Adult T-cell Leukemia/Lymphoma (ATLL) is classified as a peripheral CD4+ T-cell neoplasm caused by the human T-cell lymphotropic virus type 1 (HTLV-1). Typical symptoms are associated with leukemic infiltration; however, atypical and exaggerated manifestations of verrucous carcinoma have also been described.  We present here the case of a patient with multiple skin lesions, ischemic necrosis in the hallux and lymphadenopathies. Biopsies were taken, which showed verrucous epidermal carcinoma and cutaneous lymphoma. Splenomegaly and adenopathy in mesentery, retro peritoneum and lymph node chains in the limbs were observed. Bone marrow examination showed findings compatible with T-cell leukemia/lymphoma; and it was ELISA positive for HTLV-1/2.The patient had a good initial response to a CHOP scheme  with filgrastim. However, the patient had a relapse and died before the second cycle. Comorbidity could lead to the associated risk factors model. According to this model, secondary immunodeficiency caused by HTLV-1 may induce the development of verrucous carcinomas; alternatively, the disease could be due to a correlation between HTLV-1 and the human papillomavirus (HPV). Secondary findings to leukemic infiltration are described, and an uncommon and excessive expression of verrucous carcinomas can be observed.This case report describes a 52-year-old woman from the coast of Nariño (Colombia). The patient presented with a 10-year history of progressive development of intensely pruritic papules, plaques and nodules. Symptoms started on the neck and thereafter slowly became widespread. No relevant associated family history was reported.During the physical exam, generalized xerosis, multiple and confluent excoriations, papules, plaques and nodules were observed. Lesions were found on the nape of the neck, anterior thorax, abdomen and extremities, including the palms and soles . The facThe patient reported pain on right hallux that started a week prior to the professional examination. The exam revealed a dry necrotic lesion Fig.B. A complete blood count reported 52,800 leukocytes, of which 67.39% were lymphocytes, 11.92% were neutrophils and 15.19% were eosinophils. Determined values for hemoglobin, hematocrit and platelets were 12.16%, 40.43% and 281, respectively. Biochemical assessment showed an increase in lactate dehydrogenase activity (LDH= 833 mg/dL), although renal and hepatic function test results were normal. Anti-HTLV-1/2 titer, signal to cut-off (S/CO) ratio, was measured by chemiluminescent microparticle immunoassay (CMIA). High positive (156.30 S/CO) ratios were obtained for HTLV-1/2. Human immunodeficiency virus (HIV) and Venereal Disease Research Laboratory (VDRL) tests were negative. A direct potassium hydroxide (KOH) mount of a skin scraping showed negative results for mycosis and scabies.Biopsies of infiltrated plaques were taken from both upper extremities and from the right leg. These biopsies demonstrated cutaneous lymphoma  A and B.Biopsies from exophytic tumors from the left femoral region and the right knee both demonstrated verrucous carcinomas  C y D.Doppler ultrasound of the lower extremities was performed due to the involvement of the right hallux. Ultrasound revealed the absence of flow in the anterior and posterior tibial arteries and the dorsalis pedis and plantar arteries.X-ray computed tomography (CT) was performed for the neck and thoracoabdominal regions. The scanner revealed many adenopathies involving several lymph node chains in the neck, armpits, inguinal region, retroperitoneum and mesentery. Splenomegaly was also observed.A bone marrow biopsy revealed normal trabecular bone, 65% of total marrow cellularity in separate marrow spaces, myeloid hyperplasia and severe eosinophilia. Flow cytometry of the bone marrow reported 48.4% pathological cells with CD4+, CD25+, CD45+, weak sCD3, CD5++ and 10% of CD7+ cells.These results led to the diagnosis of HTLV-1 infection-associated ATLL during the acute stage associated with a verrucous subtype of squamous cell carcinoma. Treatment with polychemotherapy was initiated after concluding that the patient had an unresectable cancer. The patient received a combination of CHOP  and polyethylene glycol (PEG) filgrastim (6 mg PEG filgrastim). The initial response to polychemotherapy was favorable; however, the patient had a subsequent relapse and died before the second cycle.Adult T-cell Leukemia/Lymphoma is associated with all cases of HTLV-1 infection. HTLV-1 plays a central role in ATLL pathogenesis. The HTLV-1 genome is integrated into the genome in T cells prior to viral replication Squamous cell carcinoma presents a broad variety of clinical manifestations, including papules, plaques, hyperkeratotic nodules and ulcerative lesions. These lesions can be developed on any skin surface. Verrucous carcinoma is a subtype of squamous cell carcinoma presenting with exophytic, cauliflower-like lesions similar to large warts The patient age fell in the more frequent range for ATLL. The patient was likely infected at a young age through either breastfeeding or sexual intercourse. The patient's chronic ailment, which began as an infective dermatitis, is remarkable.During adulthood, the patient had presented with the reported lesions for more than a decade. Without proper handling of the lesions, they transformed into malignant neoplasms that consisted of multiple verrucous carcinomas. It is possible that the exact reason for this transformation can be discovered.The concept of comorbidity leads to a possible direct causation model. According to this model, a chronic skin infiltration during ATLL will be responsible for verrucous carcinomas 13. It is known that HTLV-1 may worsen the clinical course of infections with other pathogens, including other viruses, such as HPV ,However, the concept of comorbidity could lead to the associated risk factors model. According to this model, secondary immunodeficiency caused by HTLV-1 may induce the development of verrucous carcinomas; alternatively, the disease could be due to a correlation between HTLV-1 and human papillomavirus (HPV),Persistent infection with HPV has been identified as a cofactor for the development of squamous cell carcinoma. The clinical and histopathological findings of verrucous carcinomas can be correlated with a permanent state of HPV infection, which can persist due to HTLV-1 infection. The persistence of verrucous carcinomas is facilitated by abnormalities in CD4+ T cells Zidovudine and interferon-α are promising treatments for this type of disease A Tax peptide-pulsed dendritic cell vaccine is a promising immunotherapy for ATLL remission at 2 months and for maintaining the remission for 2 years after vaccination This case report described a patient diagnosed with a HTLV-1 infection-associated ATLL in addition to verrucous carcinoma. Verrucous carcinoma is a subtype of squamous cell carcinoma with distinctive clinical and histopathological features. One of its risk factors is immunosuppression secondary to lymphomas; in addition, it can develop as ulcers on chronic inflammatory dermatoses. These two risk factors are present in the case (described here), so we consider that the immunosuppression caused by lymphoma and the chronic ulcerated lesions caused by HTLV infection facilitated the appearance of verrucous carcinoma. Preventing the virus from passing from mother to child is a key issue for the eradication of this disease. ,La leucemia/linfoma de células T del adulto se clasifica como una neoplasia de células T CD4+ periféricas desencadenada por el virus linfotrópico de células T humanas tipo 1 (HTLV-1) ,,La infección es endémica en varias islas del sur de Japón, la Cuenca del Caribe, África occidental, el noreste de Irán y el sureste de los Estados Unidos En Colombia se ha registrado el virus y la enfermedad con mayor prevalencia en el sur de la costa pacífica colombiana, alcanzado cifras de serología positiva en un 5,1% de la población negra del municipio de Tumaco La presentación clínica de los pacientes con leucemia/linfoma de células T del adulto asociado a HTLV-1 aún continúa caracterizándose. Exponemos como, además de los hallazgos más conocidos secundarios a la infiltración leucémica, se puede exhibir una manifestación atípica y exagerada de carcinomas verrucosos. Este reporte de caso describe a una mujer de 52 años de la Costa (Pacífica) de Nariño (Colombia). La paciente presentó una historia de 10 años de desarrollo progresivo de pápulas, placas y nódulos intensamente pruriginosos. Los síntomas comenzaron en el cuello y luego se extendieron lentamente. No se informó de ningún antecedente familiar asociado relevante. Durante el examen físico se observaron escoriaciones múltiples y confluentes, xerosis generalizada, pápulas, placas y nódulos. Se encontraron lesiones en la nuca, el tórax anterior, el abdomen y las extremidades, incluyendo las palmas de las manos y las plantas de los pies . La cara La paciente informó dolor en el hallux derecho, el cual comenzó una semana antes del examen médico. El examen reveló una lesión necrótica seca B.  Un recuento sanguíneo completo informó 52,800 leucocitos, de los cuales 67,39% eran linfocitos, 11.92% eran neutrófilos y 15.19% eran eosinófilos. Los valores determinados para hemoglobina, hematocrito y plaquetas fueron 12.16%, 40.43% y 281, respectivamente. La evaluación bioquímica mostró un aumento en la actividad de la lactato deshidrogenasa (LDH= 833 mg/dL), aunque los resultados de las pruebas de función renal y hepática fueron normales. Para los títulos de anticuerpos anti-HTLV - 1/2, se midió la relación señal a punto de corte (S/CO) mediante el método de inmunoensayo de quimioluminiscencia de micro-partículas (CMIA). Se obtuvieron relaciones positivas altas (156.30 S/CO) para HTLV-1/2. Las pruebas del virus de inmunodeficiencia humana (VIH) y las pruebas para enfermedades de transmisión sexual (ETS) fueron negativas. Un examen directo de un raspado de piel con hidróxido de potasio (KOH) mostró resultados negativos para micosis y escabiosis.  Se tomaron biopsias de placas infiltradas de ambas extremidades superiores y de la pierna derecha. Estas biopsias demostraron linfoma cutáneo , A y B. Las biopsias de los tumores exofíticos de la región femoral izquierda y la rodilla derecha demostraron ambas carcinomas verrugosos , C y D. La ecografía Doppler de las extremidades inferiores se realizó debido al compromiso del hallux derecho. El ultrasonido reveló ausencia de flujo en las arterias tibial anterior y posterior y en las arterias dorsal y plantar del pie. Se realizó una tomografía computarizada (TC) de rayos X para las regiones cervical y toracoabdominal. El escáner reveló muchas adenopatías que comprometían varias cadenas de ganglios linfáticos en el cuello, axilas, región inguinal, retroperitoneo y mesenterio. También se observó esplenomegalia. Una biopsia de médula ósea reveló hueso trabecular normal, el 65% de la celularidad total de la médula en espacios medulares separados, hiperplasia mieloide y eosinofilia severa. La citometría de flujo de la médula ósea informó un 48,4% de células patológicas con CD4 +, CD25 +, CD45 +, sCD3 débil, CD5 ++ y 10% de células CD7 +. Estos resultados condujeron al diagnóstico de ATLL asociado a infección por HTLV-1 en fase aguda, asociado con un subtipo verrugoso de carcinoma de células escamosas. Se inició tratamiento con poliquimioterapia después de concluir que la paciente tenía un cáncer no resecable. La paciente recibió una combinación de CHOP  y polietilenglicol (PEG) filgrastim (6 mg de PEG filgrastim). La respuesta inicial a la poliquimioterapia fue favorable; sin embargo, la paciente tuvo una recaída posterior y murió antes del segundo ciclo.La leucemia/linfoma de células T del adulto se asocia en todos los casos con la infección por HTLV-1, desempeñando este virus un papel cardinal en su patogénesis. El virus se incorpora en el genoma de las células T antes de su expansión clonal  El carcinoma de células escamosas presenta una amplia variedad de manifestaciones clínicas, incluyendo pápulas, placas, nódulos hiperqueratósicos y lesiones ulcerosas. Estas lesiones se pueden desarrollar en cualquier superficie de la piel. El carcinoma verrugoso es un subtipo de carcinoma de células escamosas que presenta lesiones exofíticas similares a grandes verrugas  La edad de la paciente está en el rango más frecuente para la ATLL. La paciente probablemente se infectó a una edad temprana a través de la lactancia materna o las relaciones sexuales. La enfermedad crónica de la paciente, que comenzó como una dermatitis infecciosa, es notable. Durante la edad adulta, la paciente había presentado las lesiones reportadas durante más de una década. Sin un manejo adecuado, las lesiones se transformaron en neoplasmas malignos que consistían en múltiples carcinomas verrugosos. Es posible que la razón exacta de esta transformación pueda ser descubierta., El concepto de comorbilidad conduce a un posible modelo de causación directa. De acuerdo con este modelo, una infiltración crónica de la piel durante la ATLL sería responsable de carcinomas verrugosos , La infección persistente con VPH se ha identificado como un cofactor para el desarrollo de carcinoma de células escamosas. Los hallazgos clínicos e histopatológicos de los carcinomas verrugosos pueden estar correlacionados con un estado permanente de infección por VPH, que puede persistir debido a la infección por HTLV-1. La persistencia de los carcinomas verrugosos es facilitada por anomalías en células T CD4+  La zidovudina y el interferón-α son tratamientos prometedores para este tipo de enfermedad La vacuna de células dendríticas pulsadas con péptido Tax es una inmunoterapia prometedora por remisión de la enfermedad a los 2 meses y el mantenimiento hasta los 2 años , Una vacuna de células dendríticas pulsadas con péptido Tax es una inmunoterapia prometedora para la remisión de la ATLL a los 2 meses, y para mantener la remisión durante 2 años después de la vacunación  Este reporte de caso describió a una paciente diagnosticada con ATLL asociada a infección por HTLV-1, además de carcinoma verrugoso.El carcinoma verrugoso es un subtipo de carcinoma de células escamosas con rasgos distintivos clínicos e histopatológicos. Uno de sus factores de riesgo es la inmunosupresión secundaria a linfomas; además, puede desarrollarse como úlceras en dermatosis inflamatorias crónicas. Estos dos factores de riesgo están presentes en el caso (descrito aquí), por lo que se considera (por lo que consideramos) que la inmunosupresión causada por el linfoma y las lesiones ulceradas crónicas causadas por la infección HTLV facilitaron la aparición del carcinoma verrugoso. Prevenir el paso del virus de la madre al hijo es un asunto clave para la erradicación de esta enfermedad.


Acinetobacter.The extensive use of antibiotics has led to the emergence of multi-resistant strains in some species of the genus Acinetobacter ssp. strains isolated from 52 patients collected between March 2009 and July 2010 in medical intensive care units in Cali - Colombia.To investigate the molecular characteristics of multidrug-resistant of  The susceptibility to various classes of antibiotics was determined by disc diffusion method, and the determination of the genomic species was carried out using amplified ribosomal DNA restriction analysis (ARDRA) and by sequencing of the 16s rDNA gene. Also, the genes of beta-lactamases as well as, integrases IntI1 and IntI2 were analyzed by PCR method.A. calcoaceticus- A. baumannii complex. All of them were multi-resistant to almost the whole antibiotics except to tigecycline and sulperazon, and they were grouped into five (I to V) different antibiotypes, being the antibiotype I the most common (50.0%). The percent of beta-lactamases detected was: blaTEM (17.3%), blaCTX-M (9.6%), blaVIM (21.2%), blaIMP (7.7%), blaOXA-58 (21.2%), and blaOXA-51 (21.2%). The phylogenetic tree analysis showed that the isolates were clustering to A. baumannii (74.1%), A. nosocomialis (11.1%) and A. calcoaceticus (7.4 %). Besides, the integron class 1 and class 2 were detected in 23.1% and 17.3% respectively. The phenotypic identification showed that the isolates belong mainly to A. baumanii mainly, and they were multiresistant. The resistance to beta-lactams may be by for presence of beta-lactamases in the majority of the isolates.  The isolates were identified to species  Acinetobacter spp. is reported to be involved in hospital-acquired infections with increasing frequency Acinetobacter spp infections A. calcoaceticus-A. baumannii complex (ACB complex) is mostly antibiotic-resistant Acinetobacter strains ,A. baumannii-Resistance to beta-lactam agents, including carbapenems in the ACB complex is due mainly to the production of the extended-spectrum beta-lactamases (ESBLs), but can also result from several other mechanisms including alterations in outer membrane proteins and penicillin binding proteins and increased activity of efflux pumps attI1, into which resistance genes can be inserted by site-specific recombination in the form of gene cassettes ,A. baumannii have been published ,A. baumannii in our region. However, the distribution of class 2 integron is highly frequent in A. baumannii clinical isolates from Argentina, Chile, and Brazil ,Most genes encoding these ESBLs are found on plasmids, or in the form of a gene cassette in an integron. Integrons are genetic elements that possess a particular recombination site, known as Acinetobacter spp. The objectives of the present study were to analyze the phenotypic and molecular characteristics of ACB complex and antibiotic resistance in clinical isolates in a Colombian tertiary-care hospital. As well as determine the antimicrobials resistance profiles of the isolated strains. We also tested for the presence of MBL or ESBL producing To test the hypothesis that most genes encoding MBL or ESBL are found on gene cassettes of integrons, we have examined representative isolates for the presence of class 1 and class 2 integrons and the associated antimicrobial resistance genes by PCR. Knowledge on the epidemiology and molecular mechanisms of antimicrobial resistance in this important pathogen are essential to implement intervention strategies.A descriptive study was carried out and was endorsed by the ethics committee of the hospital.Acinetobacter ssp strains collected from clinical specimens, previously identified by the Vitek GNI card  that they grew on standard MacConkey agar at 37° C for 48 h, between March 2009 and July 2010 of a medical intensive care unit at Rafael Uribe Uribe University Hospital from Cali - Colombia. The clinical samples were obtained from: the nasal swabs, 24 (46.2%); wounds, 12 (26.1%); catheter tip, 6 (11.6%); the urinary tract, 6 (11.6%); and 4 (7.7%) blood. All of the samples were stored at −80° C in nutrient broth with 15% glycerol. From the 52 Acinetobacter spp clinical isolates strains, 24 (46.2%) were obtained. The study included 52 Acinetobacter baumannii (ATCC® 19606(tm)), and Escherichia coli (ATCC® 25922(tm)) were used as quality control strains. The antibiotic discs (Oxoid ®) tested were the follows: trimetroprim/sulfametoxazol ; ticarcillin/clavulanato ; gentamicin ; tobramycin ; ciprofloxacin ; ceftazidime ; cefepime ; aztreonam ; imipenem ; meropenem ; ampicillin/sulbactam ; amikacin ; cefoprazone/sulbactam ; and tigecycline . According to Manchanda et al. Acinetobacter spp have defined whether the isolates are resistant to three antibiotics different to ceftazidime, such as ciprofloxacin, gentamicin, and imipenem.The susceptibility to various classes of antibiotics was determined by disc diffusion method on a Mueller-Hinton (MH) agar , by the Clinical and Laboratory Standard Institute (CLSI) guidelines Acinetobacter spp were determined by ARDRA, according to Vaneechoutte et al. TM" kit  according to the manufacturer's instructions. After to electrophoresis, the gel was stained with ethidium bromide (1.5 μg/mL) and analyzed on a FOTO/Analyst(r) Investigator/FX Systems (FOTODYNE Incorporated). For each sample, the PCR reaction was performed for 16S rDNA amplification using the following primer pair: Acf5´-TGG CTC AGA TTG AAC GCT GGC GGC-3´ and Acr5´-TAC CTT GTT ACG ACT TCA CCC CA-3´. The PCR products were digested with the following enzymes: CfoI; Alu; Mbo; and MspI (Fermentas(tm)) and separated by polyacrylamide gel electrophoresis (PAGE 8.0%). The genomic species of et alA. baumannii (ATCC® 19606(tm)) strain was used as controls. The last restriction profiles were compared to strain library database (http://users.ugent.be/~mvaneech/ARDRA/Acinetobacter.html) to identify the species according to Dijkshoorn The 27 PCR products to 16S rDNA gene were purified using the High Pure PCR product Purification Kit Version 20 kit, according to company instruction (Roche Applied Science®) and then, each purified PCR products were direct sequencing by Sanger dideoxy method using an ABI 3730XL sequencer. The 16S rDNA sequences were aligned with 27 Acinetobacter reference sequences harbored in the GenBank-NCBI dataset. ,Staphylococcus aureus sequence was used as outgroup.The phylogenetic tree was done using the MEGA software v.5 under Maximum Likelihood model with the Kimura-2-parameters, and Gamma distribution assuming invariable sites (K2+G+I). The robustness of phylogenetic tree was calculated by a bootstrap no parametric with 1,000 replicates blaTEM; blaSHV; blaOXA; blaCTX-M; blaIMP; and blaVIM, were detected by PCR using the primers are listed in -). The PCR reaction final volume of 50 μl with 5-10 ng (genomic DNA) reaction buffer, 1 U of Taq polymerase , 200 µM each deoxynucleoside triphosphate, 1.5 or 2.5 mM MgCl2, 10 pmol of each primer. Thermocycler temperature was 94° C for 5 min; 94° C for 30 s by 35 cycles. To blaTEM, 52° C for 45 s; blaOXA-51 and blaOXA-58, 62° C for 1 min; blaCXT-M, 51° C for 45 s; blaVIM and blaIMP 51° C for 1 min; and 72° C for 60 s. The final step of 10 min at 72° C.ESBL genes, such as (intI) and 2 (intII) genes were amplified as previously described ,2, 10 pmol of each primer. PCR conditions were as follows: a hot start at 94° C for 5 min; 94° C for 30 s by 35 cycles, 30 s at both 55° C; and a final step of 10 min at 72° C.The integrase class 1 o C and 2 min).The reaction mixture to the degenerate primers hep35 and hep36 were equivalents to the previous except for the concentration of each primer (2.0 µM), and for the PCR extension steps . Categorical variables were analyzed using χAcinetobacter spp. were resistant to trimethoprim /sulfamethoxazole, gentamicin, amikacin, tobramycin, ticarcillin/clavulanic acid, cefepime, ceftazidime, and imipenem. They were resistance rates of 100% while presenting variable susceptibility to ciprofloxacin , levofloxacin , ampicillin-sulbactam  and meropenem . The antimicrobial agents to which Acinetobacter spp strains were most susceptible were tigecycline and sulperozone. In contrast, 21.2% (11/52) and 28.8% (15/52) of them were resistant to tigecycline and sulperozone, respectively. In addition, all isolates were resistant to at least three classes of antibiotics , hence meeting the criteria for multidrug resistance et al. Antibiotyping tested by disk diffusion method showed multi-resistance to a large range of antibiotics. Most isolates of p <0.05)  different antibiotypes. Most the isolates belonging to antibiotype I (50.0%), with fewer isolates belonging to antibiotype IV (19.3%), antibiotype II (17.3%) and antibiotype V, with only 1.9% of all the isolates. Interestingly, the isolates belonging to antibiotype I were susceptible to tigecycline and sulperozone, and most clinically significant isolates were found in nasal swabs (57.7%), followed by wound and catheter tips  (p <0.05) . Twenty-p <0.05) and was detected more frequently in wound . This antibiotype was first detected in March of 2009 and appeared again in July, August, and November of the same year, as well in April, May, and June of 2010. As shown in A. baumannii (37.1%) exhibited five distinct antibiotypes. Twelve of the isolates (54.5%) were classified as having antibiotype I, two (9.1%) isolates to antibiotype III, and four (18.2%) isolates to antibiotype and one (5%) isolate to antibiotype V. Four strains of A. calcoaceticus revealed two distinct antibiotypes, and three strains of 13TU showed three different antibiotypes.The antibiotype IV significantly grouped the PDR (19.3%) isolates , three (5.8%) were A. nosocomialis (13TU), two were A. calcoaceticus, and two were A. pitti (genospecies 3).The results revealed that 23 (44.0%) isolates had the combined profile '1 1 1 2 3' or '1 1 1 2 1' for the several enzymes For the NCBI-BLAST analysis, 27 strains were queried using sequences of a 1,500 bp fragment of the 16S rDNA. This identification of all clinical isolates to the species level showed that all amplicons had sequence concordance of 61 to 99% A. baumannii while A. nosocomialis constituted 11.1% (3/27) of the total. However, we find ambiguity between the two methods when defining the genospecies A. calcoaceticus, Acinetobacter 3U, Acinetobacter 13U as shown in  In ACB complex were subjected to PCR experiments to detect the ESBL genes, including blaTEM, blaSHV, blaCTX-M, blaOXA-51, blaOXA-58, blaVIM, and blaIMP. Thirty-nine isolates (75.0%) carried several bla genes (up to two genes).All ESBL-producing isolates in blaTEM-1 and five (9.6%) isolates contained blaCTXM-9, while blaOXA-58 was found significantly in all carbapenem-resistant A. baumannii strains (p <0.05). The blaTEM-1 gene was identified in four isolates of A. baumannii, and one isolate of A. calcoaceticus. The blaCTXM-9 gene was detected in two isolates of A. calcoaceticus, two isolates of A. baumannii, and one isolate of 13TU, the blaOXA-58 gene was detected in once an isolate of A. baumanni, two isolates of A. calcoaceticus, and one isolate of 13TU. All A. baumannii isolates were positive for blaOXA-51-like genes. PCR did not detect the blaOXA-23 and blaSHV genes.PCR amplification of class A beta-lactamase genes revealed that 17.3% (9/52) of the isolates carried ACB complex, blaVIM-2 and blaIMP-1 were found in 21.2%, and 7.7% of isolates, respectively. In 30.0% of the A. baumannii strains were detected the blaVIM-2 gene, and all were obtained from nasal swabs.Among MBL-producing isolates in Acinetobacter species isolated. PCR performed the determination of the size of any inserted gene cassette within the genome. Overall, PCR of the integrase gene resulted in a frequency of integron-positive isolates of 38.5% (20/52) with various insert sizes within the ACB complex, in according to with previous studies that have reported a high frequency of multiresistant gram-negative isolates containing integrons .PCR detection of the intI1, intI2, and integrase genes demonstrated the presence of integrons in ACB complex. The length the amplicons of variable regions ranged between 0.75 to 2.5 kb; 0.75 kb (13.0%), 2.5 kb (5.0%) and (0.75 +2.5 kb) (7.0%). Further, PCR could be helpful to determine their gene cassette assortments. The most number of isolates with integrons belonging to antibiotype I and were found in nasal swabs and wounds. The intI2 gene of class 2 integrons were detected in 17.3% (9/52) of the isolates. The presence of class 2 integrons, in six isolates, which also contained a class 1 integron was statistically significant (p <0.05).Class 1 integrons were found in 23.1% (12/52) of the isolates of blaTEM-1 and blaOXA genes. Additionally, isolates belonging to antibiotype II and III also contained integrons. In contrast, no integrin-positive isolates were found in antibiotype V.Class 1 and 2 integrons were detected in two isolates belonging to antibiotype I and IV with A. baumannii. Class 1 integrons were detected in 26.1% (6/23) of the A. baumannii isolates, whereas only one A. baumannii strain contained a class 2 integron  from wounds, and one (4.5%) from urinary tracts, although the association was not statistically significant (p <0.05). Also, the integron-positive A. baumannii isolates contained blaTEM-1and blaVIM-2 genes.The integrons were found in 30.0% (7/23) isolates of integron . IntegroA. baumannii have been reported throughout the world ,ACB complex were more frequent in nasal tracking (46.2%), and of these, 63.6% corresponds to A. baumannii in patients admitted to the ICU. This finding is significant because the nasal colonization in patients older than 65 years with pre-existing lung disease or any debilitating diseases especially in the ICU has a higher risk to develop a Health care-associated infections (HAIs) ,Nosocomial infections due to p <0.05), a result similar to the one reported by some authors in Brazil in the same years of this study, where we found isolates with this feature in 11.0% On the other hand, it concerns that all the 52 isolates were multidrug resistant to antibiotics, and tigecycline only sulperazona maintained the antimicrobial activity against the majority of the isolates evaluated (80.0%). Also, we identified PDR isolates (19.3%), with a statistically significant value  and carbapenems (imipenem and meropenem). We detected the presence of beta-lactamase type OXA-51 and OXA-58, which would explain the resistance so marked to carbapenem, similarly reported by Gales et alThe reports of the SENTRY in countries of Latin America, Europe, and the United States indicate that Acinetobacter spp. present high rates of resistance even to carbapenem. A multicenter study conducted by Higgins Acinetobacter species identification by the Vitek-2 GNI system. It highlights the need to regard such results as preliminary data. Accurate identification using molecular methods is not only important in the investigation of outbreaks caused by Acinetobacter species, but also is relevant in epidemiological studies such as this report. Our results are like the reports published in other geographic regions et al. Acinetobacter spp. They make it a potentially useful treatment option against highly resistant bacteria; however, few of these bacteria also present resistance to tigecycline. This study demonstrated the poor capacity of ACB complex and those of A. baumannii, bla  was detected. Although the presence of the beta-lactamase TEM-1 is reported as one of the leading causes of resistance to beta-lactamic antibiotics in the A. baumannii isolates, in this study, only 22.7 % of the isolates were carriers of the gene blaTEM-1. In recent years the trend has changed; the increase in the resistance to carbapenems is mainly due to the presence of metallo beta-lactamases and class D type carbapenemase OXA, whose overexpression is regulated by the presence of upstream insertion elements, such as ISAba1Within multiresistant isolates of the ACB complex and 50.0% of A. baumannii presented beta-lactamases type OXA-58. Despite that, some reports have suggested that genes of OXA type beta-lactamases are transported in integrons ,A. baumannii that contained these genes type did not show related to integrons. These results are consistent with those reported by Poirel et al. In this study, 38.5% of the isolates of A. baumannii tend to contain a greater number of integrons that are non-epidemic, and affirms that the use of antibiotics has a high impact on the development of the diversity and maintenance of these strains in the ICU The presence of integrons (class 1 and 2) in 40% of the isolates was statistically significant; both classes of integrons have been described between the members of the genus Acinetobacter isolated in both clinical and environmental settings A. baumanni-,ACB complex and A. baumannii. The integration of these elements in the bacterial chromosome can affect the expression of genes such as blaOXA-51, which encodes an Amp c, b, and the chromosomal carbapenemase. In this study, all 22 isolates of A. baumannii showed resistance to cephalosporins and carbapenems; however, only 25% of them detected integrons within the genome. Of the ACB complex, 32 isolates were not integrons, by which the multidrug resistance to antibiotics in these isolates must be related to other mechanisms of resistance which may be plasmid-mediated or through the reduction of the cell membrane or wall permeability et al. The class 1 integron presents multiple cassettes, which confers resistance towards several antibiotics, as a distinctive phenotypic stamp on the isolates of  Acinetobacter spp. está involucrada en infecciones adquiridas en el hospital con una frecuencia creciente Acinetobacter spp A. calcoaceticus- A. baumannii (complejo ACB) son principalmente cepas de Acinetobacter resistentes a antibióticos ,Se ha reportado que A. baumannii-La resistencia a los betalactámicos, incluidos los carbapenémicos en el complejo ACB, se debe principalmente a la producción de betalactamasas de espectro extendido (ESBLs), pero también a otros mecanismos, como alteraciones en proteínas de la membrana externa y proteínas de unión a penicilina y aumento de la actividad de las bombas de explusión attl1, en el cual los genes de resistencia pueden insertarse mediante recombinación sitio específica en forma de casetes de genes ,A. baumannii,A. baumannii en nuestra región. Sin embargo, la distribución del integrón de clase 2 es muy frecuente en aislamientos clínicos de A. baumannii de Argentina, Chile y Brasil ,La mayoría de los genes que codifican estos ESBLs se encuentran en plásmidos, o en forma de un casete genético en un integrón. Los integrones son elementos genéticos que poseen un sitio de recombinación particular, conocido como Acinetobacter spp.Los objetivos del presente estudio fueron analizar las características fenotípicas y moleculares del complejo de ACB y la resistencia a antibióticos en aislados clínicos en un hospital colombiano de atención terciaria. Además de determinar los perfiles de resistencia antimicrobiana de las cepas aisladas. También se comprobó la presencia de MBL o ESBL en Para probar la hipótesis de que la mayoría de los genes que codifican MBL o ESBL se encuentran en los casetes génicos de los integrones, se examinaron por PCR, en aislados representativos, la presencia de los integrones de clase 1 y clase 2 y los genes asociados a resistencia antimicrobiana. El conocimiento sobre la epidemiología y los mecanismos moleculares de la resistencia a los antimicrobianos en este importante patógeno es esencial para implementar estrategias de intervención.Se llevó a cabo un estudio descriptivo respaldado por el comité de ética del hospital.Acinetobacter spp obtenidas de muestras clínicas, previamente identificadas por la tarjeta Vitek GNI , que crecieron en agar MacConkey estándar a 37 °C durante 48 h, entre marzo de 2009 y julio de 2010 de una unidad de cuidados intensivos médicos en el Hospital Universitario Rafael Uribe Uribe de Cali - Colombia. Las muestras clínicas se obtuvieron de: Rastreo nasal, 24 (46.2%); heridas, 12 (26.1%); punta del catéter, 6 (11.6%); el tracto urinario, 6 (11.6%); y sangre, 4 (7.7%). Todas las muestras se almacenaron a -80 °C en caldo nutritivo con 15% de glicerol. De las 52 cepas aisladas de Acinetobacter spp, se obtuvieron 24 (46.2%).El estudio incluyó 52 cepas de Acinetobacter baumannii (ATCC(r) 19606 (tm)) y Escherichia coli (ATCC(r) 25922 (tm)) se usaron como cepas de control de calidad. Los discos de antibióticos (Oxoid(r)) probados fueron los siguientes: trimetroprima/sulfametoxazol ; ticarcilina/clavulanato ; gentamicina ; tobramicina ; ciprofloxacina ; ceftazidima ; cefepime ; aztreonam ; imipenem ; meropenem ; ampicilina/sulbactam ; amikacina ; cefoprazona/sulbactam ; y tigeciclina . De acuerdo con Manchanda et al.Acinetobacter spp. MDR si los aislados son resistentes a tres antibióticos diferentes a la ceftazidima, como ciprofloxacina, gentamicina e imipenem.La susceptibilidad a varias clases de antibióticos se determinó mediante el método de difusión de disco en un agar Mueller-Hinton (MH) , según las directrices del Instituto Clínico y de Laboratorio Estándar (CLSI) Acinetobacter spp. fue determinada por ARDRA, de acuerdo con Vaneechoutte et alTM" ) de acuerdo con las instrucciones del fabricante. Después de la electroforesis, el gel se tiñó con bromuro de etidio (1.5 μg/mL) y se analizó en un FOTO/Analyst(r) Investigator/FX Systems (FOTODYNE Incorporated). Para cada muestra, la reacción de PCR se realizó para la amplificación del gen 16s ADNr utilizando el siguiente par de cebadores: Acf5'-TGG CTC AGA TTG AAC GCT GGC GGC-3'y Acr5'-TAC CTT GTT ACG ACT TCA CCC CA-3'. Los productos de PCR se digirieron con las siguientes enzimas: CfoI; Alu; Mbo; y MspI (Fermentas (tm)) y separados por electroforesis en gel de poliacrilamida (PAGE 8.0%).La especie genómica de et alLos últimos perfiles de restricción se compararon con la base de datos de la biblioteca de cepas (http://users.ugent.be/~mvaneech/ARDRA/Acinetobacter.html) para identificar la especie de acuerdo con Dijkshoorn ®) y luego, cada producto de PCR purificado se secuenció directamente mediante el método dideoxi de Sanger usando un Secuenciador ABI 3730XL. Las secuencias de 16S ADNr se alinearon con 27 secuencias de referencia de Acinetobacter albergadas en la base de datos GenBank-NCBI.Se purificaron 27 productos de PCR para el gen 16s ADNr, usando el kit "High Pure PCR Purification Kit Version 20, de acuerdo con las instrucciones de la compañía . La robustez del árbol filogenético se calculó mediante un bootstrap no paramétrico con 1,000 réplicas blaTEM; blaSHV; blaOXA; blaCTX-M; blaIMP; y blaVIM, se detectaron por PCR usando los cebadores enumerados en la -2, 10 pmol de cada primer. La temperatura del termociclador fue de 94° C durante 5 min; 94° C durante 30 s por 35 ciclos. Para blaTEM, 52° C durante 45 s; blaOXA-51 y blaOXA-58, 62° C durante 1 minuto; blaCXT-M, 51° C durante 45 segundos; blaVIM y blaIMP 51° C durante 1 min; y 72° C durante 60 s. Una etapa final de 10 min a 72° C.Genes de ESBL, tales como ,2, 10 pmol de cada cebador. Las condiciones de PCR fueron las siguientes: un inicio con choque de calor a 94 °C durante 5 min; 35 ciclos de 30 s a 94 °C, 30 s a 55 °C; y un paso final de 10 min a 72 °C.Los genes de la integrasa clase 1 (intI) y 2 (intII) se amplificaron como se describió previamente La mezcla de reacción para los cebadores degenerados hep35 y hep36 eran equivalentes a los anteriores excepto por la concentración de cada cebador (2.0 μM) y para los pasos de extensión de la PCR (72º C y 2 min).2. Todas las pruebas fueron de dos colas con p <0.05 considerado significativo.Los datos se analizaron usando Stata versión 11.0 . Las variables categóricas se analizaron mediante la prueba χAcinetobacter spp. fueron resistentes a trimetoprima / sulfametoxazol, gentamicina, amikacina, tobramicina, ticarcilina/ácido clavulánico, cefepime, ceftazidima e imipenem con tasas de resistencia del 100%; mientras presentaban susceptibilidad variable a ciprofloxacina , levofloxacina , ampicilina-sulbactam  y meropenem . Los agentes antimicrobianos a los que las cepas de Acinetobacter spp fueron más susceptibles fueron la tigeciclina y la sulperozona. Por el contrario, el 21.2% (11/52) y el 28.8% (15/52) de ellos fueron resistentes a tigeciclina y sulperozona, respectivamente. Además, todos los aislamientos fueron resistentes a al menos tres clases de antibióticos , cumpliendo así los criterios de resistencia a múltiples fármacos et al.Los antibióticos probados por el método de difusión en disco mostraron resistencia múltiple a una amplia gama de antibióticos. La mayoría de los aislamientos de p <0.05)  antibiotipos diferentes. La mayoría de los aislamientos pertenecientes al antibiotipo I (50.0%), con menos aislados pertenecientes al antibiotipo IV (19.3%), antibiotipo II (17.3%) y antibiotipo V, con solo 1.9% de todos los aislados. Curiosamente, los aislados pertenecientes al antibiótipo I eran susceptibles a tigeciclina y sulperozona, y la mayoría de los aislados clínicamente significativos se encontraban en rastreo nasal (57.7%), seguidos de heridas y puntas de catéter  (p <0.05) . Del antp <0.05) y se detectó con mayor frecuencia en heridas . Este antibiotipo se detectó por primera vez en marzo de 2009 y apareció nuevamente en julio, agosto y noviembre del mismo año, así como en abril, mayo y junio de 2010. Como se muestra en la A. baumannii (37.1%) exhibieron cinco antibiotipos distintos. Doce de los aislados (54.5%) se clasificaron como antibiotipo I, dos (9.1%) aislados para antibiotipo III, cuatro (18.2%) aislamientos para antibiotipo IV y un (5.0%) aislado para antibiotipo V. Cuatro cepas de A. calcoaceticus revelaron dos antibiotipos distintos, y tres cepas de 13TU mostraron tres antibiotipos diferentes.El antibiotipo IV agrupó significativamente los aislados de PDR (19.3%) (A. baumannii), tres (5.8%) fueron A. nosocomialis (13TU), dos fueron A. calcoaceticus y dos fueron A. pitti (genospecies 3).La identificación genómica de 52 cepas pertenecientes al complejo ACB se realizó mediante el método ARDRA y secuenciación  y 4. LosPara el análisis NCBI-BLAST, se consultaron 27 cepas utilizando secuencias de un fragmento de 1,500 pb del ADNr 16s. Esta identificación de todos los aislados clínicos a nivel de especie mostró que todos los amplicones tenían una concordancia de secuencia de 61 a 99% Acinetobacter mediante el análisis de secuenciación del ADNr 16s. De todos los aislamientos, el 74.1% (20/27) se agruparon con A. baumannii mientras que A. nosocomialis constituyó el 11.1% (3/27) del total. Los métodos moleculares (ARDRA y análisis de secuencia) aplicados en este estudio nos permitieron discriminar dentro del complejo ACB cada una de las especies que lo componen. Sin embargo, encontramos ambigüedad entre los dos métodos al definir las genoespecies A. calcoaceticus, Acinetobacter 3U, Acinetobacter 13U como se muestra en la En la blaTEM, blaSHV, blaCTX-M, blaOXA-51, blaOXA-58, blaVIM y blaIMP. Treinta y nueve aislamientos (75.0%) portaban varios genes bla (hasta dos genes).Todos los aislados productores de ESBL en el complejo ACB se sometieron a experimentos de PCR para detectar los genes ESBL, que incluyen blaTEM-1 y cinco (9.6%) aislados contenían blaCTXM-9, mientras que blaOXA-58 se encontró significativamente en todas cepas de A. baumannii resistentes a carbapenem (p <0.05). El gen blaTEM-1 se identificó en cuatro aislados de A. baumannii y un aislado de A. calcoaceticus. El gen blaCTXM-9 se detectó en dos aislados de A. calcoaceticus y un aislado de 13TU, el gen blaOXA-58 se detectó en un aislado de A. baumanni, dos aislados de A. calcoaceticus y un aislado de 13TU. Todos los aislamientos de A. baumannii fueron positivos para genes similares a blaOXA-51. La PCR no detectó los genes blaOXA-23 y blaSHV.La amplificación por PCR de los genes de beta-lactamasa de clase A reveló que el 17.3% (9/52) de los aislados contenían blaVIM-2 y blaIMP-1 se encontraron en 21.2% y 7.7% de los aislamientos, respectivamente. En 30.0% de las cepas de A. baumannii se detectó el gen blaVIM-2, y todas se obtuvieron de rastreos nasales.Entre los aislamientos productores de MBL en el complejo ACB, Acinetobacter aisladas. La PCR realizó la determinación del tamaño de cualquier casete de gen insertado dentro del genoma. En general, la PCR del gen de la integrasa dio como resultado una frecuencia de aislamientos positivos para el integrón del 38.5% (20/52) con diversos tamaños de insertos dentro del complejo ACB, de acuerdo con estudios previos que informaron una alta frecuencia de gramnegativos multirresistentes aislados que contienen integrones -,,La detección por PCR de los genes intl1, intl2 e integrasa demostró la presencia de integrones en las especies de p <0.05%).Los integrones de clase 1 se encontraron en el 23.1% (12/52) de los aislamientos del complejo ACB. La longitud de los amplicones de las regiones variables oscilaba entre 0.75 y 2.5 kb; 0.75 kb (13.0%), 2.5 kb (5.0%) y (0.75 + 2.5 kb) (7.0%). Adicionalmente, la PCR podría ser útil para determinar sus surtidos de casete genético. La mayoría de los aislamientos con integrones pertenecientes al antibiotipo I se encontraron en rastreos nasales y heridas. El gen intI2 de los integrones de clase 2 se detectó en el 17.3% (9/52) de los aislados. La presencia de integrones de clase 2, en seis aislamientos, que también contenían un integrón de clase 1 fue estadísticamente significativa  de los aislamientos de A. baumannii, mientras que solo una cepa de A. baumannii contenía un integrón de clase 2 (A. baumannii (13.6%) obtenidos de rastreos nasales, dos (9.1%) de las heridas y uno (4.5%) de las vías urinarias, aunque la asociación no fue estadísticamente significativa (p <0.05). Además, los aislamientos de A. baumannii positivos para el integrón contenían los genes blaTEM-1 y blaVIM-2.Los integrones se encontraron en 30.4% (7/23) aislados de  clase 2 . Los intA. baumannii en todo el mundo ,A. baumannii en pacientes ingresados en la UCI. Este hallazgo es significativo porque la colonización nasal en pacientes mayores de 65 años con enfermedad pulmonar preexistente o cualquier enfermedad debilitante, especialmente en la UCI, tiene un mayor riesgo de desarrollar infecciones asociadas a la atención médica (IAH) ,Se han notificado infecciones nosocomiales por Por otro lado, preocupa que los 52 aislamientos fueran multi-resistentes a los antibióticos, y la tigeciclina y sulperazona fueran las únicas que mantuvieron la actividad antimicrobiana contra la mayoría de los aislados evaluados (80.0%). Además, se identificaron aislamientos de PDR (19.3%), con un valor estadísticamente significativo (p≤0.05), un resultado similar al reportado por algunos autores en Brasil en los mismos años de este estudio, donde se encontraron aislamientos con esta característica en 11% A. baumannii ha aumentado en los últimos años. Específicamente, en Bogotá entre los años 2001 y 2008, hubo cepas aisladas sensibles a carbapenémicos, quinolonas, y a cefalosporinas de última generación y aminoglucósidos en el 30% de los casos et al. y carbapenémicos (imipenem y meropenem). Detectamos la presencia de beta-lactamasa tipo OXA-51 y OXA-58, lo que explicaría la resistencia tan marcada al carbapenem, reportado de manera similar por Gales et alLos informes de SENTRY en países de América Latina, Europa y los Estados Unidos indican que Acinetobacter por el sistema Vitek-2 GNI. Resalta la necesidad de considerar tales resultados como datos preliminares. La identificación precisa mediante métodos moleculares no solo es importante en la investigación de los brotes causados por especies de Acinetobacter, sino que también es relevante en estudios epidemiológicos como este informe. Nuestros resultados son similares a los informes publicados en otras regiones geográficas et al.Acinetobacter spp. Lo anterior, lo convierte en una opción de tratamiento potencialmente útil contra bacterias altamente resistentes; sin embargo, algunas de estas bacterias también presentan resistencia a la tigeciclina.Este estudio demostró la escasa capacidad de identificación de especies de A. baumannii, se detectó bla . Aunque la presencia de la beta-lactamasa TEM-1 se informa como una de las principales causas de resistencia a los antibióticos beta-lactámicos en los aislados de A. baumannii, en este estudio, solo el 22.7% de los aislados fueron portadores del gen blaTEM- 1. En los últimos años, la tendencia ha cambiado; el aumento de la resistencia a los carbapenémicos se debe principalmente a la presencia de metalo-beta-lactamasas y carbapenemasa tipo OXA de clase D, cuya sobreexpresión está regulada por la presencia de elementos de inserción aguas arriba, como ISAba1 Dentro de aislamientos multirresistentes del complejo ACB y los de A. baumannii presentaron beta-lactamasas tipo OXA-58. A pesar de eso, algunos informes han sugerido que los genes de beta-lactamasas tipo OXA se transportan en integrones ,A. baumannii que contenían estos genes no mostraron relación con integrones. Estos resultados son consistentes con los informados por Poirel et al.En este estudio, el 38.5% de los aislados de complejo ACB y el 50.0% de Acinetobacter aislados tanto en entornos clínicos como medioambientales A. baumannii tienden a contener un mayor número de integrones que no son epidémicos, y afirma que el uso de antibióticos tiene un gran impacto en el desarrollo de la diversidad y el mantenimiento de estas cepas en la UCI La presencia de integrones (clase 1 y 2) en el 40% de los aislamientos fue estadísticamente significativa; ambas clases de integrones se han descrito entre los miembros del género A. baumanni-,. baumannii. La integración de estos elementos en el cromosoma bacteriano puede afectar la expresión de genes como blaOXA-51, que codifica un Amp c, b, y la carbapenemasa cromosómica. En este estudio, los 22 aislamientos de A. baumannii mostraron resistencia a cefalosporinas y carbapenémicos; sin embargo, solo el 25% de ellos detectaron integrones dentro del genoma. Del complejo ACB, en 32 aislamientos no fueron detectados integrones, por lo que la resistencia a múltiples antibióticos en estos aislamientos debe relacionarse con otros mecanismos de resistencia que pueden ser mediados por plásmidos o mediante la reducción de la permeabilidad membrana celular o de la pared et al.El integrón de clase 1 presenta múltiples casetes, lo que confiere resistencia a varios antibióticos, como un sello fenotípico distintivo en los aislados de


An affiliation for the thirteenth author is missing. Nuno Taveira is also affiliated with #3 Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Ciências da Saúde Egas Moniz, Caparica, Portugal.


There are errors in the funding section. The correct funding information is as follows: This work was supported by grants from the Instituto de Salud Carlos III-Fondo Europeo de Desarrollo Regional (ISCIII-FEDER) , the Consejería de Economía, Innovación, Ciencia y Empleo de la Junta de Andalucía , the Consejería de Salud y Bienestar Social de la Junta de Andalucía , the Sociedad Andaluza de Neurología, the Jacques and Gloria Gossweiler Foundation, the Fundación Alicia Koplowitz and the FundaciónMutuaMadrileña. Ismael Huertas was supported by the "PFIS" programme [FI14/00497], Silvia Jesús by the Rio Hortega programme, Juan Francisco Martin Rodríguez by the Sara Borrell programme, and Pilar Gómez-Garre by the Miguel Servet programme, all from the ISCIII-FEDER. The Publisher apologizes for the errors.


Scientific Reports 10.1038/s41598-017-18532-2, published online 09 January 2018Correction to: This Article contains an error in Figure 1, in which the colours of certain slides are incorrect. The correct Figure In addition, the Article contains an error in the legend of Figure 1.“Of the four bugs in this example, only the first one was scored as positive without ambiguity (hence its darker colour); the three light-coloured bugs might or might not have been infected: for the third and fourth, there were some ambiguous detections; for the last one, the six non-detections could have arisen either because the bug was not infected or because the tests failed to detect the parasite.”should read:“Of the four bugs in this example, only the first one was scored as positive without ambiguity (hence its darker colour); the three light-coloured bugs might or might not have been infected: for the second and third, there were some ambiguous detections; for the last one, the six non-detections could have arisen either because the bug was not infected or because the tests failed to detect the parasite.”This Article also contains an error in the Acknowledgements section.“We thank the vector and parasite surveillance staff of Goiás State Health Department and the Federal District Environmental Surveillance Agency, Brazil. We also thank F. das Chagas, D.A. Rocha, and V.J. de Mendonça for assistance. M.R.F. de Oliveira made useful comments on an earlier draft of the manuscript, and R.N. This work was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior  and the Fundação de Amparo à Pesquisa do Distrito Federal , Brazil. Additional support came from the Instituto René Rachou and the Vice-Presidência de Pesquisa e Laboratórios de Referência .”should read:“We thank the vector and parasite surveillance staff of Goiás State Health Department and the Federal District Environmental Surveillance Agency, Brazil. We also thank F. das Chagas, D.A. Rocha, and V.J. de Mendonça for assistance. M.R.F. de Oliveira made useful comments on an earlier draft of the manuscript. This work was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior  and the Fundação de Amparo à Pesquisa do Distrito Federal , Brazil. Additional support came from the Instituto René Rachou and the Vice-Presidência de Pesquisa e Laboratórios de Referência .”


Due to a production error, the Institute in Franciso Hontoria's affiliation (affiliation 4) was incorrectly given as “Instituto de Ciencias Marinas de Andalucía (CSIC).” The correct affiliation is: “Instituto de Acuicultura de Torre de la Sal (CSIC), Torre de la Sal, Castellón, Spain”. The publisher apologizes for this mistake. The original version of this article has been updated.


Editors Note: This book is written in Spanish and the review is given in both English and Spanish. Both reviews were written by the same individual and essentially have the same content.Code of Practice for Quality Control of Treatment Planning Systems (TPS) in Radiation Therapy, by José Miguel Delgado Rodríguez, Feliciano García Vicente, Esther Millán Cebrián. Sociedad Española de Física Médica. Ramírez de Arellano Editores, S. L. 2005, Madrid, Spain; available. secretaria@sefm.es, 50εProtocolo para Control de Calidad en Sistemas de Planificación de Terapia con Radiaciones Ionizantes, por José Miguel Delgado Rodríguez, Feliciano García Vicente, Esther Millán Cebrián. Sociedad Española de Física Médica. Ramírez de Arellano Editores, S. L. 2005, Madrid, Spain.secretaria@sefm.es, 50ε This volume, written in Spanish, is a welcome addition to Spanish speaking Medical Physicists. I am not aware of a similar book in Spanish that addresses quality control of treatment planning systems. The purpose of this volume is to present in a simple, but complete way the steps to be followed by a clinical radiation oncology physicist during the acceptance and testing of a new treatment planning system. It also recommends quality control procedures to be followed by the user. This volume is not intended to be a final document, but it may be modified and adapted according to different circumstances.The book is divided into six chapters.Chapter 1 addresses the information system. It explains the steps necessary to test the new equipment, to verify its functionality and the adequacy of the instruction manuals.The main objective of chapter 2 is the specification of radiation beams, their position in relation to the patient, the geometric configuration of the unit  and beam modeling.Chapter 3 explains the steps to be taken to verify the correct acquisition and archiving of images to be used during treatment planning. CT images and digitally reconstructed radiographs (DRR) are discussed.Beam dosimetry is presented in chapter 4. This chapter deals with the verification of the information needed by the medical physicist to implement correctly the algorithms used by the treatment planning system.Brachytherapy is addressed in chapter 5. This is not an easy subject, because of the different ways in which the activity of a radioactive source can be specified . AAPM TG43 is used as the basis of this chapter. This document is almost universally accepted and easily obtainable. Some of the pitfalls of brachytherapy are identified.Chapter 6, the last chapter, concerns the quality control of digitally reconstructed radiographs. They may come from simulators, or from CT scans. Regardless of their sources, the same care must be taken to avoid image distortion and assure the proper scaling of these images.The book includes five appendices that complement and expand, in a practical way, some of the material covered in the main text. Each chapter and each appendix contains a fairly up‐to‐date bibliography that includes the most important references used by the authors in the development of the protocol. The volume also includes a two‐page glossary with some of the key words used in the text. The inclusion of an index would have been welcome.This is a well‐written book that should be very helpful to any Medical Physicist who will go through the testing and acceptance of a new treatment planning system. The authors are to be commended for breaking down very important procedures into a set of understandable instructions.El protocolo tiene el propósito de presentar en una forma simple, pero completa, los conocimientos requeridos y pasos a seguir por un(a) Radiofísico(a) Hospitalario(a) para aceptar un sistema de planificación antes de ponerlo en uso clínico. Los autores no pretenden que este protocolo sea un documento final, sino que sirva como una guía adaptable a distintas circunstancias para evaluar y aceptar un nuevo sistema de planificación.El protocolo está dividio en seis capítulos:Sistema Informático. El físico debe conocer el hardware y software que se va a utilizar en el sistema, así como las limitaciones del mismo.Diseño y Modulado de Unidades y Haces de Radiación. En este capítulo se trata la importante tarea de la definición de las características geométricas de la unidad, así como el modelado de los haces de radiaciones ionizantes.Adquisición de Datos Anatómicos. La adquisición y manipulación correcta de imágenes es esencial en un sistema de planificación. Las imágines pueden provenir de distintas unidades, como TC, RM, SPECT, PET.Dosimetría de Haces. La aplicación e interpretación correcta de los algoritmos usados en el sistema de planificación es indispensable para asegurar que el paciente reciba la dosis prescrita.Braquiterapia. Es un área de suma importancia, debido las diferentes unidades en las que la actividad de una fuente radioactiva se puede expresar. Esto puede ocasionar errores en la dosis absorbida por el paciente Los autores siguen las recomendaciones del Grupo de Trabajo # 43 de la AAPM (TG43).Presentación y Transferencia de Datos y Resultados. Es de suma importancia la fidelidad y calidad de las imágenes digitales reconstruídas (RDR), en la verificación y ejecución de un plan en una unidad de teleterapia y braquiterapia.Cada capítulo está organizado en una forma lógica que explica los pasos a seguir, las pruebas que se deben realizar, el material necesario para llevar a cabo los procedimientos indicados y el análisis de los resultados obtenidos, los valores aceptables y la frecuencia con la cual cada prueba debe repetirse. Al final de cada capítulo hay detalles y advertencias que se deben de tener en cuenta para evitar errores. El documento tiene cinco anexos que complimentan el protocolo.Cada capítulo y de cada anexo tiene una blibliografía que incluye las referencais más importantes usadas por los autores en el desarrollo del protocolo. La mayoría de las referencias son bastante recientes y fáciles de obtener. El libro contiene un glosario de términos importantes que se usan en el texto del protocolo. El libro no tiene un índice que pudiera facilitar su uso.Las pruebas a realizar, así como el análisis de los resultados son explícitos y relativamente fáciles de implementar. Los autores han logrado simplificar y exponer de una manera práctica lo que es en realidad una labor de suma importancia desde el punto de vista clínico.


There is information missing from the Funding section. The correct funding information is as follows: This study was supported by grants from PTDC/SAU-ORG/110856/2009 from Fundação para a Ciência e a Tecnologia do Ministério da Educação e Ciência, Portugal; from Instituto de Salud Carlos III (PI12/00605), Ministerio de Ciencia e Innovacion, Spain; and from the Fondo Europeo de Desarrollo Regional (FEDER). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


The publisher apologizes for the error.The following information is missing from the Funding section: This study was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (


A ultrassonografia vascular (UV) é o exame de escolha para estudar o sistema venoso superficial dos membros inferiores e mensurar o diâmetro das veias safenas, podendo ser utilizada como parâmetro para o planejamento cirúrgico.Identificar pela UV os diâmetros de veias safenas magnas sem refluxo em mulheres e sua relação com a idade, altura, Classificação Clínica, Etiologia, Anatomia e Fisiopatologia (CEAP) e índice de massa corporal (IMC).Estudo transversal em mulheres com sintomas de IVC primária , sem cirurgia prévia de varizes e sem refluxo detectado pela UV, nas quais foram mensurados os diâmetros da veia safena magna (VSM) na crossa, coxa e perna, que foram comparados com a idade, altura, classe clínica CEAP e IMC.Foram avaliadas 353 mulheres, das quais 146 foram incluídas no estudo sendo 88 avaliadas unilateralmente e 58 bilateralmente. Os diâmetros encontrados para a VSM sem refluxo foram de aproximadamente 6,5 mm na crossa, 4,0 mm na coxa proximal, 3.0 mm na coxa médio-distal e joelho e 2,5 mm na perna. Em todos os segmentos mensurados houve diferença estatisticamente significativa  na correlação dos diâmetros com IMC. Não houve diferença estatística na correlação da medida dos diâmetros com classe CEAP, altura e idade das pacientes.Observou-se que os diâmetros de veias safenas magnas sem refluxo independem da classe clínica CEAP 0 ou 1 e 2; da idade e da altura das pacientes. Entretanto, os diâmetros da VSM se relacionam significativamente com o IMC das pacientes. A insuficiência venosa crônica (IVC) é definida como um estado de anormalidade do funcionamento venoso causada por incompetência valvular, associada ou não à obstrução do fluxo venoso. Tal condição pode afetar o sistema venoso superficial, profundo e as veias perfurantes, devido a distúrbios congênitos ou adquiridosA IVC constitui importante problema de saúde pública e socioeconômico, visto que essa condição é a 14ª maior causa de afastamento temporário do trabalho no Brasil, atingindo aproximadamente 20% da população adulta em países do Ocidente, com 3,6% da população apresentando úlcera venosaA ultrassonografia vascular (UV) é o exame de escolha para identificar e localizar obstruções ou refluxos no sistema venoso, além de possibilitar a mensuração do diâmetro das veias safenas, que pode ser utilizado como parâmetro para o planejamento cirúrgico. Contudo, não existem na literatura muitas evidências sobre o calibre normal da veia safena magna (VSM) em mulheresEngelhorn et al.Da mesma forma, ao avaliar a relação entre diâmetro da VSM e presença de refluxo proximal em 182 membros inferiores, Mendoza et al. observaram os valores de 10,5 mm na JSF e 6,2 mm na coxa proximal como preditores de refluxo, sendo a medida da coxa proximal considerada mais sensível e específica para ser utilizada como parâmetro clínicoO objetivo deste estudo foi identificar pela UV o diâmetro de veias safenas magnas sem refluxo em mulheres e sua relação com idade, altura, classe clínica da Classificação Clínica, Etiologia, Anatomia e Fisiopatologia (CEAP) (C0 a C2) e índice de massa corporal (IMC).Foi realizado um estudo transversal em mulheres encaminhadas consecutivamente ao laboratório vascular com queixas de IVC para realização do mapeamento venoso pela UV.Foram incluídas pacientes maiores de 18 anos, com sintomas de IVC primária nas classes clínicas (CEAP) C0, C1 e C2, sem cirurgia prévia de varizes e sem refluxo na veia safena magna detectado pela UV. Foram excluídos homens e foram excluídas mulheres com IVC primária nas classes clínicas (CEAP) C3 a C6, IVC secundária e congênita, safenectomia prévia, tromboflebite recente ou antiga nas veias safenas, e cirurgia bariátrica prévia.As pacientes foram avaliadas em um laboratório vascular certificado pela ISO 9001 por ultrassonografistas vasculares experientes com certificado de área de atuação pela Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV).O estudo foi aprovado pelo Comitê de Ética em Pesquisa da Pontifícia Universidade Católica do Paraná, sob protocolo 1.183.464.No momento do estudo pela UV com as pacientes em posição ortostática, foi realizada a avaliação clínica e classificação (CEAP) de cada um dos membros inferiores (MMII) e foram registrados idade, peso e altura das pacientes para o cálculo do IMC.As pacientes foram avaliadas com aparelhos Siemens-Antares® e Siemens-X700®, inicialmente para a exclusão de trombose venosa recente ou antiga, em decúbito dorsal, com cortes ultrassonográficos transversais em modo B e manobras de compressibilidade das veias, utilizando transdutores de baixa frequência (5 Mhz).O estudo da VSM foi realizado com a paciente em posição ortostática, com transdutor de alta freqüência (7-10 Mhz), para a obtenção das imagens das veias em cortes ultrassonográficos transversais em modo B e mensuração dos diâmetros da VSM na crossa, coxa proximal, coxa média, coxa distal, joelho, perna proximal, perna média e perna distal.versus a classe C2, e nos casos com avaliação bilateral da veia safena foi calculada a média dos diâmetros dos dois lados.Para a análise estatística foi considerado o diâmetro médio da VSM em cada segmento mensurado. A correlação dos diâmetros da VSM com a idade e o IMC foi realizada considerando as classes C0 e C1 t de Student para amostras independentes. A condição de normalidade das variáveis foi avaliada pelo teste de Kolmogorov-Smirnov. Para a análise da associação entre os diâmetros e outras variáveis quantitativas, foi estimado o coeficiente de correlação de Pearson. Valores de p < 0,05 indicaram significância estatística. Os dados foram analisados com o programa computacional IBM SPSS Statistics v. 20.Para a comparação de dois grupos em relação ao diâmetro da veia safena, foi usado o teste Foram incluídas no estudo 146 mulheres com idade variando entre 21 e 79 anos, , sendo 88 avaliadas unilateralmente e 58 bilateralmente. O total de veias safenas mensuradas foi de 204, sendo 107  do lado direito e 97  do lado esquerdo.Em relação ao peso e à altura , as médiDos 204 MMII avaliados, 5  foram classificados como C0, 164  como C1, e 35  como C2.A média dos diâmetros da VSM  foi de 6versus C2  is defined as an abnormal state of venous function caused by valve incompetence, which may or may not be associated with obstruction of venous flow. The condition can affect the superficial and deep vein systems and perforating veins, may be due to congenital or acquired disorders,Chronic venous insufficiency is an important problem both for public health and socioeconomically, since it is the 14th-ranked cause of temporary absence from work in Brazil, affecting approximately 20% of the adult population in Western countries, where 3.6% of the population have venous ulcers.Vascular ultrasonography (VU) is the examination technique of choice for identifying and locating obstructions or reflux in the venous system, and also offers the possibility of measuring the diameters of saphenous veins, which can be used as parameters when planning surgery. However, there is little evidence in the literature on the normal caliber of the great saphenous vein (GSV) in women.Engelhorn et al. determined a relationship between presence of reflux and diameters of the GSV at the saphenofemoral junction (SFJ) (> 9 mm), the thigh (> 7 mm), and the leg > 5 mm). In the absence of reflux, the caliber of the GSV was below 5 mm at the SFJ and < 3 mm at the thigh. However, in the leg it was not possible to correlate absence of reflux with specific GSV calibers. mm. In tAlong the same lines, Mendoza et al.The objective of this study was to use VU to measure the diameters of great saphenous veins free from reflux, in women, and their relationships with age, height, clinical class according to the Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) system (C0 to C2), and body mass index (BMI).A cross-sectional study was conducted of women referred consecutively to a vascular laboratory with CVI-related complaints for venous mapping with VU.The patients recruited were over the age of 18, had symptoms of primary CVI in (CEAP) clinical classes C0, C1, or C2, had not had prior surgery for varicose veins, and were free from reflux in the great saphenous vein, according to VU examination. Men were not recruited and women were excluded if they had primary CVI in (CEAP) clinical classes C3 to C6, secondary and congenital CVI, prior saphenectomies, recent or historic thrombophlebitis of saphenous veins, or prior bariatric surgery.Patients were assessed in a vascular laboratory certified to ISO 9001 by experienced vascular ultrasonographers, certified in their areas of expertise by the Brazilian Angiology and Vascular Surgery Society (Sociedade Brasileira de Angiologia e de Cirurgia Vascular).The study was approved by the Research Ethics Committee at the Pontifícia Universidade Católica do Paraná, under protocol number 1.183.464.During the VU examination, with patients in a standing position, a clinical assessment and classification (CEAP) was conducted of each lower limb and patients’ age, weight, and height were recorded, for calculation of BMI.Patients were examined using Siemens-Antares® or Siemens-X700®, initially to rule out recent or chronic venous thrombosis, in decubitus dorsal, with transverse ultrasonographic sweeps in mode B and vein compressibility maneuvers, using a low frequency transducer (5 Mhz).The GSV was studied with the patient standing upright, with a high-frequency transducer (7-10 Mhz) to obtain transverse ultrasound images of the vein in mode B, measuring the diameter of the GSV at the SFJ, proximal thigh, mid thigh, distal thigh, knee, proximal leg, mid leg, and distal leg.The mean GSV diameter at each segment was used for the purposes of statistical analysis. Correlations between GSV diameters and age and BMI were analyzed by comparing classes C0 and C1 against class C2, and in cases in which the saphenous veins were examined bilaterally, the mean diameter of both sides was calculated.t test for independent samples was used to compare two groups in terms of saphenous vein diameter. Normality of variables was tested using the Kolmogorov-Smirnov test. Pearson’s correlation coefficients were estimated to analyze associations between diameters and other quantitative variables. Results with p < 0.05 were defined as statistically significant. Data were analyzed with IBM SPSS Statistics v. 20.Student’s A sample was recruited comprising 146 women with ages ranging from 21 to 79 years (mean: 45.3 years), 88 of whom were assessed unilaterally and 58 bilaterally. The total number of saphenous veins measured was 204: 107 (52.5%) on the right side and 97 (47.5%) on the left side.Mean weight and height  were 67.Five of the total of 204 lower limbs assessed (2.5%) were classified as C0, 164 (80.4%) as C1, and 35 (17.2%) as C2.Mean GSV diameters  were 6.5With the exception of the proximal leg measurements, there were no statistically significant differences between clinical classes C0/C1 and C2 for any of the GSV segments assessed . FiguresIn contrast, although the correlation coefficients for associations between patients’ BMI and the diameter of the GSV at the different segments measured  varied fStill with relation to BMI, considering the mean value of 25, a comparison between patients with BMI < 25 and those with BMI ≥ 25  showed tThere was no statistically significant relationship between age of patients and GSV diameter at any of the segments measured .In addition to BMI and age, patients’ height and weight were also compared in relation to GSV diameter, but no statistically significant differences were observed.Vascular ultrasonography can be used to study the anatomy and hemodynamics of the venous system, allowing surgical planning to be tailored to each extremity. In addition to patterns of reflux in the saphenous veins,Engelhorn et al.The objective of this study was to use VU to identify the diameters of different segments of great saphenous veins free from reflux, exclusively in women because of the higher prevalence of CVI in females, and in view of the possibility that diameter could be used as a parameter in treatment decision-making. Additionally, there is a need to preserve the GSV as an option for cardiac or peripheral bypass and for endovascular varicose vein treatment techniques.There is little evidence available in the literature on the caliber of GSVs without reflux in women. The mean diameters of the saphenous vein observed in this study were: 6.59 mm at the SFJ; 4.22 mm at the proximal thigh; 3.36 mm at the mid thigh; 3.13 mm at the distal thigh; 3.03 mm at the knee; 2.56 mm at the proximal leg; 2.43 mm at the mid leg; and 2.52 mm at the distal leg.In addition to investigating normal diameters of the great saphenous vein, we also correlated these diameters with patients’ age, height, and BMI. Seidel et al. also used VU to assess 52 lower limbs in 26 volunteers (six men and 20 women) without clinical signs of CVI and compared mean GSV diameters with each patient’s BMI, without detecting any statistically significant differences.In our study, when we correlated mean values of diameters of the different segments of the GSV with the BMI of the patients examined, we observed that, although the correlation was weak, there was a statistically significant difference between findings, demonstrating a tendency that the higher the BMI, the greater the mean diameter along almost the entire extension of the GSV.Considering the mean BMI value of 25 in the patients studied and using that value to compare mean diameters between patients with BMI ≥ 25 and patients with BMI < 25, it was observed that, with the exception of the distal thigh and the knee, there was a statistically significant difference between these groups of patients.Taken in isolation, patients’ height and weight were not related to any statistically significant difference in any of the GSV segments measured.Kröger et al.In our study, we assessed the relationship between GSV diameters and patients’ ages, since the prevalence of CVI tends to increase with age. Capitão et al.In conclusion, we identified diameters of GSVs without reflux of approximately 6.5 mm at the SFJ, 4.0 mm at the proximal thigh, 3.0 mm at the mid thigh, distal thigh, and knee, and 2.5 mm at the leg. Additionally, we concluded that these diameters are irrespective of CEAP clinical class 0/1 or 2, of age, and of height, but are related to patients’ BMI.


Adolescent suicide is a major public health issue, and early and accurate detection is of great concern. There are many reliable instruments for this purpose, such as the Columbia-Suicide severity rating scale (C-SSRS), but no validation exists for Spanish speaking Latin American adolescents.  To assess psychometric properties and cut-off scores of the C-SSRS in Spanish speaking adolescents. Exploratory assessment with principal component analysis (PCA) and Varimax rotation, and confirmatory analysis (CFA) were performed on two groups with 782 and 834 participants respectively (N=1616). Mean age was 24.8 years. A Receiver operator analysis was applied to distinguish between control and suicide-risk subgroups adolescents. Promax rotation yielded two 10-items factors, for suicide ideation and behavior respectively. C-SSRS was positively correlated with other suicide risk scales, such as Beck Depression Inventory-II, Suicidal Behaviors Questionnaire-Revised, or PHQ-9. Confirmatory factor analysis yielded a two-factor solution as the best goodness of fit model. C-SSRS showed adequate ability to detect suicide risk group with positive predictive value of 68.3%. ROC analyses showed cutoff scores of ≥ 6 and ≥ 4 for suicide ideation and behavior scales respectively This research offers data supporting psychometric validity and reliability of C-SSRS in nonclinical Spanish-speaking students. Added benefits are flexible scoring and management easiness. This questionnaire yields data on distinct aspects of suicidality, being more parsimonious than separate administration of a bunch of questionnaires.  Suicide rates have been growing worldwide with an estimate of over 800,000 deaths and almost ten suicide attempts for each death. According to the World Health Organization, every 40 seconds, a person commits suicide being the second leading cause of death among 15-29 year old Subjects were randomly recruited from a public university in Argentina. Sample size was calculated according to the followingformula:n is the required sample size, t is the confidence level at 99%, p is the estimated prevalence of suicide in the area, and m is the margin of error at 5%. Were included students which assisted at university courses between 1st March 2015 and 1st May 2015, aged between 18 and 35 years old, and exploratory and confirmatory psychometric analysis were performed with two randomly selected groups with 782 and 834 participants respectively . Submissions of 78 respondents from both groups were discarded due to missing data. Final sample included group 1 with 737 participants, 442 women (60%) and 295 men (40%) and group 2 with 801 participants, 489 women (61%) and 312 men (39%). Mean age of participants was 25.6 ±7.3. No statistical differences were found between both groups on age = 1.87, p= 0.80, ns). Written informed consent was obtained from all respondents. Study protocol was approved by the Faculty Ethics Committee. Face-to-face interviews were carried out by senior research interviewers trained in questionnaire administration procedures, and participants completed the questionnaire package in small groups of 15 to 20 during the same regular school day. In which The 12-item Short Form Health SurveyBrief version of the Social Support QuestionnaireAlcohol Use Disorders Identification Test  or no (0).Demographic data Included student self-reported gender and grade level, and socioeconomic status (SES), which was coded as a binary variable with 1 (above) and 0 (below) the minimal national wage.The Scale for Suicide Ideation (SSI)The Beck Depression Inventory-II (BDI-II)) is a 21-item self-report instrument to assess depression severity. Items are rated from 0 to 3 and scores range from 0-9 , 10-16 (mild), 17-29 (moderate), and 30-63 (severe). The BDI-II has adequate internal consistency (0.93). Suicidal Behaviors Questionnaire-Revised (SBQ-R)) evaluates past suicide ideation, frequency, threats, attempts and self-reported suicide likelihood. It has a Cronbach´s α of 0.87, and a cut-off point of ≥7 yields sensitivity between 83.0%-92.5%, and specificity between 90.6%-96.0%; in adolescent psychiatric inpatients a score of 8 has sensitivity of 80% and specificity of 91%. Beck Hopelessness Scale (BHS)Satisfaction with Life Scale (SWLS)) is a 5-item, self-report questionnaire that assess satisfaction with life. Items are rated on a 7-point Likert scale, has a Cronbach's α of 0.87 and adequate temporal validity (rtt = 0.54) at four years. The Positive and Negative Affect Schedule (PANAS)PHQ-9The Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime (KSADS-PL)The Columbia Suicide Severity Rating Scale (C-SSRS) was developed by researchers from Columbia, Pennsylvania and Pittsburgh Universities to evaluate suicidal ideation and behavior and has been translated into a myriad of languages including Spanish. It is composed of four categories: severity and intensity of suicidal ideation, suicidal behavior and lethality. The scale uses a lifetime and worst point timeframe. The Lifetime/Recent version records past and recent suicidality, Last Visit version assesses suicidality since patient's last visit. Screener version is used in ER settings and crisis call centers for non-mental health users. In the present study the C-SSRS categories were rearranged to facilitate definitions and improve outcomes report : severity (0-5), frequency (0-5), duration (0-5), controllability (0-5), deterrents (0-5), and reasons (0-5). Suicidal Behavior has 2 mutually exclusive items scored in an ordinal scale : intensity (0-5) and lethality (0-5). In case that any participant endorsed active suicidal ideation with plan or intent to act on it, was prompted to arrange further evaluation with a mental health team or to the emergency room, to ensure proper management of the event. s report . SuicidaParticipants completed questionnaires assessing distressful states, quality of life, drugs or alcohol consumption and social support. After that they were administered the clinical instruments assessing depressive mood, suicide risk, quality of life and finally the C-SSRS. The sample was divided into suicidal and non-suicidal subgroups to assess the C-SSRS discriminant and criterion-related validity Inclusion criteria for the suicidal subgroup included: SBQ-R total score of ≥7 BDI-II total score of ≥10 (mild -to-severe depressive symptoms) K-SADSPL score of 2 on item-1  and a score of 2 on any of items 2-4  regardless of ideation PHQ-9 score ≥8 M = 23.8 ±5.38) and gender. Using these criteria, 138 participants (9%), 82 women and 56 men were assigned to the suicidal subgroup, and the remaining 1,400 participants (91%) to the non-suicidal control subgroup. No differences were found between both groups for age  and Promax rotation. Kaiser-Meyer-Olkin and Bartlett's sphericity tests were used to determine data adequacy for factorial processing. Quantitative variables were reported by mean and standard deviation (±SD) for comparing variables; otherwise Student's t-test was used. Categorical variables were evaluated by χ2 was used to allow for non-normality and robust goodness-of-fit indices. Criterion for goodness-of-fit was set at 0.90 for Incremental fit index (IFI) t test and one-way MANOVA between suicidal and non-suicidal subgroups. Relative contribution of sociodemographic and psychiatric factors, together with C-SSRS subscales to suicidal risk was assessed using stepwise multiple regression analysis Scale factors were elicited using Velicer's minimum average partial correlation (MAP) and Cattell's scree tests. Confirmatory factor analysis (CFA) was conducted with group 2 (N= 801), using EQS software t = 0.765, p <0.09) although this difference was not statistically significative. p <0.001).The C-SSRS ideation subscale yielded a Guttmann split-half reliability of .91 and a Cronbach's alpha of 0.87, 0.89 and 0.93 for the whole sample, the suicide-risk and control groups respectively, with good internal consistency. Suicide intensity, severity and behavior subscales had Cronbach's alpha of 0.73, 0.89 and 0.91 respectively. Lowest scores for floor and ceiling effects were found in 11.8%, 10.5%, 10.1%, and 11.3% of cases in severity, behavior, intensity and lethality subscales respectively. Highest scores were for intensity subscale (2.4%). C-SSRS inter-items mean correlation was 0.64 . Item-total C-SSRS corrected correlation score are presented in 2 = 2,740.4, p <0.001) indicated that factor model was adequate for data processing. Velicer's minimum average partial correlation test and scree plot yielded a two-factor solution. All items had factor loadings ≥0.40  and Bartlett's sphericity test  and 4.91 (95% CI: 3.76-4.61) respectively. First factor contained 10 items (1 to 10) consistent with concept of suicide ideation. Second factor included 10 items (11 to 20) reflecting suicide behavior. Both factors were moderately and positively correlated with each other (r = 0.67). F = 4.67, p <0.01, d= 0.79) and lower in suicide behavior = 3.86, p <0.05, d= 0.82), which is a usual finding in general population. C-SSRS had a positive relationship with SSI , BDI-II , SBQ-R , BHS , PANAS-NA , KSADS-PL item 1  and negative correlations with SWLS  and PANAS-PA   with the two C-SSRS subscales weighted scores as dependent variables and gender as independent variable showed significant gender differences, women had higher scores in suicide ideation  .t test between suicidal and non-suicidal subgroup showed significant differences  = -10.21, p <0.001, d= 4.56). A stepwise multiple regression analysis was used to assess incremental validity of C-SSRS subscales as independent variables in predicting suicide risk . Adjusted R2 increased = 1,564.31, d= 6.76 p <0.001) after C-SSRS subscales were entered in the equation. A ide risk . SociodeThe result of the CFA with the default and restricted 1, 2 and 4 factors models, together with factor correlation scores are shown in r = 0.23 and -0.37 respectively). A significant difference was found for gender with bi-serial point correlation  and independent t-test (t(988) = -2.01, d= 0.66, p <0.025). Mantel-Haenszel (αMH) test showed statistical gender differences only in non-specific suicidal thoughts and controllability (p <0.01). A positive correlation was found between drug or alcohol use and C-SSRS , and independent t-test revealed that users scored higher in suicide ideation and behavior (t(988)= 4.09, d= 0.68, p <0.022). Social support was negatively correlated with ideation severity (t(988) = -3.14, d= 0.64, p <0.036).Correlations of C-SSRS with age and educational level were almost null and statistically non-significant  indicated medium accuracy. ROC analyses and cutoff scores of C-SSRS are shown in In spite of high suicidal ideation rates in non-clinical high-school students, little attention has been paid to validation of self-report instruments with this population. Based on this study, the C-SSRS appears to be valid and reliable. Factor analysis supports a two-dimensional model, including suicide ideation and behavior. Cronbach's alpha estimates for C-SSRS indicate a high internal consistency. Convergent validity with other suicidality scales suggests they assess a common construct. However non-redundant, non-overlapping outcomes could be observed with PHQ-9 or SWLS, were measures like sleep, appetite disturbance or pleasurable activities do not correlate with C-SSRS subscales. EFA revealed a factor structure slightly different from that proposed by the authors We presented data supporting the reliability and validity of the C-SSRS in a nonclinical sample of university Spanish-speaking students. It appears that this questionnaire is a useful instrument, both as a research and a clinical tool, combining feasible administration and flexible scoring system. This questionnaire yields data on four distinct aspects of suicidality, being in consequence more parsimonious than separate administration of a bunch of questionnaires to participants.  ,. Los registros de 78 encuestados de ambos grupos fueron descartados debido a datos incompletos. La muestra final incluyó a un primer grupo con 737 participantes, 442 mujeres (60%) y 295 hombres (40%); y a un segundo grupo con 801 participantes, 489 mujeres (61%) y 312 hombres (39%). La edad media de los participantes fue de 25.6 ±7.3. No se encontraron diferencias estadísticas entre ambos grupos en edad  = 1.87, p = 0.80, ns). El consentimiento informado se obtuvo para todos los encuestados. El protocolo de investigación fue aprobado por el Comité de Ética de la Facultad. Las entrevistas cara a cara fueron realizadas por investigadores capacitados en la administración de la C-SSRS, y los participantes completaron el conjunto de pruebas en pequeños grupos de 15 a 20 durante el mismo día de clases regulares.La version breve de la Encuesta de Salud de 12 ítemsLa version breve del Cuestionario de Apoyo SocialTest de Identificación de Trastorno en el uso de Alcohol  o no (0).Datos demográficos Incluyeron género declarado por el estudiante y nivel socio-económico (SES), el cual se codificó como una variable binaria con 1 (encima) y 0 (debajo) del salario mínimo nacional.La escala de Ideación Suicida (SSI)El Inventario de Depresión de Beck—II (BDI-II)) es un instrumento de auto-reporte de 21 ítems para evaluar la severidad de la depresión. Los items se puntúan de 0 a 3 y los resultados van desde 0-9 (mínimo), 10-16 (leve), 17-29 (moderado), y 30-63 (severo). El BDI-II tiene una consistencia interna adecuada (0.93). El Cuestionario de Comportamientos Suicidas Revisado (SBQ-R)Escala de Desesperanza de Beck (BHS)Escala de Satisfacción con la Vida (SWLS)) es un cuestionario de auto-reporte de 5 ítems, que evalúa la satisfacción con la vida. Los items se puntúan con una escala de Likert de 7 puntos, y tiene un coeficiente alfa de Cronbach de 0.87 y adecuada validez temporal (rtt = 0.54) a los 4 años. La Escala de Afectos Positivos y Negativos (PANAS)PHQ-9Escala de Trastornos Afectivos y Esquizofrenia para jóvenes en edad escolar -Actual y a lo largo de toda la vida (KSADS-PL)La Escala de Evaluación de Severidad de Riesgo de Suicidio de Columbia (C-SSRS) fue desarrollada por investigadores de la Universidad de Columbia, Pennsylvania y Pittsburgh, para evaluar el comportamiento y la ideación suicida, habiendo sido traducida a múltiples idiomas incluyendo el español. Se compone de cuatro categorías: gravedad e intensidad de la ideación suicida, y severidad y letalidad del comportamiento suicida. El Instrumento utiliza como escala temporal la evaluación a lo largo de la vida y el momento de mayor gravedad. La versión de la escala que toma en cuenta el período de vida más reciente registra las tendencias suicidas pasadas y presentes en el último mes, y la versión sobre la última visita evalúa el cambio en las tendencias suicidas desde la última consulta del paciente. La versión de la escala para tamizado se utiliza en entornos de atención de urgencias y en centros de llamadas de crisis para los usuarios de servicios de salud en general que no tienen trastornos mentales diagnosticados. En el presente estudio las categorías del C-SSRS fueron adaptadas para facilitar las definiciones y mejorar el informe de los resultados . La sub-Los participantes completaron los cuestionarios socio-demográficos incluyendo evaluación de calidad de vida, consumo de medicamentos o alcohol y apoyo social. Después de administrar los instrumentos clínicos para evaluar estado de ánimo depresivo, riesgo de suicidio y calidad de vida, se aplicó finalmente la C-SSRS. La muestra se dividió en dos subgrupos de riesgo suicida y sin riesgo o de control para evaluar la capacidad discriminante de la C-SSRS. Los criterios de inclusión para el subgrupo de riesgo de suicidio incluyeron: 1) puntuación total del SBQ-R de ≥7 2) puntaje total del BDI-II ≥10 (síntomas depresivos leves a severos) 3) un puntaje en la K-SADSPL de 2 en el ítem 1 (ideación suicida leve) y un puntaje de 2 en cualquiera de los ítems 2-4 (actos suicidas de intensidad leve) independientemente de la ideación 4) un puntaje en el PHQ-9 ≥8 Utilizando estos criterios, los 138 participantes (9% de la muestra), con 82 mujeres y 56 hombres fueron asignados para el subgrupo de riesgo de suicidio, en tanto que los restantes 1,400 participantes (91%) fueron para el subgrupo de control. No se encontraron diferencias entre ambos grupos en cuanto a la edad (M = 23.8 ±5.38) y el género.Análisis estadístico 2 para ajustarse a la no normalidad de los datos. El criterio de bondad de ajuste fue fijado en 0,90 para el Indice incremental de ajuste (IFI) . La validez de criterio se determinó aplicando test t y un MANOVA de una vía entre los subgrupos de riesgo suicida y control. La contribución relativa de al riesgo suicida de los factores sociodemográficos y psiquiátricos, junto con la sub-escalas de la C-SSRS se determinó mediante un análisis de regresión múltiple stepwise La comparación entre variables cuantitativas fueron reportadas usando la media y desviación estándar (±SD); de lo contrario se utilizó la prueba t de Student. Las variables categóricas fueron analizadas por prueba de χ2 o exacta de Fisher. El Grupo 1 se utilizó para realizar un análisis factorial exploratorio. La consistencia interna se determinó con el coeficiente alfa de Cronbach. Efecto techo y suelo se calcularon para no superar el límite del 15% de los participantes. Se evaluó la correlación de elementos con coeficiente de rango de Spearman bivariada y para el tamaño de efecto se calculó la d de Cohen. La validez de constructo de la C-SSRS se evaluó con análisis de componentes principales (PCA) y rotación Promax. Fueron utilizadas las pruebas de Kaiser-Meyer-Olkin y de esfericidad de Bartlett para determinar la adecuación de datos para el procesamiento factorial. Los factores escalares fueron extraídos mediante la prueba de correlación parcial mínima de Velicer y pruebas de sedimentación. Para el análisis factorial confirmatorio (CFA) se empeló el grupo 2 (N = 801), utilizando el programa EQS p <0.09, respectivamente) aunque esta diferencia no fue estadísticamente significativa.En la p < 0.001).La sub-escala de ideación suicida de la C-SSRS tuvo un índice de fiabilidad de mitades de Guttmann de.91 y un alfa de Cronbach de 0.87, 0.89 y 0.93 para toda la muestra y los grupos de riesgo de suicidio y control respectivamente, con una buena consistencia interna. Las sub-escalas de intensidad y gravedad de ideación suicida y severidad y letalidad de comportamiento suicida tuvieron un alfa de Cronbach de 0.73, 0.89 y 0.91 respectivamente. Las puntuaciones más bajas de los efectos techo y suelo fueron encontradas en el 11.8%, 10.5%, 10.1% y 11.3% de los casos para las sub-escalas de intensidad y severidad de ideación suicida y gravedad y letalidad de comportamiento suicida, respectivamente. Las puntuaciones más altas fueron para la sub-escala de intensidad (2.4% de los ítems). La media de correlación entre ítems para la C-SSRS fue 0.64 . La correlación corregida entre puntuación total e ítems de la C-SSRS se presenta en la p < 0.001) indicaron la adecuación muestral para el procesamiento factorial. El test de Velicer de correlación mínima parcial y el test de sedimentación arrojaron una solución de 2 factores. Todos los ítems tenían una carga factorial ≥0.40  y el test de esfericidad de Bartlett  y 4.91  respectivamente. El primer factor tenía 10 ítems (1 a 10) consistente con el concepto de ideación suicida. El segundo factor incluía 10 ítems (11 a 20) reflejando el comportamiento suicida. Ambos factores estaban correlacionados positive y moderadamente entre sí (r= 0.67). p <0.01, d = 0.79. En tanto que las mujeres tenían menores puntajes en comportamiento suicida  = 3.86, p <0.05, d= 0.82), lo cual representa un hallazgo usual en la población general. La C-SSRS tuvo una relación positiva con SSI , BDI-II , SBQ-R , BHS , PANAS-NA , ítem 1 de la KSADS PL  y correlación negativa con la SWLS  y PANAS PA  (El análisis de varianza multivariado (MANOVA) de una vía con las puntuaciones ponderadas de las dos sub-escalas de la C-SSRS como variables dependientes y el género como variable independiente demostró diferencias de género significativas, ya que las mujeres tenían puntuaciones más altas en ideación suicida con un puntaje en Hotelling T2 = 0,03; F y un valor en test exacto = 4.67,  <0.045) .t entre los subgrupos de riesgo suicida y control mostró significativas diferencias = -10.21, p <0.001, d= 4.56). El análisis de regresión múltiple stepwise permitió evaluar la validez discriminante de las subescalas de la C-SSRS como variables independientes para predecir el riesgo de suicidio . La R2 ajustada aumentó = 1,564.31, d= 6.76 p <0.001) después que las subescalas de la C-SSRS se introdujeron en la ecuación. El test suicidio . Los facEl resultado del AFC con los modelos predeterminado y restringidos de 1, 2 y 4 factores, junto con los puntajes de las correlaciones factoriales se muestran en las r= 0.23 and -0.37 respectivamente). Se encontró una diferencia significativa para género analizadas con punto de correlación bi-serial  y test-t independiente (t(988)= -2.01, d= 0.66, p <0.025). El test de Mantel-Haenszel (αMH) mostró diferencias significativas entre géneros solo para ideación suicida no específica y para el factor de controlabilidad (p <0.01). Se encontró una correlación positiva entre el uso de drogas y alcohol y la C-SSRS , y un test-t para muestras independientes reveló que los usuarios tenían mayores puntajes en las subescalas de ideación y comportamiento suicidas (t(988)= 4.09, d= 0.68, p <0.022). El apoyo social correlacionó negativamente con la severidad de ideación suicida (t(988) = -3.14, d= 0.64, p <0.036).Las correlaciones de la C-SSRS con la edad y niveles educacionales fueron mínimas y no significativas  indicó una precisión alta. Este análisis junto con los puntos de corte de la C-SSRS se muestra en la A pesar de las altas tasas de suicidio entre estudiantes sin patología clínica, se ha prestado poca atención a la validación de escalas de auto-reporte para esta población. Basándonos en el presente estudio, la C-SSRS resulta ser un instrumento válido y confiable. El análisis factorial apoya una solución de dos factores, incluyendo la ideación y el comportamiento suicidas. Las estimaciones alfa de Cronbach para la C-SSRS señalan una alta consistencia interna, en tanto que la validez convergente con tras escalas de riesgo de suicido sugiere que evalúan un constructo común a todas. Sin embargo se observaron resultados de correlación no redundantes ni colineares con las escalas PHQ-9 o SWLS, donde otras medidas tales como sueño, trastorno del apetito o actividades placenteras no correlacionan con las subescalas de la C-SSRS. El AFE mostró una estructura factorial discretamente diferente de la propuesta por los autores Se presentan datos que apoyan la confiabilidad y validez de la C-SSRS en una muestra no clínica de estudiantes universitarios hispano-hablantes. El cuestionario demostró ser un instrumento útil tanto para la investigación como para la evaluación clínica, combinando la flexibilidad de su administración con puntajes de amplio rango para cada una de las medidas. El cuestionario ofrece datos sobre cuatro aspectos diferentes de la suicidalidad siendo en consecuencia mas practico que la administración separada de varios instrumentos adicionales.


There is an error in affiliation 3 for authors Patricia Gutiérrez-Carcedo and José Raul Herance. Affiliation 3 should be:Grup de Recerca en Imatge Mèdica Molecular, Diabetes and Metabolism Vall d’Hebron Research Institute, CIBERDEM, CIBBIM-Nanomedicine, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.


The following information is missing from the Funding section: LCLF also acknowledges BNDES FUNTEC Project Enzimas e leveduras para produção de etanol a-partir da biomassa da cana).