreto, where malaria cases are concentrated, COVID-19 has led to near-complete closure of the primary healthcare system, and diagnosis and treatment of acute febrile illnesses, including malaria, has plummeted. Here, we describe the potential association of COVID-19 with a markedly reduced number of reported malaria cases due to the reduced control activities carried out by the Peruvian Malaria Zero Program, which could lead to malaria resurgence and an excess of morbidity and mortality.

Background: Artificial intelligence (AI) and machine learning (ML) are interwoven into our everyday lives and have grown enormously in some major fields in medicine including cardiology and radiology. While these specialties have quickly embraced AI and ML, orthopedic surgery has been slower to do so. Fortunately, there has been a recent surge in new research emphasizing the need for a systematic review. The primary objective of this systematic review will be to provide an update on the advances of AI and ML in the field of orthopedic surgery. The secondary objectives will be to evaluate the applications of AI and ML in providing a clinical diagnosis and predicting post-operative outcomes and complications in orthopedic surgery., Methods: A systematic search will be conducted in PubMed, ScienceDirect, and Google Scholar databases for articles written in English, Italian, French, Spanish, and Portuguese language articles published up to September 2020. References will be screened and assessed for eligibility by at least two independent reviewers as per PRISMA guidelines. Studies must apply to orthopedic interventions and acute and chronic orthopedic musculoskeletal injuries to be considered eligible. Studies will be excluded if they are animal studies and do not relate to orthopedic interventions or if no clinical data were produced. Gold standard processes and practices to obtain a clinical diagnosis and predict post-operative outcomes shall be compared with and without the use of ML algorithms. Any case reports and other primary studies assessing the prediction rate of post-operative outcomes or the ability to identify a diagnosis in orthopedic surgery will be included. Systematic reviews or literature reviews will be examined to identify further studies for inclusion, and the results of meta-analyses will not be included in the analysis., Discussion: Our findings will evaluate the advances of AI and ML in the field of orthopedic surgery. We expect to find a large quantity of uncontrolled studies and a smaller subset of articles describing actual applications and outcomes for clinical care. Cohort studies and large randomized control trial will likely be needed., Trial Registration: The protocol will be registered on PROSPERO international prospective register of systematic reviews prior to commencement.

Acute respiratory distress syndrome (ARDS) is the main cause for the COVID-19 infection-related morbidity and mortality. Recent clinical evidences suggest increased level of cytokines and chemokines targeting lung tissue as a prominent etiological factor. The immunomodulatory effect of mesenchymal stem cells (MSCs) as the alternative therapy for the treatment of inflammatory and autoimmune diseases is well known. Several studies have also revealed that similar therapeutic impacts of parent MSCs are also exhibited by MSCs-derived extracellular vesicles (EVs) including exosomes. In this review, we explored the therapeutic potential of both MSCs and exosomes in mitigating the COVID-19 induced cytokine storm as well as promoting the regeneration of alveolar tissue, attributed to the intrinsic cytokines and growth factor present in the secretome. The preliminary studies have demonstrated the safety and efficacy of MSCs and exosomes in mitigating symptoms associated with COVID-19. Thus, they can be used on compassionate basis, owing to their ability to endogenously repair and decrease the inflammatory reactions involved in the morbidity and mortality of COVID-19. However, more preclinical and clinical studies are warranted to understand their mechanism of action and further establish their safety and efficacy.

Human movement affects malaria epidemiology at multiple geographical levels; however, few studies measure the role of human movement in the Amazon Region due to the challenging conditions and cost of movement tracking technologies. We developed an open-source low-cost 3D printable GPS-tracker and used this technology in a cohort study to characterize the role of human population movement in malaria epidemiology in a rural riverine village in the Peruvian Amazon. In this pilot study of 20 participants (mean age = 40 years old), 45,980 GPS coordinates were recorded over 1 month. Characteristic movement patterns were observed relative to the infection status and occupation of the participants. Applying two analytical animal movement ecology methods, utilization distributions (UDs) and integrated step selection functions (iSSF), we showed contrasting environmental selection and space use patterns according to infection status. These data suggested an important role of human movement in the epidemiology of malaria in the Peruvian Amazon due to high connectivity between villages of the same riverine network, suggesting limitations of current community-based control strategies. We additionally demonstrate the utility of this low-cost technology with movement ecology analysis to characterize human movement in resource-poor environments., (Copyright © 2020 Carrasco-Escobar, Fornace, Wong, Padilla-Huamantinco, Saldaña-Lopez, Castillo-Meza, Caballero-Andrade, Manrique, Ruiz-Cabrejos, Barboza, Rodriguez, Henostroza, Gamboa, Castro, Vinetz and Llanos-Cuentas.)

Several conditions can lead to the development of a subchondral cyst. The mechanism by which the cysts form, their location, and their severity depend on the underlying pathology, although the exact pathogenesis is not fully elucidated. Treatment options vary according to the location of the cyst, with less invasive procedures such as calcium phosphate cement injection to a joint arthroplasty when there is an extensive cyst in communication with the joint space. If the cyst is circumscribed, an intraosseous bioplasty (IOBP) can be performed. Described in this paper is an IOBP, a minimally invasive technique that preserves the joint and can be applied to most subchondral cysts. In our patient, both the appearance of the cyst at imaging and pain after IOBP greatly improved with the combined use of decompression and grafting. In those patients in whom conservative management fails to ameliorate symptoms, IOBP should be considered., Competing Interests: The authors declare no conflict of interest.

Background: Case management is one of the principal strategies for malaria control. This study aimed to estimate the economic costs of uncomplicated malaria case management and explore the influence of health-seeking behaviours on those costs., Methods: A knowledge, attitudes and practices (KAP) survey was applied to 680 households of fifteen communities in Mazan-Loreto in March 2017, then a socio-economic survey was conducted in September 2017 among 161 individuals with confirmed uncomplicated malaria in the past 3 months. Total costs per episode were estimated from both provider (Ministry of Health, MoH) and patient perspectives. Direct costs were estimated using a standard costing estimation procedure, while the indirect costs considered the loss of incomes among patients, substitute labourers and companions due to illness in terms of the monthly minimum wage. Sensitivity analysis evaluated the uncertainty of the average cost per episode., Results: The KAP survey showed that most individuals (79.3%) that had malaria went to a health facility for a diagnosis and treatment, 2.7% received those services from community health workers, and 8% went to a drugstore or were self-treated at home. The average total cost per episode in the Mazan district was US$ 161. The cost from the provider's perspective was US$ 30.85 per episode while from the patient's perspective the estimated cost was US$ 131 per episode. The average costs per Plasmodium falciparum episode (US$ 180) were higher than those per Plasmodium vivax episode (US$ 156) due to longer time lost from work by patients with P. falciparum infections (22.2 days) than by patients with P. vivax infections (17.0 days). The delayed malaria diagnosis (after 48 h of the onset of symptoms) was associated with the time lost from work due to illness (adjusted mean ratio 1.8; 95% CI 1.3, 2.6). The average cost per malaria episode was most sensitive to the uncertainty around the lost productivity cost due to malaria., Conclusions: Despite the provision of free malaria case management by MoH, there is delay in seeking care and the costs of uncomplicated malaria are mainly borne by the families. These costs are not well perceived by the society and the substantial financial impact of the disease can be frequently undervalued in public policy planning.

Observational, cross-sectional, populational study to determine the prevalence of infection by hepatitis B virus (HBV), hepatitis D virus (HDV), human immunodeficiency virus (HIV) and human T-lymphotropic virus type 1 and 2 (HTLV-1/2) in the Matsés ethnic group, after immunization against HBV. ELISA and qPCR tests were used in 963 residents. The prevalence of HBsAg, Anti-HBc and Anti-HBs was 3.32%, 36.03% and 58.67% respectively. In 3.1% of the population the viral load was greater than 2000 IU/mL. In children under 10 years, the prevalence of HBsAg and anti-HBc was 0.0% and 2.6%, respectively, while protective antibodies were found in 94.4%. The prevalence of HIV and HTLV-1/2 infection was 1.5% and 0.6%, respectively. It is therefore concluded that there are low rates of HBV and HDV infection in the Matsés child population. Likewise, the presence of HIV and HTLV-1/2 infection is confirmed.

Objective: Voice disorders are very common in the pediatric population, with 6% and 23% of all children presenting with some form of dysphonia [1,2]. For many years, these patients have been underdiagnosed. There has been increasing awareness and interest in the study of voice alterations in children, and, most importantly, their impact in their quality of life. To do this, an instrument capable of measuring the quality of life in pediatric patients with vocal pathology is required, which can be used extensively in the scientific community. The objective of our study is to carry out the translation, transculturalization and validation of pVHI (Pediatric Voice Handicap Index) to Argentinian Spanish-speakers., Material and Methods: A study was carried out in the Hospital de Pediatria Dr. JP Garrahan in the city of Buenos Aires, Argentina. It included patients between 3 and 18 years old. The pVHI was translated and transculturalized for said population and for its validation, a survey was carried out in two groups of patients: one group being children with a background of both reconstructive larynx surgery, and dysphonia (n = 35) and the other group being control patients, without any voice pathology (n = 35). The survey was conducted among either parents or caregivers of the children in question., Results: A significant difference was found between both groups, for both overall pVHI score and survey subgroups score (p < 0.001) with an optimal internal confidence and a good Alpha Cronbach for each of the subgroups (functional 0,92; organic 0,87 and emotional 0,88). Test-retest for reliability revealed "p-values" without any significant difference (p > 0.05) for each of all subgroups (functional 0,68; organic 0,32 and emotional 0,72)., Conclusion: The validation and transculturalization of the rate of pediatric vocal impairment to Argentinian Spanish population presented an adequate validity and reliability. The rate of pediatric vocal impairment was identified through this simple and practical survey, offering additional information on the child's own vocal perception by part of the caregiver. We recommend this survey being included as a valuable tool in the evaluation of pediatric dysphonia in Spanish-speaking families., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: Acute exacerbation of COPD (AECOPD) is among the most frequent causes for hospital admission, causing morbidity and mortality. Infection is the most frequent cause, and studies on pollution have shown higher hospital admission and mortality with inconsistent results. The objective was to identify if there is a change in levels of particulate matter (PM) during the days leading up to the symptom onset., Patients and Methods: A retrospective study was carried out on medical records of patients with AECOPD from a University Hospital. PM values of the consultation day, onset symptoms, and up to three previous days were recorded. Moreover, clinical presentation, laboratory findings, treatments, and hospital outcomes were recorded., Results: A total of 250 medical records were included, mean age of 77 years, hospital stay mean of 6.7 days, 26.8% with no previous exposure was identified, coexistence with asthma was 5%, Obstructive Sleep Apnea Syndrome 15%, Pulmonary Hypertension 34%, antibiotic use 62%, ICU admission of 14% with non-invasive mechanical ventilation of 68%, and in-patient mortality of 2.4%. PM 2.5 of 48 hrs before onset symptoms median was 20.1 μg/m 3 versus 15 and 16.5 for the day of symptoms and 3 days prior to onset symptoms ( p <0.001). PM 10 of 46.65 μg/m 3 , versus 39 and 35.6, respectively ( p <0.001). Expectoration OR 4.74; Purulence OR 6.58; Pleuritic pain OR 3.62; Antibiotic use OR 2.87, and corticoids use OR 2.62, all with p <0.05., Conclusions: Patients with AECOPD have a higher median of particulate matter 48 hrs prior to symptomatic onset, as well as greater use of antibiotics and corticosteroids., Competing Interests: The authors report no conflicts of interest in this work.

Background: Faced with the resurgence of malaria, malaria surveillance in the Peruvian Amazon incorporated consecutive active case detection (ACD) interventions using light microscopy (LM) as reactive measure in communities with an unusual high number of cases during high transmission season (HTS). We assessed the effectiveness in malaria detection of this local ACD-based strategy. Methods: A cohort study was conducted in June⁻July 2015 in Mazan, Loreto. Four consecutive ACD interventions at intervals of 10 days were conducted in four riverine communities (Gamitanacocha, Primero de Enero, Libertad and Urco Miraño). In each intervention, all inhabitants were visited at home, and finger-prick blood samples collected for immediate diagnosis by LM and on filter paper for later analysis by quantitative real-time polymerase chain reaction (qPCR). Effectiveness was calculated by dividing the number of malaria infections detected using LM by the number of malaria infections detected by delayed qPCR. Results : Most community inhabitants (88.1%, 822/933) were present in at least one of the four ACD interventions. A total of 451 infections were detected by qPCR in 446 participants (54.3% of total participants); five individuals had two infections. Plasmodium vivax was the predominant species (79.8%), followed by P. falciparum (15.3%) and P. vivax - P. falciparum co-infections (4.9%). Most qPCR-positive infections were asymptomatic (255/448, 56.9%). The ACD-strategy using LM had an effectiveness of 22.8% (detection of 103 of the total qPCR-positive infections). Children aged 5⁻14 years, and farming as main economic activity were associated with P. vivax infections. Conclusions: Although the ACD-strategy using LM increased the opportunity of detecting and treating malaria infections during HTS, the number of detected infections was considerably lower than the real burden of infections (those detected by qPCR).

Bilateral vocal cord paralysis (BVCP) is the second most common cause of neonatal stridor. The aim of this study was to describe the demographic features, aetiology, comorbidities, and management of our patients with BVCP., Material and Methods: We conducted a retrospective review of the clinical charts of all patients diagnosed with BVCP seen at the Department of Respiratory Endoscopy between 2011 and 2015., Results: 47 patients were included. Mean age at diagnosis was 1 month and male sex predominated (63%). The aetiology was congenital in 59% and acquired in 41% of the infants. The cause was most frequently idiopathic in the former group and secondary to postoperative injury in the latter. Overall, 42 patients (89%) required tracheostomy, without statistically significant differences between the causes. Of all the patients, 39% regained vocal-cord mobility; 44% of those with congenital BVCP, 31% of those with acquired BVCP and 62.5% with idiopathic BVCP. In five patients a laryngotracheoplasty was performed with a posterior costal cartilage graft and one underwent posterior cordectomy. All were decannulated. In one patient vocal-cord lateralization was performed, avoiding tracheostomy., Conclusion: BVCP was most commonly of congenital cause and was mainly idiopathic within this group of patients, with a slight male preponderance. A high percentage of patients required tracheostomy. A higher recovery rate of vocal-cord mobility was observed in idiopathic BVCP, which allowed for successful decannulation. In this series, decannulation was possible in all patients that underwent surgery; however, further studies with comparison of techniques and objective assessment of swallowing and phonation are necessary., (Copyright © 2018 Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Migraine and allergies are a common occurrence. The aim of this study was to investigate the relationship between respiratory allergy and migraine in childhood., Materials and Methods: We screened 800 children for headache and its characteristics. After that we investigated the presence of allergy performing prick tests, rhinoscopy, endoscopy, rhinomanometry, cytology and mucociliary clearance tests., Results: Out of 800 children screened, 96 suffered from headache. Among these, 67 suffered from both headache and allergy. We found a significant correlation between allergy and headache onset in the morning and headache onset in the evening in non-allergic subjects. The average duration of a headache attack was independent from the presence of allergy, as well as the frequency of the cephalalgy attacks, and location of the pain. Prodromal symptoms connected with headache were reported to be: dizziness, aura, sparkling scotoma, nausea and vomiting, and they were associated with absence of allergy. We also found a relationship between female gender and headache onset, but in teenagers only. Paracetamol or FANS were used in the majority of cases, but antihistamine therapy and/or topical nasal sprays were also reported., Discussion: For an effective diagnostic and therapeutic approach to migraine, the pediatrician should take into account atopy and its related allergic manifestations requiring a consultation with an otorhinolaryngologist or allergist if necessary. Our findings also stress the potential role of medicines that are not usually administered in migraine attacks, such as antihistamines or topical decongestant nasal sprays.

Purpose: To assess the long-term results and complications of scleral-fixated posterior chamber intraocular lenses (PC IOLs) with the knotless Z-suture technique., Setting: University Eye Hospital, Tübingen, Germany., Design: Retrospective case series., Methods: Records of consecutive patients who had implantation of scleral-fixated PC IOLs with the knotless Z-suture technique with a minimum follow-up of 3 years were reviewed., Results: Sixty-six eyes of 62 patients were included. The mean preoperative corrected distance visual acuity (CDVA) was 0.71 logarithm of the minimum angle of resolution (logMAR) ± 0.58 (SD). The mean CDVA was 0.67 ± 0.54 logMAR (P = .257; n = 66) after 3 years, 0.73 ± 0.55 logMAR (P = .399; n = 60) after 5 years, 0.8 ± 0.68 logMAR (P = .348; n = 30) after 8 years, and 1.09 ± 0.76 logMAR (P = .069; n = 13) after 10 years. Failure because of suture breakage was observed in 11 eyes (16.7%) after a mean of 7.5 years. Kaplan-Meier time-to-event analysis showed a 40% failure probability after 10 years. Traumatic aphakia was the only risk factor for failure (odds ratio 4.1; 95% confidence interval, 1.0-18.3; P = .049). Complications included retinal detachment (15%), cystoid macular edema (9%), increased intraocular pressure requiring surgical intervention (7.6%), corneal edema (4.5%), and posterior iris-chafing syndrome with microhyphema (3%)., Conclusions: Implantation of scleral-fixated PC IOLs using the knotless Z-suture was a safe technique resulting in good visual outcomes. The long-term success of the procedure was dependent on the material properties of the suture., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background: Loop-mediated isothermal DNA amplification (LAMP) methodology offers an opportunity for point-of-care (POC) molecular detection of asymptomatic malaria infections. However, there is still little evidence on the feasibility of implementing this technique for population screenings in isolated field settings., Methods: Overall, we recruited 1167 individuals from terrestrial ('road') and hydric ('riverine') communities of the Peruvian Amazon for a cross-sectional survey to detect asymptomatic malaria infections. The technical performance of LAMP was evaluated in a subgroup of 503 samples, using real-time Polymerase Chain Reaction (qPCR) as reference standard. The operational feasibility of introducing LAMP testing in the mobile screening campaigns was assessed based on field-suitability parameters, along with a pilot POC-LAMP assay in a riverine community without laboratory infrastructure., Results: LAMP had a sensitivity of 91.8% (87.7-94.9) and specificity of 91.9% (87.8-95.0), and the overall accuracy was significantly better among samples collected during road screenings than riverine communities (p≤0.004). LAMP-based diagnostic strategy was successfully implemented within the field-team logistics and the POC-LAMP pilot in the riverine community allowed for a reduction in the turnaround time for case management, from 12-24 hours to less than 5 hours. Specimens with haemolytic appearance were regularly observed in riverine screenings and could help explaining the hindered performance/interpretation of the LAMP reaction in these communities., Conclusions: LAMP-based molecular malaria diagnosis can be deployed outside of reference laboratories, providing similar performance as qPCR. However, scale-up in remote field settings such as riverine communities needs to consider a number of logistical challenges (e.g. environmental conditions, labour-intensiveness in large population screenings) that can influence its optimal implementation.

Malaria has steadily increased in the Peruvian Amazon over the last five years. This study aimed to determine the parasite prevalence and micro-geographical heterogeneity of Plasmodium vivax parasitaemia in communities of the Peruvian Amazon. Four cross-sectional active case detection surveys were conducted between May and July 2015 in four riverine communities in Mazan district. Analysis of 2785 samples of 820 individuals nested within 154 households for Plasmodium parasitaemia was carried out using light microscopy and qPCR. The spatio-temporal distribution of Plasmodium parasitaemia, dominated by P. vivax, was shown to cluster at both household and community levels. Of enrolled individuals, 47% had at least one P. vivax parasitaemia and 10% P. falciparum, by qPCR, both of which were predominantly sub-microscopic and asymptomatic. Spatial analysis detected significant clustering in three communities. Our findings showed that communities at small-to-moderate spatial scales differed in P. vivax parasite prevalence, and multilevel Poisson regression models showed that such differences were influenced by factors such as age, education, and location of households within high-risk clusters, as well as factors linked to a local micro-geographic context, such as travel and occupation. Complex transmission patterns were found to be related to human mobility among communities in the same micro-basin.

Background and Aim: The aim of our study has been to investigate the perception of aspects related to nasal perforation among experts in Rhinology and ENT surgeons. Our aim was reporting the situations in different Countries to improve the knowledge of colleagues interested in this topic., Methods: A panel of experts prepared a 20-question questionnaire regarding nasal perforations and their surgical repair, that were emailed to all the members of SIR (Società Italiana di Rnologia - Italian Society of Rhinology)., Results: Data obtained from their answers showed that Cottle technique (64%) is the most common technique to perform septoplasty worldwide. 37% of the sample reported an occurrence of nasal septal perforation in less than 1% of patients and 75% attributed this occurrence to the skill of the surgeon, to infections, to drug use and to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned. The most common closure technique is the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others. The majority agreed not to suggest septal perforation surgery in minimal (less than 3-4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%). The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke epistaxis and systemic diseases were also claimed. Failure in repair surgery has been observed to occur in less than 30% of cases., Discussion and Conclusions: Given the great difficulty to make random studies about controversial topics and obtain statistically significant data related to that, expert opinion shall be of great value (expert opinion, level of evidence 5)., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. All rights reserved.)

Introduction Obstructive Sleep Apnea Syndrome (OSAS) is characterized by recurrent episodes of prolonged partial or complete obstruction of the upper airways. Several study groups studied the effect of snoring and OSAS on auditory function, showing an increase in the incidence of hearing loss in apneic patients, an earlier onset and/or a degree of hearing loss deeper than in peers. The aim of our study is to evaluate the audiological performance of a population of simple-snoring patients and patients suffering from mild OSAS, and the impact that such pathological condition can have on the auditory function, considering the significant levels of chronic noise. Materials and Methods Data was collected by analyzing audiometric exams on snoring patients and a control group of non-snoring patients. Our study included simple snoring patients without OSAS (AHI &lt; 5) or with low level of OSAS (5&lt; AHI &lt; 15). Possible hearing loss was classified in a crescent scale (A-B-C-D-E), from greater to minor auditory performance, according to the indications of the national protocol of occupational medicine for evaluation of hearing loss in patients exposed to chronic noise. Results We have found independence between simple snorers, mild-OSAS snorers and non-snoring patients compared to the scale of hearing performance classification. Conclusions Our results show a distribution of hearing loss in the different groups that appear independent of the presence or absence of snoring, complicated or uncomplicated by mild OSAS.

Malaria remains a major public health problem in the Peruvian Amazon where the persistence of high-risk transmission areas (hotspots) challenges the current malaria control strategies. This study aimed at identifying significant space-time clusters of malaria incidence in Loreto region 2002-2013 and to determine significant changes across years in relation to the control measures applied. Poisson regression and purely temporal, spatial, and space-time analyses were conducted. Three significantly different periods in terms of annual incidence rates (AIR) were identified, overlapping respectively with the pre-, during, and post- implementation control activities supported by PAMAFRO project. The most likely space-time clusters of malaria incidence for P. vivax and P. falciparum corresponded to the pre- and first two years of the PAMAFRO project and were situated in the northern districts of Loreto, while secondary clusters were identified in eastern and southern districts with the latest onset and the shortest duration of PAMAFRO interventions. Malaria in Loreto was highly heterogeneous at geographical level and over time. Importantly, the excellent achievements obtained during 5 years of intensified control efforts totally vanished in only 2 to 3 years after the end of the program, calling for sustained political and financial commitment for the success of malaria elimination as ultimate goal.

Malaria in Peru, dominated by Plasmodium vivax, remains a public health problem. The 1990s saw newly epidemic malaria emerge, primarily in the Loreto Department in the Amazon region, including areas near to Iquitos, the capital city, but sporadic malaria transmission also occurred in the 1990s-2000s in both north-coastal Peru and the gold mining regions of southeastern Peru. Although a Global Fund-supported intervention (PAMAFRO, 2005-2010) was temporally associated with a decrease of malaria transmission, from 2012 to the present, both P. vivax and Plasmodium falciparum malaria cases have rapidly increased. The Peruvian Ministry of Health continues to provide artemesinin-based combination therapy for microscopy-confirmed cases of P. falciparum and chloroquine-primaquine for P. vivax Malaria transmission continues in remote areas nonetheless, where the mobility of humans and parasites facilitates continued reintroduction outside of ongoing surveillance activities, which is critical to address for future malaria control and elimination efforts. Ongoing P. vivax research gaps in Peru include the following: identification of asymptomatic parasitemics, quantification of the contribution of patent and subpatent parasitemics to mosquito transmission, diagnosis of nonparasitemic hypnozoite carriers, and implementation of surveillance for potential emergence of chloroquine- and 8-aminoquinoline-resistant P. vivax Clinical trials of tafenoquine in Peru have been promising, and glucose-6-phosphate dehydrogenase deficiency in the region has not been observed to be a limitation to its use. Larger-scale challenges for P. vivax (and malaria in general) in Peru include logistical difficulties in accessing remote riverine populations, consequences of government policy and poverty trends, and obtaining international funding for malaria control and elimination., (© The American Society of Tropical Medicine and Hygiene.)

Introduction: Lower back pain (LBP) is the most common complaint worldwide and the leading cause of disability in the workplace. In Colombia there are no epidemiological data on low back pain in aviation. This study aimed to characterize lower back pain in pilots and maintenance technicians in a Colombian commercial airline., Methods: Information was collected from the total population in a Colombian commercial airline in Bogota during the period from 2011 to 2013 using a voluntary survey which requested demographics, occupational (LEST survey) factors, back pain, and chronic pain (chronic pain grade scale)., Results: The prevalence rate of LBP in pilot respondents was 71% and the factors associated previously have belonged to the military forces: occupational exposure to physical load and work time. Chronic low back pain was at a prevalence of 49%. The prevalence of LBP in maintenance technicians was 65%. Associated factors were again similar to military forces and included mental workload. Chronic pain had a prevalence of 65%. Factors associated with chronic low back pain were the technicians' time in office and physical load., Discussion: The prevalence of lower back pain in pilots is similar to that presented in the airline world population. In the case of maintenance technicians, the prevalence was higher than those found in other similar groups, but very similar to prevalences presented in different business industries, including the transport sector. Fajardo Rodriguez HA, Ortiz Mayorga VA. Characterization of low back pain in pilots and maintenance technicians on a commercial airline. Aerosp Med Hum Perform. 2016; 87(9):795-799.

Pipunculidae presently have around 1,400 known species, but it is poorly known in Colombia, with only ten reported species in all territory. The genera Eudorylas Aczél and Tomosvaryella Aczél are the most abundant. This work provides information on the species distribution. No endemic genera have been recorded to date from Colombia.

AbstractIn February 2014, the Malaria Elimination Working Group, in partnership with the Peruvian Ministry of Health (MoH), hosted its first international conference on malaria elimination in Iquitos, Peru. The 2-day meeting gathered 85 malaria experts, including 18 international panelists, 23 stakeholders from different malaria-endemic regions of Peru, and 11 MoH authorities. The main outcome was consensus that implementing a malaria elimination project in the Amazon region is achievable, but would require: 1) a comprehensive strategic plan, 2) the altering of current programmatic guidelines from control toward elimination by including symptomatic as well as asymptomatic individuals for antimalarial therapy and transmission-blocking interventions, and 3) the prioritization of community-based active case detection with proper rapid diagnostic tests to interrupt transmission. Elimination efforts must involve key stakeholders and experts at every level of government and include integrated research activities to evaluate, implement, and tailor sustainable interventions appropriate to the region.

Objectives: To provide an epidemiological framework of symptoms related to Foreign Body (FB) injuries due to Button Battery (BB)., Methods: Data on BB ingestion/inhalation have been obtained from the ButtonBatteryDB. The ButtonBatteryDB is a database collecting information on BB injuries in children (0-18 years of age). Data on 348 BB injures have been derived from the Registry of Foreign Body Injuries "Susy Safe" (269 cases) and from published scientific literature reporting case reports of FB injuries (79 cases)., Results: Most of injured children were male and BBs were found more often in the mouth/esophagus/stomach (ICD935) and in the nose (ICD932). Analyzing symptoms related to BB located in the esophagus/mouth/stomach, we found that children had higher probability of experiencing dysphagia (30.19%, 95% C.I. 17.83-42.55), fever and cough (26.42%, 95% C.I. 14.55-38.28), compared to the other symptoms. Referring to the probability that symptoms occurred simultaneously, fever and cough are more likely (3.72%, 95% C.I. 1.0-6-43) to jointly showing up in children with BB in mouth/esophagus/stomach (ICD935), followed by fever and dysphagia (2.66%, 95% C.I. 0.36-4.96) and by fever and irritability/crying, fever and drooling, dysphagia and irritability/crying (2.13% C.I. 0.00-4.19, 95% C.I.), Conclusions: These findings provide new insight in clinical presentation of BB injuries: the identification of unique patterns of symptoms related to BB injuries is useful to perform an early diagnosis (and to guarantee a prompt medical reaction), also when the injury is un-witnessed., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: With low and markedly seasonal malaria transmission, increasingly sensitive tools for better stratifying the risk of infection and targeting control interventions are needed. A cross-sectional survey to characterize the current malaria transmission patterns, identify hotspots, and detect recent changes using parasitological and serological measures was conducted in three sites of the Peruvian Amazon., Material and Methods: After full census of the study population, 651 participants were interviewed, clinically examined and had a blood sample taken for the detection of malaria parasites (microscopy and PCR) and antibodies against P. vivax (PvMSP119, PvAMA1) and P. falciparum (PfGLURP, PfAMA1) antigens by ELISA. Risk factors for malaria infection (positive PCR) and malaria exposure (seropositivity) were assessed by multivariate survey logistic regression models. Age-specific seroprevalence was analyzed using a reversible catalytic conversion model based on maximum likelihood for generating seroconversion rates (SCR, λ). SaTScan was used to detect spatial clusters of serology-positive individuals within each site., Results: The overall parasite prevalence by PCR was low, i.e. 3.9% for P. vivax and 6.7% for P. falciparum, while the seroprevalence was substantially higher, 33.6% for P. vivax and 22.0% for P. falciparum, with major differences between study sites. Age and location (site) were significantly associated with P. vivax exposure; while location, age and outdoor occupation were associated with P. falciparum exposure. P. falciparum seroprevalence curves showed a stable transmission throughout time, while for P. vivax transmission was better described by a model with two SCRs. The spatial analysis identified well-defined clusters of P. falciparum seropositive individuals in two sites, while it detected only a very small cluster of P. vivax exposure., Conclusion: The use of a single parasitological and serological malaria survey has proven to be an efficient and accurate method to characterize the species specific heterogeneity in malaria transmission at micro-geographical level as well as to identify recent changes in transmission.

Background: Focal screening and treatment (FSAT) of malaria infections has recently been introduced in Peru to overcome the inherent limitations of passive case detection (PCD) and further decrease the malaria burden. Here, we used a relatively straightforward mathematical model to assess the potential of FSAT as elimination strategy for Plasmodium falciparum malaria in the Peruvian Amazon Region., Methods: A baseline model was developed to simulate a scenario with seasonal malaria transmission and the effect of PCD and treatment of symptomatic infections on the P. falciparum malaria transmission in a low endemic area of the Peruvian Amazon. The model was then adjusted to simulate intervention scenarios for predicting the long term additional impact of FSAT on P. falciparum malaria prevalence and incidence. Model parameterization was done using data from a cohort study in a rural Amazonian community as well as published transmission parameters from previous studies in similar areas. The effect of FSAT timing and frequency, using either microscopy or a supposed field PCR, was assessed on both predicted incidence and prevalence rates., Results: The intervention model indicated that the addition of FSAT to PCD significantly reduced the predicted P. falciparum incidence and prevalence. The strongest reduction was observed when three consecutive FSAT were implemented at the beginning of the low transmission season, and if malaria diagnosis was done with PCR. Repeated interventions for consecutive years (10 years with microscopy or 5 years with PCR), would allow reaching near to zero incidence and prevalence rates., Conclusions: The addition of FSAT interventions to PCD may enable to reach P. falciparum elimination levels in low endemic areas of the Amazon Region, yet the progression rates to those levels may vary substantially according to the operational criteria used for the intervention.

Aims: We present a multicenter, prospective, open-label study to assess the efficacy and safety of a phytomedicine. The aim of the research was to evaluate the efficacy and safety of 14 days of treatment with Sinupret for acute rhinosinusitis. Sinupret is a herbal preparation used to restore and maintain the physiological function of the membranes in the sinus cavity., Methods: Sixty patients with acute rhinosinusitis based on the EPOS guidelines were enrolled in the study. Thirty patients were treated with Sinupret Forte, while 30 patients were treated with intranasal fluticasone furoate. The criteria for the evaluation of efficacy were the major symptom scores according to the investigator and the Health-Related Quality of Life score. The criteria used to evaluate safety were the number of patients with adverse events, the patients' vital signs, and laboratory safety., Results: All patients considered showed significant improvements in symptoms. Among the patients treated with Sinupret, none had an adverse event, while 3 patients treated with fluticasone furoate had minor adverse events. The patients' vital signs and laboratory values were normal., Conclusions: The results of this study suggest that this phytomedicinal preparation has a significant level of efficacy in acute rhinosinusitis and that treatment is safe., (© 2015 S. Karger AG, Basel.)

Anopheles darlingi Root is the most important malaria vector in the Amazonia region of South America. However, continuous propagation of An. darlingi in the laboratory has been elusive, limiting entomological, genetic/genomic, and vector-pathogen interaction studies of this mosquito species. Here, we report the establishment of an An. darlingi colony derived from wild-caught mosquitoes obtained in the northeastern Peruvian Amazon region of Iquitos in the Loreto Department. We show that the numbers of eggs, larvae, pupae, and adults continue to rise at least to the F6 generation. Comparison of feeding Plasmodium vivax ex vivo of F4 and F5 to F1 generation mosquitoes showed the comparable presence of oocysts and sporozoites, with numbers that corresponded to blood-stage asexual parasitemia and gametocytemia, confirming P. vivax vectorial capacity in the colonized mosquitoes. These results provide new avenues for research on An. darlingi biology and study of An. darlingi-Plasmodium interactions.

Animals living in nontropical climates modify their physiology and behavior to adapt to seasonal environmental changes. Part of this adaptation involves the release of catecholamine from sympathetic nerve endings and the adrenal medulla, which play a major role in regulating energy balance. The aim of this work was to investigate whether adult male viscachas in their natural habitat exhibits structural changes in the adrenal medulla during the annual seasonal cycle. In August-September, chromaffin granules revealed ultrastructural changes suggestive of piecemeal degranulation. Quantitative morphometric analysis by transmission electron microscopy showed a significantly lower percentage of resting chromaffin granules and a higher percentage of altered granules and empty containers in August-September (late winter) compared to February-March (late summer), suggesting an increased secretory process of catecholamines in August-September. The mechanism of piecemeal degranulation might amplify this process, encouraging the adaptive response to winter environmental conditions. Tissue levels of epinephrine, norepinephrine, and dopamine (analyzed by high-performance liquid chromatography) changed throughout the year, reaching maximum values in February-March and minimum values in August-September. These results demonstrate morphological and biochemical seasonal variations of the adrenal medulla, suggesting that epinephrine might promote energy mobilization, which allow the Lagostomus to cope with adverse environmental conditions and thus to survive during winter season., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: To investigate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in rural and urban community settings of Bolivia and Peru., Methods: MRSA nasal carriage was investigated in 585 individuals living in rural and urban areas of Bolivia and Peru (one urban area, one small rural village, and two native communities, one of which was highly isolated). MRSA isolates were subjected to molecular analysis for the detection of virulence genes, characterization of the staphylococcal cassette chromosome mec (SCCmec), and genotyping (multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE))., Results: An overall very low prevalence of MRSA nasal carriage was observed (0.5%), with MRSA carriers being detected only in a small rural village of the Bolivian Chaco. The three MRSA isolates showed the characteristics of community-associated MRSA (being susceptible to all non-beta-lactam antibiotics and harboring the SCCmec type IV), were clonally related, and belonged to ST1649., Conclusions: This study provides an insight into the epidemiology of MRSA in community settings of Bolivia and Peru. Reliable, time-saving, and low-cost methods should be implemented to encourage continued surveillance of MRSA dissemination in resource-limited countries., (Copyright © 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Context: While several articles describe clinical management of foreign bodies injuries in the upper air tract, little epidemiological evidence is available from injury databases., Objective: This article aims to understand the burden of airway FB injuries in high-, low-, and middle-income countries as emerging from scientific literature., Data Sources: One thousand six hundred ninety-nine published articles 1978-2008., Study Selection: A free text search on PubMed database ((foreign bodies) or (foreign body)) and ((aspiration) or (airways) or (tracheobronchial) or (nasal) or (inhalation) or (obstruction) or (choking) or (inhaled) or (aspirations) or (nose) or (throat) or (asphyxiation)) and ((children) or (child))., Data Extraction: Information on reported injuries according to country, time period, children sex and age, FB type, site of obstruction, symptoms, signs, diagnostic and therapeutic procedures, delay at the diagnosis, complications, number of deaths., Results: Serious complications occur both in high-income and low-middle income countries in a considerable proportion of cases (10% and 20%, respectively). Similarly, death is not infrequent (5-7% of cases)., Conclusions: Few countries have good systematic data collection and there's a lack of sensibility in parents and clinicians in terms of acknowledge of the choking risk. On the contrary, international surveillance systems able to collect information in a standardized way need to be implemented., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: While coverage of long-lasting insecticide-treated nets (LLIN) has steadily increased, a growing number of studies report gaps between net ownership and use. We conducted a mixed-methods social science study assessing the importance of net preference and use after Olyset® LLINs were distributed through a mass campaign in rural communities surrounding Iquitos, the capital city of the Amazonian region of Peru., Methods: The study was conducted in the catchment area of the Paujil and Cahuide Health Centres (San Juan district) between July 2007 and November 2008. During a first qualitative phase, participant observation and in-depth interviews collected information on key determinants for net preference and use. In a second quantitative phase, a survey among recently confirmed malaria patients evaluated the acceptability and use of both LLINs and traditional nets, and a case control study assessed the association between net preference/use and housing structure (open vs. closed houses)., Results: A total of 10 communities were selected for the anthropological fieldwork and 228 households participated in the quantitative studies. In the study area, bed nets are considered part of the housing structure and are therefore required to fulfil specific architectural and social functions, such as providing privacy and shelter, which the newly distributed Olyset® LLINs ultimately did not. The LLINs' failure to meet these criteria could mainly be attributed to their large mesh size, transparency and perceived ineffectiveness to protect against mosquitoes and other insects, resulting in 63.3% of households not using any of the distributed LLINs. Notably, LLIN usage was significantly lower in houses with no interior or exterior walls (35.2%) than in those with walls (73.8%) (OR = 5.2, 95CI [2.2; 12.3], p<0.001)., Conclusion: Net preference can interfere with optimal LLIN use. In order to improve the number of effective days of LLIN protection per dollar spent, appropriate quantitative and qualitative methods for collecting information on net preference should be developed before any LLIN procurement decision is made.

Background: Quinolones are potent broad-spectrum bactericidal agents increasingly employed also in resource-limited countries. Resistance to quinolones is an increasing problem, known to be strongly associated with quinolone exposure. We report on the emergence of quinolone resistance in a very remote community in the Amazon forest, where quinolones have never been used and quinolone resistance was absent in 2002., Methods: The community exhibited a considerable level of geographical isolation, limited contact with the exterior and minimal antibiotic use (not including quinolones). In December 2009, fecal carriage of antibiotic resistant Escherichia coli was investigated in 120 of the 140 inhabitants, and in 48 animals reared in the community. All fluoroquinolone-resistant isolates were genotyped and characterized for the mechanisms of plasmid- and chromosomal-mediated quinolone resistance., Principal Findings: Despite the characteristics of the community remained substantially unchanged during the period 2002-2009, carriage of quinolone-resistant E. coli was found to be common in 2009 both in humans (45% nalidixic acid, 14% ciprofloxacin) and animals (54% nalidixic acid, 23% ciprofloxacin). Ciprofloxacin-resistant isolates of human and animal origin showed multidrug resistance phenotypes, a high level of genetic heterogeneity, and a combination of GyrA (Ser83Leu and Asp87Asn) and ParC (Ser80Ile) substitutions commonly observed in fluoroquinolone-resistant clinical isolates of E. coli., Conclusions: Remoteness and absence of antibiotic selective pressure did not protect the community from the remarkable emergence of quinolone resistance in E. coli. Introduction of the resistant strains from antibiotic-exposed settings is the most likely source, while persistence and dissemination in the absence of quinolone exposure is likely mostly related with poor sanitation. Interventions aimed at reducing the spreading of resistant isolates (by improving sanitation and water/food safety) are urgently needed to preserve the efficacy of quinolones in resource-limited countries, as control strategies based only on antibiotic restriction policies are unlikely to succeed in those settings.

Objective: The analysis of foreign bodies (FB) injuries in the upper aero-digestive tract is not available for Ecuador and in this context, the present article represent the is the first presenting to the international community the basic epidemiological data on the Ecuador's experience on foreign bodies juries., Methods: Data on 258 cases were gleaned using Susy Safe database, choosing the cases coming from Ecuador's institutions, namely Francisco De Icaza Bustamante Children Hospital, in Guayaquil (Ecuador) which collects data on children injuries due to foreign bodies with the aid of a standardized case report forms., Results: Patients showed a female:male ratio of 1:1.2. Fifty-three percent of the children were younger than 2 years of age, with a mean age of 3.22 years. The most frequent location of retrieval was the oesophagus (37.98%) followed by the ears (34.88%). Coins were the most frequent cause of accident (37.21%). Seeds and grain were the most frequent food FBs and they were seen in 13.95% of cases. Adult presence was recorded in 113 cases. There was indeed a significant correlation between the presence of an adult and the activity that the children were doing when the incident occurred., Conclusions: This first breach into the analysis of injuries in Ecuador gives the confirmation that the results coming from country's data agreed with the general Susy Safe ones. Similar preventive strategies are therefore highly recommended, stressing that primary prevention has the main role in children's protection., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: There is an increasing body of literature reporting treatment failure of the currently recommended radical treatment of Plasmodium vivax infections. As P. vivax is the main malaria species outside the African continent, emerging tolerance to its radical treatment regime could have major consequences in countries like Peru, where 80% of malaria cases are due to P. vivax. Here we describe the results of a 1-year longitudinal follow up of 51 confirmed P. vivax patients living around Iquitos, Peruvian Amazon, and treated according to the Peruvian national guidelines., Methodology: Each month a blood sample for microscopy and later genotyping was systematically collected. Recent exposure to infection was estimated by detecting antibodies against the P. vivax circumsporozoite protein (CSP) and all PCR confirmed P. vivax infections were genotyped with 16 polymorphic microsatellites., Results: During a 1-year period, 84 recurrent infections, 22 positive also by microscopy, were identified, with a median survival time to first recurrent infection of 203 days. Most of them (71%) were asymptomatic; in 13 patients the infection persisted undetected by microscopy for several consecutive months. The genotype of mostly recurrent infections differed from that at day 0 while fewer differences were seen between the recurrent infections. The average expected heterozygosity was 0.56. There was strong linkage disequilibrium (I(A)(s) = 0.29, p<1.10(-4)) that remained also when analyzing only the unique haplotypes, suggesting common inbreeding., Conclusion: In Peru, the P. vivax recurrent infections were common and displayed a high turnover of parasite genotypes compared to day 0. Plasmodium vivax patients, even when treated according to the national guidelines, may still represent an important parasite reservoir that can maintain transmission. Any elimination effort should consider such a hidden reservoir.

Objectives: To assess the competency of microscopists for malaria diagnosis using standardized slide sets in the Peruvian Amazon., Material and Methods: Cross-sectional study carried out in 122 first level health facilities of the Peruvian Amazon, between July and September 2007. Within the frame of the project "Control Malaria in the border areas of the Andean Region: A community approach" (PAMAFRO), we evaluated the malaria diagnosis performance in 68 microscopists without expertise (< 1 year of expertise) and 76 microscopists with expertise (> 1 year) using standardized sets of 20 blood smear slides according to the World Health Organization (WHO) recommendations. A correct diagnosis (correct species identification) was defined as "agreement", a microscopist was qualified as an "expert" if they have an agreement ≥90% (≥ 18 slides with correct diagnosis), as a "referent" with an agreement between 80% and <90%, "competent" if they are between 70 and <80% and "in training" if they have <70%., Results: Microscopists with expertise (68.6%) had more agreement than those without expertise (48.2%). The competency assessment was acceptable (competent, referent, or experts levels) in 11.8% of the microscopists without expertise and in 52.6% from those with expertise. The agreement was lower using blood smear slides with P. falciparum with low parasitaemia, with P. malariae and with mixed infections., Conclusions: Is the first assessment, we found only one of three microscopists from the Peruvian Amazon is competent fro malaria diagnosis according to the WHO standards. From this baseline data, we have to continue working in order to improve the competency assessment of the microscopists within the frame of a quality assurance system.

Background: The rapid diagnostic tests for malaria (RDT) constitute a fast and opportune alternative for non-complicated malaria diagnosis in areas where microscopy is not available. The objective of this study was to validate a RDT named Parascreen under field conditions in Iquitos, department of Loreto, Peru. Parascreen is a RDT that detects the histidine-rich protein 2 (HRP2) antigen from Plasmodium falciparum and lactate deshydrogenase from all Plasmodium species., Methods: Parascreen was compared with microscopy performed by experts (EM) and polymerase chain reaction (PCR) using the following indicators: sensitivity (Se), specificity (Sp), positive (PV+) and negative predictive values (PV-), positive (LR+) and negative likehood ratio (LR-)., Results: 332 patients with suspected non-complicated malaria who attended to the MOH health centres were enrolled between October and December 2006. For P. falciparum malaria, Parascreen in comparison with EM, had Se: 53.5%, Sp: 98.7%, PV+: 66.7%, PV-: 97.8%, LR+: 42.27 and LR-: 0.47; and for non-P. falciparum malaria, Se: 77.1%, Sp: 97.6%, PV+: 91.4%, PV-: 92.7%, LR+: 32.0 and LR-: 0.22. The comparison of Parascreen with PCR showed, for P. falciparum malaria, Se: 81.8%, Sp: 99.1%, PV+: 75%, PV-: 99.4, LR+: 87.27 and LR-: 0.18; and for non-P. falciparum malaria Se: 76.1%, Sp: 99.2%, PV+: 97.1%, PV-: 92.0%, LR+: 92.51 and LR-: 0.24., Conclusions: The study results indicate that Parascreen is not a valid and acceptable test for malaria diagnosis under the field conditions found in the Peruvian Amazon. The relative proportion of Plasmodium species, in addition to the genetic characteristics of the parasites in the area, must be considered before applying any RDT, especially after the finding of P. falciparum malaria parasites lacking pfhrp2 gene in this region.

Background: Peru is one of the Latin American countries with the highest malaria burden, mainly due to Plasmodium vivax infections. However, little is known about P. vivax transmission dynamics in the Peruvian Amazon, where most malaria cases occur. The genetic diversity and population structure of P. vivax isolates collected in different communities around Iquitos city, the capital of the Peruvian Amazon, was determined., Methods: Plasmodium vivax population structure was determined by multilocus genotyping with 16 microsatellites on 159 P. vivax infected blood samples (mono-infections) collected in four sites around Iquitos city. The population characteristics were assessed only in samples with monoclonal infections (n = 94), and the genetic diversity was determined by calculating the expected heterozygosity and allelic richness. Both linkage disequilibrium and the genetic differentiation (theta) were estimated., Results: The proportion of polyclonal infections varied substantially by site (11% - 70%), with the expected heterozygosity ranging between 0.44 and 0.69; no haplotypes were shared between the different populations. Linkage disequilibrium was present in all populations (IAS 0.14 - 0.61) but was higher in those with fewer polyclonal infections, suggesting inbreeding and a clonal population structure. Strong population differentiation (theta = 0.45) was found and the Bayesian inference cluster analysis identified six clusters based on distinctive allele frequencies., Conclusion: The P. vivax populations circulating in the Peruvian Amazon basin are genetically diverse, strongly differentiated and they have a low effective recombination rate. These results are in line with the low and clustered pattern of malaria transmission observed in the region around Iquitos city.

Despite being free of charge, treatment adherence to 7-day primaquine for the radical cure of Plasmodium vivax was estimated at 62.2% among patients along the Iquitos-Nauta road in the Peruvian Amazon. The principal reason for non-adherence was the perceived adverse effects related to local humoral illness conceptions that hold that malaria produces a hot state of body, which is further aggravated by the characteristically hot medical treatment. Notably, patients were willing to adhere to the first 3 days of treatment during which symptoms are most apparent and include the characteristic chills. Nevertheless, as symptoms abate, the perceived aggravating characteristics of the medication outweigh the perceived advantages of treatment adherence. Improving community awareness about the role of primaquine to prevent further malaria transmission and fostering a realistic system of direct observed treatment intake, organized at community level, can be expected to improve adherence to the radical cure of P. vivax in this area.

Background: Access to affordable health care is limited in many low and middle income countries and health systems are often inequitable, providing less health services to the poor who need it most. The aim of this study was to investigate health seeking behavior and utilization of drugs in relation to household socioeconomic status for children in two small Amazonian urban communities of Peru; Yurimaguas, Department of Loreto and Moyobamba, Department of San Martin, Peru., Methods: Cross-sectional study design included household interviews. Caregivers of 780 children aged 6-72 months in Yurimaguas and 793 children of the same age in Moyobamba were included in the study. Caregivers were interviewed on health care seeking strategies (public/private sectors; formal/informal providers), and medication for their children in relation to reported symptoms and socio-economic status. Self-reported symptoms were classified into illnesses based on the IMCI algorithm (Integrated Management of Childhood Ilness). Wealth was used as a proxy indicator for the economic status. Wealth values were generated by Principal Component Analysis using household assets and characteristics., Results: Significantly more caregivers from the least poor stratum consulted health professionals for cough/cold (p < 0.05: OR = 4.30) than the poorest stratum. The poorest stratum used fewer antibiotics for cough/cold and for cough/cold + diarrhoea (16%, 38%, respectively) than the least poor stratum (31%, 52%, respectively). For pneumonia and/or dysentery, the poorest used significantly fewer antibiotics (16%) than the least poor (80%)., Conclusion: The poorest seek less care from health professionals for non-severe illnesses as well as for severe illnesses; and treatment with antibiotics is lacking for illnesses where it would be indicated. Caregivers frequently paid for health services as well as antibiotics, even though all children in the study qualified for free health care and medicines. The implementation of the Seguro Integral de Salud health insurance must be improved.

We report the case of an infected nonunion of the proximal femoral in an elderly patient. There was extensive involvement of the entire proximal femur precluding salvage. An impromptu use of a cephalomedullary nail coated with antibiotic-laden bone cement is described, followed by reimplantation with a revision-type proximal femoral prosthesis. The patient had resection of the proximal femur, placement of a temporary functional spacer, and reimplantation after a course of antibiotics, with good success. The method we describe is a reasonable alternative when standard off-the-shelf systems or other methods of temporary spacer creation are not available.