Costa Rican Department of Social Security

Se exponen algunos aspectos inherentes al ejercicio profesional de la medicina marítima y se plantea que, en Costa Rica, si bien se han acogido los respectivos convenios internacionales, todavía se enfrenta una necesidad urgente de formación de médicos evaluadores y la estandarización de formatos para certificados marítimos. Se resumen las propuestas en cuatro componentes fundamentales: formación académica en posgrado, protocolo oficial, infraestructura e investigación. Cerrar esta brecha no solo garantiza equidad sanitaria para trabajadores marítimos y equidad en salud ocupacional, sino que fortalece la economía azul, protege la imagen país como destino sostenible y asegura el cumplimiento de tratados internacionales ratificados.

Introduction: Aspergillosis affects mainly immunosuppressed patients, especially those with neutropenia. A decreased susceptibility of antifungals used in the treatment of this disease has been reported in the last decade. At present, in Costa Rica there is a lack of studies concerning the antifungal activity of clinical Aspergillus isolates. Thus, the purpose of the present investigation was to determine the in vitro susceptibility patterns of clinical Aspergillus fumigatus, A. flavus, A. niger, A. terreus and A. versicolor. Methods: The susceptibility of 42 Aspergillus spp. to amphotericin B, itraconazole and voriconazole was evaluated using the Clinical and Laboratory Standards Institute broth microdilution M38-A guideline for filamentous fungi. Results: The mean minimal inhibitory concentration (MIC) for A. fumigatus was 1,64 µg mL-1 for amphotericin B, 1,38 µg mL-1 for itraconazole and 3.52 µg mL-1 for voriconazole, and 33,3 % of the isolates were resistant to voriconazole. For the other species tested, the mean MIC was 7,19 µg mL-1 for amphotericin B, 0,46 µg mL-1 for itraconazole and 1,58 µg mL-1 for voriconazole. Conclusions: MIC values for amphotericin B and itraconazole of most A. fumigatus isolates were comparable to those of wild-type strains. However, a significant percentage of the isolates were resistant to voriconazole, the first line treatment for aspergillosis. Further, A. flavus, A. niger, A. terreus and A. versicolor demonstrated high MIC values for amphotericin B; thus, it is recommended to performed susceptibility testing in these cases if there is a poor response to therapy.

La esclerosis lateral amiotrófica (ELA) representa uno de los mayores desafíos clínicos dentro de las enfermedades neurodegenerativas del adulto. Su curso progresivo, el deterioro motor acelerado y el impacto multidimensional sobre la funcionalidad, la comunicación, la nutrición y la respiración obligan a replantear constantemente nuestros modelos de atención. En este contexto, los estudios que buscan caracterizar a los pacientes y sistematizar su evaluación funcional adquieren un valor estratégico para la práctica clínica y la planificación de servicios de salud.

BackgroundRespiratory Syncytial Virus (RSV) infection in adults can evolve into severe conditions. Identifying risk factors for Severe Acute Respiratory Infection (SARI) would optimize clinical management. To develop and validate a predictive model to identify adult patients with RSV at risk of developing SARI.Independent Risk FactorsIndependent Risk Factors for SARI in Adult RSV PatientsClinical Prediction ScoreClinical Prediction Score for SARI Risk in Adult RSV PatientsMethodsAnalysis of 187 adults with PCR-confirmed RSV (Mexico Hospital, 2022-2024). Using multivariate logistic regression, independent factors associated with SARI were identified. A clinical scoring system was developed, and its diagnostic performance was evaluated through ROC analysis and internal validation by bootstrap.ROC CurveROC Curve for SARI Risk Prediction ModelCalibration PlotCalibration Plot of Predicted vs Observed SARI RiskResultsSix independent risk factors for SARI were identified: age ≥80 years (OR 3.86, 95%CI 1.47-10.13), preexisting lung disease (OR 3.52, 95%CI 1.68-7.37), presence of dyspnea (OR 4.25, 95%CI 1.98-9.13), fever (OR 2.87, 95%CI 1.31-6.30), ≥3 comorbidities (OR 2.34, 95%CI 1.08-5.05), and temperature >36.5°C (OR 2.15, 95%CI 1.01-4.59). The scoring system assigned 2 points to age ≥80 years, lung disease, and dyspnea; 1 point to fever, ≥3 comorbidities, and temperature >36.5°C. The model showed excellent discriminative capacity (AUC 0.82, 95%CI 0.74-0.89) with sensitivity 76.9%, specificity 75.6%, and negative predictive value 89.5%. Internal validation confirmed the model's robustness (optimism-corrected AUC 0.79).ConclusionThe developed scoring system effectively stratifies SARI risk in adult patients with RSV, with four categories: low risk (0-1 points, < 10%), moderate (2-3 points, 10-30%), high (4-5 points, 30-60%), and very high (6-9 points, >60%). This tool could optimize clinical decisions, facilitating identification of patients requiring closer monitoring or early intervention. External validation is required before widespread implementation.DisclosuresAll Authors: No reported disclosures

BackgroundCandida species represent 80% of nosocomial fungal infections, with candidemia being the most frequent invasive disease. In Latin America, Candida resistance is generally low, but information from Central America is scarce. We aimed to describe antifungal susceptibility of Candida species isolated from bloodstream infections at two national adult hospitals in Costa Rica from 2012 to 2023.MethodsThis retrospective study analyzed the first isolate from candidemia episodes caused by C. albicans, C. tropicalis, C. parapsilosis, and C. glabrata with available susceptibility results. Testing used VITEK 2 system. Interpretation followed CLSI M27M44S-Ed3 guidelines. Amphotericin B susceptibility was defined as MIC ≤1μg/ml. Differences between species were assessed using Fisher's exact test, and temporal trends with chi-square test.ResultsWe analyzed 1,390 isolates: C. parapsilosis 689 (49.6%), C. albicans 448 (32.2%), C. tropicalis 131 (9.4%), and C. glabrata 122 (8.8%). Fluconazole susceptibility was high in C. albicans (97.1%) and C. tropicalis (96.2%), but lower in C. parapsilosis (40.6%, p< 0.001). C. glabrata isolates were predominantly susceptible-dose dependent (96.1%). Voriconazole showed high activity against C. albicans (98.7%) and C. tropicalis (96.9%), but resistance in C. parapsilosis (20.2%). Amphotericin B maintained excellent activity against all species (98.7% overall). Echinocandins demonstrated high efficacy against C. albicans, C. tropicalis, and C. parapsilosis (≥99%), but reduced activity against C. glabrata (caspofungin 41.3% susceptible, micafungin with 70.6% intermediate and 29.4% resistant). No significant temporal trends in susceptibility were observed over the 12-year period.ConclusionOur findings reveal significant azole resistance in C. parapsilosis, particularly to fluconazole (59.4%) and voriconazole (20.2%). Amphotericin B maintains excellent activity against all species. Echinocandins remain highly effective against most Candida species except C. glabrata. These patterns have important implications for empirical antifungal therapy selection in our region.DisclosuresAll Authors: No reported disclosures

Objetivo: estimar la comprensibilidad, la aplicabilidad y la interacción con el profesional de la salud de un formulario piloto de consentimiento informado para el uso de medicamentos fuera de indicación oficial implementado en el sistema público de salud de Costa Rica. Materiales y métodos: luego de hacer el procedimiento de consentimiento informado con un formulario piloto creado por el Área de Bioética de la Caja Costarricense de Seguro Social, se realizó una encuesta autoadministrada, voluntaria y anónima a pacientes adultos que por su condición médica requerían la administración de algún fármaco fuera de indicación oficial (uso off label), con el fin de evaluar la comprensibilidad del formulario antes de su oficialización a nivel institucional. Previo a la aplicación de la encuesta se realizó una entrevista cognitiva a cuatro pacientes, con el fin de identificar y solucionar problemas relacionados con la comprensión y la respuesta a los diferentes ítems. La implementación del estudio tuvo lugar en la Consulta Externa de Inmunología Clínica del Hospital Rafael Ángel Calderón Guardia, entre enero y marzo de 2024. Resultados: diez pacientes accedieron a efectuar el cuestionario. La totalidad de los encuestados calificó el formulario de consentimiento informado como comprensible (100 %) y relevante (100 %). La sección de evaluación ordinal mostró puntuaciones altas en claridad (media = 3,5), utilidad para la toma de decisiones (media = 3,2) y seguridad percibida (media = 3,1). El alfa de Cronbach global fue de 0,88, indicando una alta consistencia interna del cuestionario. El análisis de conglomerados exploratorio identificó dos perfiles de respuesta diferenciados, aunque con limitaciones atribuibles al tamaño muestral. Tres de los pacientes encuestados indicaron que el proceso de consentimiento informado con el formulario piloto debió efectuarse con más tiempo. Conclusiones: el formulario piloto de consentimiento informado analizado resultó comprensible y de moderada utilidad según los pacientes encuestados. Sin embargo, las autoridades de salud deben considerar que este procedimiento consume mucho tiempo del médico especialista tratante, lo cual limita su aplicabilidad en el contexto de la práctica clínica habitual y puede afectar la adherencia del personal médico para llevarlo a cabo.

ABSTRACTAimWe aimed to develop and test machine learning algorithms for the prediction of severe outcomes associated with MIS‐C.MethodAn observational ambispective cohort study was conducted including children aged from 1 month to 18 years old in 84 hospitals from the REKAMLATINA (Red de la Enfermedad de Kawasaki en America Latina) network diagnosed with MIS‐C from 1st January 2020 to 31st June 2022. Multiple models were developed to predict four main outcomes: paediatric intensive care unit (PICU) admission, need for inotropes, need for mechanical ventilation, and death. Performance measures were accuracy for PICU admission, inotropes use and mechanical ventilation, and the area under the receiver operating characteristic curve (AUROC) for death. Variable contribution was analysed using Shapley Additive Explanations (SHAP) values.ResultsWe included 1303 children with a diagnosis of MIS‐C. The model for the prediction of PICU admission (random forest [RF]) reached an accuracy of 0.80 (95% CI: 0.76–0.84), the model for inotrope use (RF) an accuracy of 0.86 (95% CI: 0.82–0.90), the model for mechanical ventilation (histogram‐based gradient boosting [HBGB]) an accuracy of 0.84 (95% CI 0.80–0.88), and the model for death (RF) reached an AUROC of 0.85 (95% CI 0.77–0.93).ConclusionsWe developed and validated machine learning models for the prediction of MIS‐C related outcomes that can help clinicians risk stratify patients to identify those most likely to have a severe outcome from MIS‐C.

Human proteinase 3 (hPR3) is a lysosomal enzyme of the serine protease type. In autoimmune vasculitis, autoantibodies to hPR3 appear to have a role in the inception of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), where this protein is the main autoantigen. Indeed, patients with antibodies against hPR3 have more severe symptoms, relapses, and resistance to immunosuppressive therapies, supporting an important role for this autoantigen in the pathophysiology and severity of AAV. In this review, we describe what is known about the role of hPR3 in pathophysiology, diagnosis of AAV, and some perspectives on its treatment.