Maximo O. Brito

Molecular basis of group A streptococcal virulence

The group A streptococcus (GAS) (Streptococcus pyogenes) is among the most common and versatile of human pathogens. It is responsible for a wide spectrum of human diseases, ranging from trivial to lethal. The advent of modern techniques of molecular biology has taught much about the organisms virulence, and the genomes of several GAS types have now been deciphered. Surface structures of GAS including a family of M proteins, the hyaluronic acid capsule, and fibronectin-binding proteins, allow the organism to adhere to, colonise, and invade human skin and mucus membranes under varying environmental conditions. M protein binds to complement control factors and other host proteins to prevent activation of the alternate complement pathway and thus evade phagocytosis and killing by polymorphonuclear leucocytes. Extracellular toxins, including superantigenic streptococcal pyrogenic exotoxins, contribute to tissue invasion and initiate the cytokine storm felt responsible for illnesses such as necrotising fasciitis and the highly lethal streptococcal toxic shock syndrome. Progress has been made in understanding the molecular epidemiology of acute rheumatic fever but less is understood about its basic pathogenesis. The improved understanding of GAS genetic regulation, structure, and function has opened exciting possibilities for developing safe and effective GAS vaccines. Studies directed towards achieving this long-sought goal are being aggressively pursued.

Acceptability of Male Circumcision for the Prevention of HIV/AIDS in the Dominican Republic

Background Male circumcision (MC) is an effective strategy to prevent HIV infection in heterosexual men. To our knowledge, there are no studies of the acceptability of this procedure in the Dominican Republic (DR). The main objective of this study was to assess the acceptability of MC to prevent HIV transmission among men ages 18 to 50 years in the Altagracia Province in the Dominican Republic. Because differences in culture and beliefs between Haitians and Dominicans could potentially influence their acceptability of MC, we conducted a comparative analysis based on national origin. Methods A survey was administered to a convenience sample of 368 men. The questionnaire was divided in 3 sections: 1) Background demographics (including national origin), 2) Male circumcision and 3) Sexual health. Stratified and logistic multivariate regression analyses were performed to identify factors associated with the acceptability of MC. Results The sample consisted of 238 (65%) Dominicans and 130 (35%) Haitian immigrants. Almost all participants were uncircumcised (95%) and about half (52%) were single. The overall acceptability of MC was 29%. The number of men willing to be circumcised increased to 67% after an information session explaining the benefits of the procedure. 74% of men reported that they would be willing to circumcise their sons after hearing that information. In multivariate analysis, Haitian nationality (OR = 1.86, 95% CI 1.01–3.41), knowing that circumcision improves hygiene (OR = 2.78, 95% CI 1.29–6.0) and not believing that circumcision decreases sexual pleasure (OR = 2.18, 95% CI 1.20–3.94) were associated with a higher acceptability of the procedure. Although age was not significantly associated with the willingness to be circumcised in the multivariate analysis, stratified analysis based on national origin suggested that younger Dominicans (<30 years of age) are more likely to accept the procedure when compared to their older counterparts (OR = 2.17, 95% CI 1.14–4.12). Conclusions An important number of sexually active men in the DR may be willing to be circumcised if educational resources detailing the benefits of the procedure are made available. These educational activities would constitute a great opportunity to teach about sexual health and reinforce safe sex practices.

The feasibility and acceptability of male circumcision among men, women, and health providers of the Altagracia Province, Dominican Republic

Abstract Background. Male circumcision (MC) is an effective strategy to reduce the risk of HIV acquisition in men. The objective of the present study was to evaluate the feasibility of introducing MC in the Altagracia Province and to qualitatively assess the knowledge and acceptability of MC among men, women, and health providers. Methods. Two surveys were administered to providers. The first, assessed their experience and knowledge of MC and the second, a “Health Facility Profile,” included an inventory of available surgical materials in the clinics. Fourteen focus group discussions were conducted to evaluate the acceptability of MC. Results. Forty-three providers were interviewed at 37 clinics. Median age was 33 years (range 23–55 years). Most were physicians (91%) employed by the government. Only 23% had experience with MC. Almost universally (95%), providers knew that MC has health benefits. All agreed that MC improves hygiene and 67% knew that MC decreases the risk of HIV infection. Only six clinics provided HIV counseling and testing and most lacked adequate surgical facilities and equipment. Findings of the qualitative study showed that about half the men and the majority of women were accepting of MC. Conclusions. Men, women, and providers in the Dominican Republic may be accepting of MC. Education about the benefits of the procedure is needed in the community.

Disease Severity and Mortality Caused by Dengue in a Dominican Pediatric Population

Millions are infected with dengue yearly. We evaluated the epidemiological and clinical characteristics of pediatric patients infected with dengue in the Dominican Republic. The applicability of World Health Organization (WHO) warning signs for predicting severe dengue and mortality was also studied. This study was a cross-sectional retrospective review of patients with a clinical diagnosis of dengue. Univariate and multivariate analyses were performed to evaluate characteristics associated with severity and mortality. The study included 796 subjects: 288 subjects were classified as dengue, 290 subjects had alarm signs, and 207 subjects were classified as severe dengue. Common findings included thrombocytopenia (96%), abdominal pain (71%), and vomiting (59%). The most important factors associated with severe dengue were rash (P < 0.01), severe thrombocytopenia (P < 0.01), and anemia (P < 0.01). These signs and symptoms were also associated with mortality. This study validates the current WHO warning signs of severity. Rash and severe thrombocytopenia may be early warning signs and need additional study.

A Clinical Trial to Introduce Voluntary Medical Male Circumcision for HIV Prevention in Areas of High Prevalence in the Dominican Republic.

Background Voluntary Medical Male Circumcision (VMMC) is an effective strategy to reduce the risk of HIV infection. Studies conducted in the Dominican Republic (DR) suggest that acceptability of VMMC among men may be as high as 67%. The goal of this clinical trial was to assess the acceptability, uptake and safety for VMMC services in two areas of high HIV prevalence in the country. Methods This was a single-arm, non-randomized, pragmatic clinical trial. Study personnel received background information about the risks and benefits of VMMC and practical training on the surgical technique. A native speaking research assistant administered a questionnaire of demographics, sexual practices and knowledge about VMMC. One week after the surgery, participants returned for wound inspection and to answer questions about their post-surgical experience. Results 539 men consented for the study. Fifty seven were excluded from participation for medical or anatomical reasons and 28 decided not to have the procedure after providing consent. A total of 454 men were circumcised using the Forceps Guided Method Under Local Anesthesia. The rate of adverse events (AE) was 4.4% (20% moderate, 80% mild). There were no serious AEs and all complications resolved promptly with treatment. Eighty eight percent of clients reported being “very satisfied” and 12% were “somewhat satisfied” with the outcome at the one-week postoperative visit. Conclusions Recruitment and uptake were satisfactory. Client satisfaction with VMMC was high and the rate of AEs was low. Roll out of VMMC in targeted areas of the DR is feasible and should be considered. Trial Registration ClinicalTrials.gov NCT02337179

“I Feel Like More of a Man”: A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30). We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine (OR = 1.70, 95% CI: 1.25–2.32), feeling more potent erections post-circumcision (OR = 2.25, 95% CI: 1.26–4.03), and reporting increased ability to satisfy their partners post-circumcision (OR = 2.30, 95% CI: 1.11–4.77). In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one’s partner, and men’s experiences of circumcision were shaped by social norms of masculinity. This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.

Update in internal medicine

More than 500,000 new medical articles are published every year and available time to keep updated is scarcer every day. Nowadays, the task of selecting useful, consistent, and relevant information for clinicians is a priority in many major medical journals. This review has the aim of gathering the results of the most important findings in clinical medicine in the last few years. It is focused on results from randomized clinical trials and well-designed observational research. Findings were included preferentially if they showed solid results, and we avoided as much as possible including only preliminary data, or results that included only non-clinical outcomes. Some of the most relevant findings reported here include the significant benefit of statins in patients with coronary artery disease even with mean cholesterol level. It also provides a substantial review of the most significant trials assessing the effectiveness of IIb/IIIa receptor blockers. In gastroenterology many advances have been made in the H. pylori eradication, and the finding that the cure of H. pylori infection may be followed by gastroesophageal reflux disease. Some new antivirals have shown encouraging results in patients with chronic hepatitis. In the infectious disease arena, the late breaking trials in anti-retroviral disease are discussed, as well as the new trends regarding antibiotic resistance. This review approaches also the role of leukotriene modifiers in the treatment of asthma and discusses the benefit of using methylprednisolone in patients with adult respiratory distress syndrome, among many other advances in internal medicine.

The great impostor: Lues maligna in an HIV-infected male

Lues maligna is a rare severe cutaneous manifestation of secondary syphilis. It is also known as malignant syphilis and ulceronodular syphilis. We report a case of a 58-year-old HIV-infected male who presented with diffuse, pruritic, non-tender, maculo-papular skin lesions, ulcerated nodules and plaques surrounded by an erythematous base. The disseminated skin lesions were at various stages and were located on his back, chest, arms and testicles. Patient had been receiving antiretroviral therapy. Laboratory studies had demonstrated CD4 lymphocyte count of 463 cells/mm3 and an undetectable HIV viral load. Workup revealed a rapid plasma reagin of 1:256 dilutions and the skin biopsy findings were compatible with syphilis. The skin lesions resolved with intramuscular penicillin. We herein describe a rare case of lues maligna in an HIV-infected patient with a preserved immune function and viral suppression. Such skin lesions can mimic fungal or mycobacterial infections and can pose a diagnostic challenge. Even in the modern era, syphilis remains the great impostor. Clinicians must be able to recognize this condition based on clinical characteristics and risk factors to diagnose and treat this condition promptly.

A cross-national study to compare the knowledge, attitudes, perceptions of sexually transmitted diseases and the sexual risk behaviors of Latino adolescents.

Abstract Background: Adolescents are at high risk of acquiring sexually transmitted diseases (STDs). However, little is known about differences in knowledge and risk behaviors across nationalities. The objective of this study was to assess and compare the knowledge and perceptions of STDs and the sexual risk behaviors in Latino adolescents in the United States (US) and the Dominican Republic (DR). Methods: A survey was administered to 364 high school students after obtaining parental consent. The questionnaire asked about demographics, sources of STD information, risk behaviors, and knowledge of syphilis, gonorrhea, and human immunodeficiency virus (HIV). Mean percentage scores were calculated to compare correct responses by nationality, gender, and sexual activity. Predictors of self-reported high risk sexual behavior were identified by multivariable logistic regression analysis. Results: In all, 242 (66%) US and 122 (34%) DR students were interviewed. Of these, 52% were males. Median age was 15 years (range, 13–18). Sexual activity was reported by 40% of the participants and did not differ by gender (p=0.43) or national origin (p=0.53), although it was greater for adolescents older than 15 years of age (60% vs. 35%, p<0.001). US students identified abstinence as an effective STD prevention method more often than their counterparts (p=<0.001). Knowledge of specific STDs was higher in girls (p=0.002) and Dominicans (p=0.003). Predictors of high risk behavior were male gender (OR<uni-003D;2.50, 95% CI 1.35–4.63) and being sexually active (OR<uni-003D;3.09, 95% CI 1.71–5.59). Conclusions: Sexual activity at an early age was prevalent, and knowledge of STDs low in these two groups of high school students. Males and sexually active individuals were more likely to engage in high risk behaviors. Girls and Dominican students exhibited greater knowledge of specific STDs.

Zika Virus Epidemic in the Dominican Republic, 2016

Abstract Background The first cases of Zika (ZIKV) in the Americas were reported in Easter Island, Chile in 2014. The epidemic spread to Brazil and Central America in 2015. We describe the extent and distribution of the countrywide ZIKV epidemic in the Dominican Republic. Methods The DR Ministry of Health (MoH) instituted active surveillance, monitoring and mandatory reporting of suspected cases of ZIKV in 2015 through the National System of Epidemiologic Surveillance (SINAVE). In the pre-epidemic period, the MoH conducted active search and blood testing of suspected cases in communities rumored to have cases of the disease. During the epidemic, the MoH conducted weekly monitoring of all cases of febrile exanthems, flaccid paralysis and meningitis, and also conducted rapid surveys in highly populated areas to identify local outbreaks. Data from SINAVE was exported and analyzed using SAS. Results A total of 5226 cases ZIKV were reported to the MoH from January 2016 to December 2016 (figure). Cases were 74% female, of whom 1275 (33%) were pregnant. Most of the cases (51%) were diagnosed in the age group of 20 to 39, and did not differ by gender. The majority (58%) of cases were reported from a metropolitan area. Almost all cases (82%) were treated in the outpatient setting, while 17% were hospitalized. Only 3 patients died and 95% had an uncomplicated course. There were 285 cases of Guillain BarrŽ Syndrome (GBS; Figure), with the epidemic curve showing a peak 2–4 weeks following the peak of the epidemic. Compared with patients with suspected ZIKV (n = 1054), those with GBS were more likely to be male (47% vs. 19%, P < 0.001), aged ≥40 years (53% vs. 19%, P < 0.001),, more likely to have complications (18% vs. 6%, P < 0.001) and comorbidity (2% vs. 0.2%, P = 0.04) Seventeen (6%) of confirmed GBS cases resulted in death.Figure Cases of Zika and GBS, Dominican Republic, 2016 Conclusion The DR reported one of the largest ZIKV outbreaks in the Americas. The epidemic started early in 2016 and had all but subsided by May 2017. Although most cases had an uncomplicated course, incidence of GBS was high. Disclosures All authors: No reported disclosures.