Diseño y evaluación de nuevas técnicas de diagnóstico serológico y molecular para el diagnóstico de las infecciones de transmisión sexual

El terme infeccions de transmissió sexual (ITS) inclou una sèrie de síndromes causats per agents patògens que poden ser adquirits mitjançant l'activitat sexual am un augment de la seva als últims anys. Sota el concepte d'ITS s'agrupen tant les malalties venèries clàssiques (uretritis, sífilis, chancroide i limfogranuloma veneri) i aquelles en què la via sexual no és l'únic (hepatitis B i C, l'amebiasis intestinal en HSH, la infecció per virus de la immunodeficiència humana (VIH) i algunes parasitosis). Els patògens més importants engloben Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis, VIH i altres microorganismes emergents com el Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum i Ureaplasma parvum. El correcte diagnòstic de les ITS té importància tant com a problema de salut pública com per les complicacions que poden produir en aquells pacients no diagnosticats. A la pràctica clínica moltes vegades les ITS són diagnosticades sindrómicament bé per no disposar de proves sensibles, bé per la manca en alguns laboratoris d'aquestes eines. La Tesi té 3 objectius principals que s'han abordat en tres articles diferents. El primer objectiu és l'avaluació d'una tècnica de avidesa per a la identificació d'infecció recent pel VIH 1 utilitzant un immunoassaig automatitzat de quimioluminiscència (QLIA). RITA de l'anglès Recent Infection Testing Algorithm és un nom genèric per a una sèrie de tècniques de laboratori que distingeixen la infecció recent pel VIH. L'estudi indica que l'assaig d'avidesa avaluat és un mètode fiable per identificar infeccions recents per VIH-1 i podria ser utilitzat dins un algoritme RITA per estimar la incidència d'infecció per VIH-1 en la població. El segon objectiu de la Tesi va ser descriure la utilitat d'una tècnica automatitzada Vitros Syphilis TPA (assaig treponèmic per QLIA) per fer el diagnòstic de la sífilis comparant-lo amb tècniques de enzimoimmunoanàlisi, així com a primer pas de el nou algoritme revers de la sífilis en relació a les proves clàssiques, Rapid Plasma Reagin (RPR) i Treponema Pallidum hemagglutination assay (TPHA). Aquesta tècnica permet actuar com a tècnica de cribratge en laboratoris amb alta càrrega de treball gràcies al seu alt valor predictiu negatiu. Per completar l'estudi de les ITS, el tercer objectiu de la Tesi va ser estudiar i avaluar una nova tècnica de biologia molecular mitjançant PCR multiplex, a partir de diferents tipus de mostres provinents de poblacions seleccionades i estudiades prèviament per altres tècniques. Aquest mètode permetria detectar a partir d'una sola mostra, set diferents agents causals d'ITS (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis i Mycoplasma genitalium). Les dades obtingudes de sensibilitat, especificitat i valors predictius al comparar-los amb les tècniques convencionals utilitzades en el nostre laboratori van ser molt bons, permetent per tant, l'adopció d'aquests mètodes com a tècnica per al diagnòstic de les MTS. Un altre punt fort va ser la possibilitat de detecció de Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis i Mycoplasma genitalium. La seva controvertida detecció, sobretot dels tres primers, encara avui, presenta algunes ombres que esperem poder aclarir a mesura que anem coneixent. Les noves tècniques moleculars i immunològiques avaluades en aquesta Tesi han resultat útils per a la detecció d'agents causals d'ITS. En general, els assajos de PCR són molt sensibles i específics en comparació amb altres tècniques com els cultius. D'altra banda, la introducció d'estratègies basades en PCR múltiples permetria identificar pacients amb coinfeccions i també explicar errors en tractaments.The term sexually transmitted infections (STIs) includes a number of syndromes caused by pathogens that can be acquired through sexual activity with a high incidence in recent years. Under the concept of STI are grouped both classical venereal diseases (urethritis, syphilis, chancroid and lymphogranuloma venereum) and others with different ways of transmission (hepatitis B and C, MSM intestinal amebiasis, infection with human immunodeficiency virus (HIV) and some parasites). Encompass the most important pathogens Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis, HIV and other emerging organisms like Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum. The correct diagnosis of STIs is important for public health problem and because the complications that can occur in patients undiagnosed. In clinical practice often STIs have a syndromeic diagnosis, sometiems by the lack of sensitive of the diagnostic tests employed or by the lack of these tools in some laboratories. The Thesis has three main objectives that have been addressed in three different articles. The first objective is to evaluate an avidity technique to identifying recent infection by HIV 1 using an automated chemiluminescence immunoassay (QLIA). Recent Infection Testing Algorithm (RITA) is a generic name for a variety of laboratory techniques that distinguish the recent HIV acquisition. The study indicates that the test is a reliable method to identify recent HIV-1 infection and could be used in a RITA algorithm to estimate the incidence of HIV-1 infection in the population. The second objective of the Thesis was to describe the use of an automated technical VITROS Syphilis TPA (treponemal QLIA assay) for diagnosis of syphilis compared to other enzymeimmunoassays, as well as the classic reaginic test, and its use as a first step in the new reverse algorithm comparing with the classic Rapid Plasma Reagin (RPR) with subsequent confirmation with Treponema Pallidum hemagglutination assay (TPHA). The easy use of this automatic system can be implemented as a screening test in laboratories with high workload due to its high negative predictive value. To complete the study of STIs, the third aim of the Thesis was to study and evaluate a new biology molecular technique using PCR multiplex with different types of samples from selected populations previously studied by other techniques. This method allows the detection of seven major pathogens of STI (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis and Mycoplasma genitalium) from a single sample. The data obtained were compared with the conventional methods performed in our laboratory. The sensitivity, specificity and predictive values obtained were highly significant, allowing the adoption of this technique for the diagnosis of STIs. Another objective was the ability to detect Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis and Mycoplasma genitalium. His controversial presence, still presents some shadows that hopefully we can clarify as we know them. New molecular and immunological techniques evaluated in this Thesis have been useful for detecting causative agents of STI. In general, PCR assays are highly sensitive and specific when compared with other techniques such culture or wet mounts examinations. Furthermore, the introduction of multiple PCR based strategies would identify patients with coinfections and also explain failures in treatments

Schistosomiasis Among Female Migrants in Non-endemic Countries : Neglected Among the Neglected? A Pilot Study

Schistosomiasis among migrant populations in Europe is an underdiagnosed infection, yet delayed treatment may have serious long-term consequences. In this study we aimed to characterize the clinical manifestations of Schistosoma infection among migrant women, and the degree of underdiagnosis. We carried out a prospective cross-sectional study among a migrant population living in the North Metropolitan Barcelona area and coming from schistosomiasis-endemic countries. We obtained clinical, laboratory and socio-demographic data from electronic clinical records, as well as information about years of residence and previous attendance at health services. Blood sample was obtained and schistosomiasis exposure was assessed using a specific ELISA serological test. Four hundred and five patients from schistosomiasis-endemic regions were screened, of whom 51 (12.6%) were female. Seropositivity prevalence was 54.8%, but considering women alone we found a prevalence of 58.8% (30 out of 51). The median age of the 51 women was 41.0 years [IQR (35-48)] and the median period of residence in the European Union was 13 years [IQR (10-16)]. Schistosoma -positive women (N = 30) showed a higher prevalence of gynecological signs and symptoms compared to the seronegative women (96.4 vs. 66.6%, p = 0.005). Among seropositive women, the median number of visits to Sexual and Reproductive Health unit prior to diagnosis of schistosomiasis was 41 [IQR (18-65)]. The high prevalence of signs and symptoms among seropositive women and number of previous visits suggest a high rate of underdiagnosis and/or delayed diagnosis of Schistosoma infection, particularly female genital schistosomiasis, among migrant females

Can changes in deformation regimes be inferred from crystallographic preferred orientations in polar ice?

Creep due to ice flow is generally thought to be the main cause for the formation of crystallographic preferred orientations (CPOs) in polycrystalline anisotropic ice. However, linking the development of CPOs to the ice flow history requires a proper understanding of the ice aggregate's microstructural response to flow transitions. In this contribution the influence of ice deformation history on the CPO development is investigated by means of full-field numerical simulations at the microscale. We simulate the CPO evolution of polycrystalline ice under combinations of two consecutive deformation events up to high strain, using the code VPFFT (visco-plastic fast Fourier transform algorithm) within ELLE. A volume of ice is first deformed under coaxial boundary conditions, which results in a CPO. The sample is then subjected to different boundary conditions (coaxial or non-coaxial) in order to observe how the deformation regime switch impacts the CPO. The model results indicate that the second flow event tends to destroy the first, inherited fabric with a range of transitional fabrics. However, the transition is slow when crystallographic axes are critically oriented with respect to the second imposed regime. Therefore, interpretations of past deformation events from observed CPOs must be carried out with caution, particularly in areas with complex deformation histories

Can changes in deformation regimes be inferred from crystallographic preferred orientations in polar ice?

Creep due to ice flow is generally thought to be the main cause for the formation of crystallographic preferred orientations (CPOs) in polycrystalline anisotropic ice. However, linking the development of CPOs to the ice flow history requires a proper understanding of the ice aggregate's microstructural response to flow transitions. In this contribution the influence of ice deformation history on the CPO development is investigated by means of full-field numerical simulations at the microscale. We simulate the CPO evolution of polycrystalline ice under combinations of two consecutive deformation events up to high strain, using the code VPFFT (visco-plastic fast Fourier transform algorithm) within ELLE. A volume of ice is first deformed under coaxial boundary conditions, which results in a CPO. The sample is then subjected to different boundary conditions (coaxial or non-coaxial) in order to observe how the deformation regime switch impacts the CPO. The model results indicate that the second flow event tends to destroy the first, inherited fabric with a range of transitional fabrics. However, the transition is slow when crystallographic axes are critically oriented with respect to the second imposed regime. Therefore, interpretations of past deformation events from observed CPOs must be carried out with caution, particularly in areas with complex deformation histories

Impact of the Introduction of a Two-Step Laboratory Diagnostic Algorithm in the Incidence and Earlier Diagnosis of Clostridioides difficile Infection

Our aim was to determine changes in the incidence of CD infection (CDI) following the introduction of a two-step diagnostic algorithm and to analyze CDI cases diagnosed in the study period. We retrospectively studied CDI (January 2009 to July 2018) in adults diagnosed by toxin enzyme immunoassay (EIA) (2009-2012) or toxin-EIA + polymerase chain reaction (PCR) algorithm (2013 onwards). A total of 443 patients with a first episode of CDI were included, 297 (67.1%) toxin-EIA-positive and 146 (32.9%) toxin-EIA-negative/PCR-positive were only identified through the two-step algorithm including the PCR test. The incidence of CDI increased from 0.9 to 4.7/10,000 patient-days (p < 0.01) and 146 (32.9%) toxin-negative CDI were diagnosed. Testing rate increased from 24.4 to 59.5/10,000 patient-days (p < 0.01) and the percentage of positive stools rose from 3.9% to 12.5% (p < 0.01). CD toxin-positive patients had a higher frequency of severe presentation and a lower rate of immunosuppressive drugs and inflammatory bowel disease. Mortality (16.3%) was significantly higher in patients with hematological neoplasm, intensive care unit admission and complicated disease. Recurrences (14.9%) were significantly higher with proton pump inhibitor exposure. The two-step diagnostic algorithm facilitates earlier diagnosis, potentially impacting patient outcomes and nosocomial spread. CD-toxin-positive patients had a more severe clinical presentation, probably due to increased CD bacterial load with higher toxin concentration. This early and easy marker should alert clinicians of potentially more severe outcomes

Plasmolipin regulates basolateral-to-apical transcytosis of ICAM-1 and leukocyte adhesion in polarized hepatic epithelial cells

Apical localization of Intercellular Adhesion Receptor (ICAM)-1 regulates the adhesion and guidance of leukocytes across polarized epithelial barriers. Here, we investigate the molecular mechanisms that determine ICAM-1 localization into apical membrane domains of polarized hepatic epithelial cells, and their effect on lymphocyte-hepatic epithelial cell interaction. We had previously shown that segregation of ICAM-1 into apical membrane domains, which form bile canaliculi and bile ducts in hepatic epithelial cells, requires basolateral-to-apical transcytosis. Searching for protein machinery potentially involved in ICAM-1 polarization we found that the SNARE-associated protein plasmolipin (PLLP) is expressed in the subapical compartment of hepatic epithelial cells in vitro and in vivo. BioID analysis of ICAM-1 revealed proximal interaction between this adhesion receptor and PLLP. ICAM-1 colocalized and interacted with PLLP during the transcytosis of the receptor. PLLP gene editing and silencing increased the basolateral localization and reduced the apical confinement of ICAM-1 without affecting apicobasal polarity of hepatic epithelial cells, indicating that ICAM-1 transcytosis is specifically impaired in the absence of PLLP. Importantly, PLLP depletion was sufficient to increase T-cell adhesion to hepatic epithelial cells. Such an increase depended on the epithelial cell polarity and ICAM-1 expression, showing that the epithelial transcytotic machinery regulates the adhesion of lymphocytes to polarized epithelial cells. Our findings strongly suggest that the polarized intracellular transport of adhesion receptors constitutes a new regulatory layer of the epithelial inflammatory respons

A simple new screening tool for diagnosing imported schistosomiasis

We sought to test the sensitivity and feasibility of a Schistosoma infection screening process consisting of a scored patient consultation questionnaire and a serological diagnostic test. Prospective cross-sectional study. We collected from Schistosoma-exposed individuals a 14-point check list of clinical and laboratory data related to Schistosoma infection, alongside a serological test to detect Schistosoma spp infection. A check list score was created and compared with the risk of infection and clinical recovery through an agreement analysis. Two-hundred and fifty individuals were enrolled, of whom 220 (88%) were male and 30 (12%) female. The median age was 39 (range 18-78). One hundred-fifty (60%, 95% CI 54.9%-65.1%) had a check-list score ≥2. Serology test results were positive for 142 (56.8%, 95% CI 51.6%-62%). Chronic complications compatible with long-term Schistosoma infection were detected in 29 out of these 142 (20.4%, 95% CI 13.8%-27%).,. The median score value was 3, the area under the receiver operating characteristic (ROC) curve against serology results was 0.85 and the estimated intercept check-list questionnaire score value was 1.72 (95%, CI: 1.3-2.2). Participants with a positive serological test had a substantially higher check-list score (Cohen's kappa coefficient: 0.62, 95% CI: 0.54-0.70). Ninety four percent patients empirically treated showed a subsequent improvement in clinical and laboratory parameters. A two-component process consisting of a scored patient consultation questionnaire followed by serological assay can be a suitable strategy for screening populations at high risk of schistosomiasis infection

Epidemiological, clinical, diagnostic and economic features of an immigrant population of chronic schistosomiasis sufferers with long-term residence in a nonendemic country (North Metropolitan area of Barcelona, 2002-2016)

Background. Schistosomiasis, one of the neglected tropical diseases (NTD) listed by the WHO, is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. Complications of long-term infestation include liver cirrhosis, bladder tumors and kidney failure. The objective of this study was to carry out a clinical and epidemiological characterization of a schistosomiasis-diagnosed immigrant population with long-term residencein the EU as well as to evaluate the diagnostic methods available to date. Methods and results. A total of 61 individuals with Schistosoma infection who received medical attention between June 2002 and June 2016 at the North Metropolitan International Health Unit in Barcelona (Catalonia, Spain), were included in the study. All patients were sub-Saharan African immigrants. The majority were male (91.8%) with a median age of 34 years. Symptoms attributable to infection such as haematuria, abdominal pain and dysuria were recorded in up to 90% of patients. The percentage of eosinophils decreased amongst older patients (p = 0.002) and those with symptoms associated with urinary tract infections (p = 0.017). Serology was used for diagnosis in 80.3% of the cases, with microscopic examination showingthe remaining 9.8% positive for parasite eggs. Direct microbiological diagnosis was more useful in patients with less than 5 years of residence in the EU (p = 0.05). Chronic complications were present in 22 (36%) of the patients, with renal failure affecting 20 (33%). Of these 20, 6(10%) developed terminal renal failure and required hemodialysis, while 3 (5%) received a renal transplantation. Conclusion. Morbidity associated with chronic long-term schistosomiasis is frequent among African immigrants in non-endemic countries. Better diagnostic tools and appropriate early treatment would prevent the development of visceral damage. Thorough screening in selected patients would also be useful to avoid chronic complications

La figura del defensor del menor en la Comunidad de Madrid: un análisis intergubernamental y comparado

Esta publicación da cuenta de una investigación, financiada por el Defensor del Menor de la Comunidad de Madrid (Asamblea de la Comunidad de Madrid) en que, de manera pionera, se aplica la metodología de análisis intergubernamental en España a una institución pública. También se aplica el análisis comparativo. La investigación contó con la participación en el trabajo de campo de decenas de organizaciones e instituciones públicas españolas y extranjeras. El estudio se desenvuelve en ocho capítulos, sin contar las conclusiones y las fuentes y anexos. En los primeros se realiza una aproximación a la metodología intergubernamental como marco de comprensión del conjunto de trabajo, se tratan los asuntos normativos y se analizan las redes de actores de que forma parte del Defensor del Menor, mostrando el lugar central que ocupa en varias de ellas. El capítulo VI profundiza en la legitimidad y realiza una operativización cualitativa de la misma a partir de la clásica distinción entre legitimidad institucional y por rendimientos, esquema que se confronta con las actuaciones del Defensor. El capítulo VII se plantea en qué medida el Defensor del Menor puede considerarse una organización moderna, en tanto que el VIII se centra en el análisis comparativo de esta figura con otras organizaciones defensoras de los derechos de la infancia tanto a nivel nacional como internacional

Evolution of the Use of Corticosteroids for the Treatment of Hospitalised COVID-19 Patients in Spain between March and November 2020: SEMI-COVID National Registry

Objectives: Since the results of the RECOVERY trial, WHO recommendations about the use of corticosteroids (CTs) in COVID-19 have changed. The aim of the study is to analyse the evolutive use of CTs in Spain during the pandemic to assess the potential influence of new recommendations. Material and methods: A retrospective, descriptive, and observational study was conducted on adults hospitalised due to COVID-19 in Spain who were included in the SEMI-COVID-19 Registry from March to November 2020. Results: CTs were used in 6053 (36.21%) of the included patients. The patients were older (mean (SD)) (69.6 (14.6) vs. 66.0 (16.8) years; p < 0.001), with hypertension (57.0% vs. 47.7%; p < 0.001), obesity (26.4% vs. 19.3%; p < 0.0001), and multimorbidity prevalence (20.6% vs. 16.1%; p < 0.001). These patients had higher values (mean (95% CI)) of C-reactive protein (CRP) (86 (32.7-160) vs. 49.3 (16-109) mg/dL; p < 0.001), ferritin (791 (393-1534) vs. 470 (236-996) mu g/dL; p < 0.001), D dimer (750 (430-1400) vs. 617 (345-1180) mu g/dL; p < 0.001), and lower Sp0(2)/Fi0(2) (266 (91.1) vs. 301 (101); p < 0.001). Since June 2020, there was an increment in the use of CTs (March vs. September; p < 0.001). Overall, 20% did not receive steroids, and 40% received less than 200 mg accumulated prednisone equivalent dose (APED). Severe patients are treated with higher doses. The mortality benefit was observed in patients with oxygen saturation </=90%. Conclusions: Patients with greater comorbidity, severity, and inflammatory markers were those treated with CTs. In severe patients, there is a trend towards the use of higher doses. The mortality benefit was observed in patients with oxygen saturation </=90%