ABSTRACT Background: Pseudomonas aeruginosa is an important causative agent of nosocomial infections. As pathogen, P. aeruginosa is of increasing clinical importance due to its ability to develop high-level multidrug resistance (MDR). Methods: The aim of the present study was to better understand the intrinsic virulence of circulating strains of Pseudomonas aeruginosa, by surveying and characterizing the antibiotic resistance profiles and prevalence of virulence factors in 51 clinical isolates of P. aeruginosa obtained from children admitted to Hospital del Niño-Panamá during the period of October 2016 until March 2017. Antimicrobial susceptibilities were assessed by determining the minimum inhibitory concentration for 12 antibiotics against P. aeruginosa clinical isolates using the VITEK system (https://www.biomerieux.com). Additionally, all isolates were examined by Polymerase Chain Reaction (PCR) for the presence of components of the MexAB-OprM efflux pump system (mexABR) and pyoverdine receptor genes and betalactamases resistance genes (ESBL) using gene-specific primers. Results: A total of 51 pyoverdine producing clinical isolates were analyzed, all of which expressed resistance genes such as genes of the MexAB-OprM efflux pump system (mexABR) and pyoverdine receptor genes (fpvA). Out of 51 MDR isolates, 22 were ESBL producers. The most common ESBL gene was blaTEM expressed by 43% of the isolates. The isolates tested in this study showed increased resistance to antibiotics in the following categories: (i) penicillins (ampicillin (69%), piperacillin (22%); (ii) pyrimethamines (trimethoprim, 65%); (iii) nitrofurans (nitrofurantoin, 63%), and (iv) third-generation cephalosporin cefotaxime (53%). These results underscore a high prevalence of MDR amongst clinical isolates from Panama. Conclusions: The present study indicates that prevalence of BlaTEM-carrying strains is increasing with subsequent multidrug resistance in Panamá and as well reported worldwide. The virulent factors identified in this study provide valuable information regarding the prevalence of resistance genes and their potential impact on treatments that exploit the unique physiology of the pathogen. To prevent further spread of MDR, the proportions of resistant strains of Pseudomonas aeruginosa should be constantly evaluated on healthcare institutions of Panamá. More importantly, this information can be used to better understand the evolution and dissemination of strains hoping to prevent the development of resistance in Pseudomonas aeruginosa. Future studies quantifying the expression of these virulent genes will emphasize on the acquisition of multidrug resistance.

Abstract Introduction: The precut sphincterotomy is the technique in which the incision of the papilla is made to approach the difficult bile duct, and with which access is achieved in up to 80% of these cases. The most widely used device for this is precut sphincterotome. Objective: Report the experience in the Hospital General de México “Dr. Eduardo Liceaga” in terms of indications, percentage of success and characteristics of the patient undergoing precut sphincterotomy. Material and methods: Patients who underwent precut sphincterotomy for canulation of the complex biliary tract, were retrospectively analyzed in the period from June 2014 to May 2019. Those who did not have a complete file were excluded. Results: 88 patients were included, of both sexes, from 11 to 92 years of age, being a range of 50 to 59 years the most numerous. The choledocholithiasis was the most common diagnosis prior to ERCP with 55 cases (62.5%), as well as the subsequent diagnosis with 35 cases (39.7%), with a success rate of 84.1%. As a complication there were 5 (5.6%) cases of bleeding at the time of precut, and no case of mortality secondary to this technique. Conclusions: Precut sphincterotomy is an adequate technique to access the bile duct of difficult cannulation, with which success is achieved in more than 80% of cases and with low morbidity and mortality.

Resumen Introducción: La esfinterotomía de precorte es la técnica en la cual se realiza la incisión de la papila, utilizada para el abordaje de la vía biliar difícil, y con la cual se logra acceder hasta en el 80% de estos casos. El dispositivo más ampliamente usado para esto en el esfinterotomo de precorte. Objetivo: Reportar nuestra experiencia en el Hospital General de México “Dr. Eduardo Liceaga” en cuanto a indicaciones, porcentaje de éxito y características del paciente sometido a esfinterotomía de precorte. Material y métodos: Se analizó de modo descriptivo y retrospectivo, pacientes a quienes se realizó esfinterotomia de precorte para canulación de la vía biliar compleja, en el período comprendido de junio de 2014 a mayo de 2019. Se excluyeron aquellos que no contaban con expediente completo y aquellos a quienes no se les realiza esfinterotomia precorte. Resultados: Se incluyeron 88 pacientes, de ambos sexos, con edades entre los 11 a 92 años de edad, siendo el rango mayor entre los 50 a 59 años. La coledocolitiasis fue el diagnóstico más frecuente, previo a la CPRE con 55 casos (62.5%), al igual que el diagnóstico posterior a la misma con 35 casos (39.7%), se determinó un 84.1%. de éxito para canular vía biliar compleja, en el número de casos analizados. Como complicación se presentaron 5 casos (5.6%) de sangrado al momento del precorte y ningún caso de mortalidad secundaria a esta técnica. Conclusiones: La esfinterotomia de precorte es una técnica adecuada, segura y reproducible, que nos permite accesar a la vía biliar de canulación compleja, con la que se logra el éxito en más del 80% de los casos y con baja morbi-mortalidad.

El uso de plantas forrajeras en la dieta de diferentes especies animales es una de las opciones para la producción eficiente y rentable cuando se trata de sistemas agropecuarios. Estas aportan una importante cantidad de nutrientes a los suelos, ayudándolos a su recuperación y a un mayor rendimiento en cultivos adyacentes, mejorando la economía de los productores. En la presente investigación de tipo documental se hará una descripción de las generalidades y especificaciones de la planta arbórea Tithonia diversifolia, comúnmente denominada "botón de oro", incluyendo las características agromorfológicas de cultivo y los principales resultados que se presentan cuando esta forrajera es utilizada en la alimentación de conejos, cerdos, gallinas, ovinos, bovinos, cuyes y en apicultura; especies animales, en las cuales se ha observado que dicha planta es una alternativa que permite un rendimiento productivo adecuado sin afectar el estado fisiológico ni el bienestar del animal que, por el contrario, disminuye los costos de producción en las explotaciones pecuarias.

The use of forage plants in different animal species diet is one of the options for an efficient and profitable production when it comes to farming systems. Forage plants provide an important quantity of nutrients to the land, helping it in its recovery and to a higher performance in adjacent crops improving the producers' economy. This documentary research will describe generalities and specifications of the tree plant Tithonia diversifolia commonly known as the "golden button" including agro-morphological characteristics of crops and main results when forage plants are used in rabbits, pigs, chickens, sheep, bovines, guinea pigs, and apiculture diet, animal species in which it has been possible to observe how this plant is an alternative that allows an appropriate productive efficiency without affecting the animals physiological state and their welfare, because, on the contrary, it decreases production costs in livestock exploitation.

The Evans syndrome, first described in 1951, is an autoimmune disorder characterized by the simultaneous or sequential development of hemolytic anemia and immune thrombocytopenia or immune neutropenia. It may be of primary origin or secondary to other diseases or conditions such as systemic lupus erythematosus, lymphoproliferative disorders or primary immunodeficiencies. Its association with scleroderma is considered very rare. The word scleroderma, which literally means hard skin, designates a group of diseases and syndromes of common feature in induration and thickening the skin. It is characterized by the presence of excessive deposition of connective tissue components, expressed as histic fibrosis, and structural alterations of the vascular bed. With a broad clinical view, it primarily affects the skin and certain internal organs such as gastrointestinal tract, lung, heart and kidney. We present a 75 year-old female, black skin, with a history of hypertension, type 2 diabetes, ischemic heart disease and scleroderma, the latter diagnosed six months before admission. The patient referred marked weakness, pale skin and generalized petechiae. The complete blood count detected severe anemia, thrombocytopenia and reticulocytosis. Other studies showed positive direct Coombs test and severe hypercellularity. Evans Fisher syndrome was diagnosed and treated with steroids and immunomodulators; clinical improvement and hematologic remission was achieved.

El síndrome de Evans Fisher, descrito por primera vez en 1951, es un desorden autoinmune caracterizado por la presencia simultánea o secuencial de anemia hemolítica, trombocitopenia inmune y, en ocasiones, neutropenia inmune; con una prueba de antiglobulina directa positiva. Puede ser de causa primaria o secundaria a otras condiciones, como el lupus eritematoso sistémico, los síndromes linfoproliferativos o inmunodeficiencias primarias. Es muy rara su asociación con la esclerodermia. Con el término esclerodermia, que en sentido literal significa piel dura, se designa un grupo de enfermedades y síndromes que tienen como característica común la induración y el engrosamiento cutáneos. Se caracteriza por la presencia de un depósito excesivo de los componentes del tejido conjuntivo, expresado en forma de fibrosis hística, y por alteraciones estructurales del lecho vascular. Con un cuadro clínico muy amplio, afecta fundamentalmente la piel y ciertos órganos internos, como tubo digestivo, pulmón, corazón y riñón. Se presenta una paciente femenina de 75 años de edad, piel negra, con antecedentes de hipertensión arterial, diabetes mellitus tipo 2, cardiopatía isquémica y esclerodermia, esta última diagnosticada seis meses antes de su ingreso. Acudió por decaimiento marcado, palidez cutáneo-mucosa intensa y petequias generalizadas. En los estudios realizados se detectó anemia y trombocitopenia severas, reticulocitosis, prueba de antiglobulina directa positiva e hipercelularidad medular con hiperplasia severa de los sistemas megacariopoyético y eritropoyético. Se diagnosticó un síndrome de Evans Fisher y se trató con esteroides e inmunomoduladores; se logró la mejoría clínica y la remisión hematológica.