121 resultados para Cryptosporidium
Resumo:
The purpose of this study was to determine the prevalence, associated risk factors and genotype of Giardia duodenalis infection in children attending public daycare centers in the city of Araguari, state of Minas Gerais, Brazil. Fecal samples were collected from 245 children aged 0-5 years, and questionnaires were asked about sociodemographic and hygiene-related characteristics. At the daycare centers where children tested positive, fecal samples were collected from the staff handling food, and from family members and domestic animals. Positive samples were analyzed at the dehydrogenase glutamate (gdh) locus to determine the genotype. The prevalence of G. duodenalis was 51.8%, and drinking unfiltered and unboiled water (OR 2.12, CI 1.26-3.69, p<0.001) and washing hands only with water (OR 2.14, Cl 1.19-4.04, p<0.001) were related risk factors. No association was found between test-positive children anti their family members, domestic animals and food handlers. An analysis of the sequences of 30 samples revealed that they all belonged to genotype B. (C) 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
Resumo:
Este estudo teórico propõe uma reflexão sobre a resistência intrínseca da subclasse Coccidia, particularmente o gênero Cryptosporidium, considerado como um agente potencialmente patogênico para pacientes imunocomprometidos, e suas repercussões na prática assistencial. Atualmente, as diretrizes internacionais e nacionais aprovam como procedimento seguro a desinfecção química de alto nível de endoscópios digestivos, após sua limpeza. No entanto, estudos evidenciaram que micro-organismos da subclasse Coccidia, especificamente o Cryptosporidium, responsável por infecção entérica, são mais resistentes que as micobactérias e não são inativados pelos desinfetantes químicos de alto nível, exceto pelo Peróxido de Hidrogênio a 6% e 7,5%, formulação ainda não disponível no Brasil. Conclui-se que a legislação deve incluir este agente entre os micro-organismos teste para aprovação de desinfetantes químicos de alto nível e que as autoridades sanitárias devem se esforçar para garantir que os estabelecimentos de assistência à saúde tenham acesso a produtos eficazes contra o Cryptosporidium.
Resumo:
Poiché le infestazioni parassitarie dei rettili in cattività possono incidere sulla loro salute, è stato condotto uno studio sui parassiti intestinali e gli ectoparassiti su 213 rettili del Bioparco di Roma. In cattività, dove gli animali sono confinati in piccoli spazi, la concentrazione di parassiti può essere più alta. Alcuni di essi sono innocui, ma altri, specialmente in associazione allo stress, possono essere pericolosi, causare malattie e portare anche alla morte se non trattati. Inoltre, i rettili parassitati hanno una vita più breve, sono più suscettibili ad altre malattie, hanno scarsa fertilità, ridotta crescita ed alta mortalità. Tra Gennaio 2012 e Dicembre 2014 sono stati raccolti campioni da 213 rettili che non mostravano alcun segno clinico e che includevano 23 specie di sauri, 20 specie di cheloni, 20 specie di ofidi e 4 specie di alligatori. I campioni sono stati esaminati per la presenza di parassiti intestinali mediante copromicroscopia di tipo qualitativo previa sedimentazione e successiva flottazione, mentre la tecnica di Zihel-Neelsen è stata usata per la ricerca di oocisti di Cryptosporidium . I campioni di feci sottoposti ad esame copromicroscopico qualitativo sono risultati positivi per almeno una tipologia di endoparassiti nel 49% dei casi. Il 35% dei campioni è risultato positivo per ossiuri, il 22% per coccidi, l’1% per strongili ed il 5% per ascaridi. Degli strisci fecali colorati con la tecnica di Zihel-Neelsen, il 25% sono risultati positivi per Cryptosporidium spp. Ossiuri e coccidi sono stati più prevalenti nei sauri rispetto ai cheloni, agli ofidi e agli alligatori e nel 14% è stata osservata la presenza di entrambi. Inoltre, per quanto riguarda gli ectoparassiti, sono state rilevate uova di Myocoptes musculinus nel 24% dei rettili esaminati. Tutti gli strisci risultati positivi per Cryptosporidium spp. sono stati inviati all’Università di Santiago de Compostela per essere sottoposti alla tecnica PCR.
Resumo:
The protozoon parasite Cryptosporidium parvum is an important cause of diarrhea in farm animals, but it can also infect other animals and humans. In this case report, oocysts of Cryptosporidium spp. were microscopically detected by modified Ziehl-Neelsen staining in the feces of a 9 day old Arabian colt presented with yellowish, foul smelling, diarrhea and fever of 40 degrees C. PCR and sequencing of the isolate revealed C. parvum (bovine genotype). Hemato-chemical analysis of the foals blood revealed a marked hypogammaglobulinaemia (IgG 108mg/dl). The colt responded well to a supportive therapy and administration of plasma (until a gammaglobulin-concentration of 620 mg/dl was reached) and was released in good health from the clinic after 10 days. Follow-up testing for Cryptosporidium oocycsts remained negative. Cryptosporidiosis with life-threatening diarrhea is a rare diagnosis in foals in Switzerland. Immunodeficiency increases the risk for cryptosporidiosis. We hypothesize that the low concentration of gammaglobulins together with the weak INF-gamma response normally observed in young foals may have favored the clinical manifestation with diarrhea. Foals with diarrhea should be screened for cryptosporidia with specific tests.
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Lipid metabolism is of crucial importance for pathogens. Lipids serve as cellular building blocks, signalling molecules, energy stores, posttranslational modifiers, and pathogenesis factors. Parasites rely on a complex system of uptake and synthesis mechanisms to satisfy their lipid needs. The parameters of this system change dramatically as the parasite transits through the various stages of its life cycle. Here we discuss the tremendous recent advances that have been made in the understanding of the synthesis and uptake pathways for fatty acids and phospholipids in apicomplexan and kinetoplastid parasites, including Plasmodium, Toxoplasma, Cryptosporidium, Trypanosoma and Leishmania. Lipid synthesis differs in significant ways between parasites from both phyla and the human host. Parasites have acquired novel pathways through endosymbiosis, as in the case of the apicoplast, have dramatically reshaped substrate and product profiles, and have evolved specialized lipids to interact with or manipulate the host. These differences potentially provide opportunities for drug development. We outline the lipid pathways for key species in detail as they progress through the developmental cycle and highlight those that are of particular importance to the biology of the pathogens and/or are the most promising targets for parasite-specific treatment.
Resumo:
To provide baseline parasitological data for health surveillance in free-ranging Alpine ibex (Capra ibex ibex), we assessed the endoparasite population and level of parasitism in apparently healthy ibex. Faecal samples from 148 ibex were collected between 2006 and 2008 in two different Swiss ibex colonies. They were analysed by coprology, including combined sedimentation/flotation method, sedimentation method, Baermann funnel technique and Ziehl-Neelsen staining. Gastrointestinal parasites and lungworms were identified in 100% and 81.8% of the examined animals, respectively. Highest prevalences were recorded for gastrointestinal strongylids other than Nematodirus/Marshallagia spp. (100%), Eimeria spp. (100%), Muellerius spp. (79.8%) and Nematodirus/Marshallagia spp. (79.0%). We report for the first time Cryptosporidium sp. in free-ranging Alpine ibex and Cystocaulus spp. in free-ranging ibex from Switzerland. On average, ibex were infected with 3.9 different parasites taxa (range: 1-8). Parasite prevalence and diversity varied significantly between sexes, study sites and seasons. Parasite egg output was low in 95.7% and moderate in 5.3% of the samples. Overall, the results indicate that Alpine ibex are widely infected with endoparasites and suggest that multiple infections are very common in apparently healthy populations. Furthermore, our data underline the potential influence of factors such as sex, study site and season on parasitological findings.
Resumo:
Protozoan parasites which reside inside a host cell avoid direct destruction by the immune system of the host. The infected cell, however, still has the capacity to counteract the invasive pathogen by initiating its own death, a process which is called programmed cell death or apoptosis. Apoptotic cells are recognised and phagocytosed by macrophages and the parasite is potentially eliminated together with the infected cell. This potent defence mechanism of the host cell puts strong selective pressure on the parasites which have, in turn, evolved strategies to modulate the apoptotic program of the host cell to their favour. Within the last decade, the existence of cellular signalling pathways which inhibit the apoptotic machinery has been demonstrated. It is not surprising that intracellular pathogens subvert these pathways to ensure their own survival in the infected cell. Molecular mechanisms which interfere with apoptotic pathways have been studied extensively for viruses and parasitic bacteria, but protozoan parasites have come into focus only recently. Intracellular protozoan parasites which have been reported to inhibit the apoptotic program of the host cell, are Toxoplasma gondii, Trypanosoma cruzi, Leishmania sp., Theileria sp., Cryptosporidium parvum, and the microsporidian Nosema algerae. Although these parasites differ in their mechanism of host cell entry and in their final intracellular localisation, they might activate similar pathways in their host cells to inhibit apoptosis. In this respect, two families of molecules, which are known for their capacity to interrupt the apoptotic program, are currently discussed in the literature. First, the expression of heat shock proteins is often induced upon parasite infection and can directly interfere with molecules of the cellular death machinery. Secondly, a more indirect effect is attributed to the parasite-dependent activation of NF-kappaB, a transcription factor that regulates the transcription of anti-apoptotic molecules.
Resumo:
Histo-blood group antigens (HBGAs) have been associated with susceptibility to enteric pathogens including noroviruses (NoVs), enterotoxigenic Escherichia coli (ETEC), Campylobacter jejuni, and Vibrio cholerae. We performed a retrospective cohort study to evaluate the relationship between traveler HBGA phenotypes and susceptibility to travelers' diarrhea (TD) and post-infectious complications. 364 travelers to Guadalajara, Mexico were followed prospectively from June 1 - September 30, 2007 and from June 7–July 28, 2008 for the development of TD and at 6 months for post-infectious irritable bowel syndrome (PIIBS). Noroviruses were detected from illness stool specimens with RT-PCR. Diarrheal stool samples were also assayed for enterotoxigenic and enteroaggregative E. coli, Salmonella species, Shigella species, Vibrio species, Campylobacter jejuni, Yersinia enterocolitica, Aeromonas species, and Plesiomonas species. Diarrheal stools were evaluated for inflammation with fecal leukocytes, mucus, and occult blood. Phenotyping for ABO and Lewis antigens with an ELISA assay and FUT2 gene PCR genotyping for secretor status were performed with saliva. 171 of 364 (47%) subjects developed TD. HBGA typing for the travelers revealed O (62.9%), A (34.6%), B (1.6%), and AB (0.8%) phenotypes. There were 7% nonsecretors and 93% secretors among the travelers. AB phenotypes were more commonly associated with Cryptosporidium species (P=0.04) and ETEC ( P=0.08) as causes of TD. AB and B phenotype individuals were more likely to experience inflammatory diarrhea, particularly mucoid diarrhea ( P=0.02). However, there were relatively few individuals with AB and B phenotypes. GI and GII NoV and Cryptosporidium species infections and PI-IBS were identified only in secretors, but these differences were not statistically significant, (P=1.00), (P=1.00), and (P=0.60), respectively. Additional studies are needed to evaluate whether AB phenotype individuals may be more susceptible to developing TD associated with Cryptosporidium species or ETEC, and whether AB and B phenotype individuals may be more likely to develop inflammatory TD. Further studies are needed to investigate whether nonsecretor travelers may be at less risk for developing infections with NoVs and Cryptosporidium species and PI-IBS.^
Resumo:
Aryloxyphenoxypropionates, inhibitors of the plastid acetyl-CoA carboxylase (ACC) of grasses, also inhibit Toxoplasma gondii ACC. Clodinafop, the most effective of the herbicides tested, inhibits growth of T. gondii in human fibroblasts by 70% at 10 μM in 2 days and effectively eliminates the parasite in 2–4 days at 10–100 μM. Clodinafop is not toxic to the host cell even at much higher concentrations. Parasite growth inhibition by different herbicides is correlated with their ability to inhibit ACC enzyme activity, suggesting that ACC is a target for these agents. Fragments of genes encoding the biotin carboxylase domain of multidomain ACCs of T. gondii, Plasmodium falciparum, Plasmodium knowlesi, and Cryptosporidium parvum were sequenced. One T. gondii ACC (ACC1) amino acid sequence clusters with P. falciparum ACC, P. knowlesi ACC, and the putative Cyclotella cryptica chloroplast ACC. Another sequence (ACC2) clusters with that of C. parvum ACC, probably the cytosolic form.
Resumo:
O propósito do presente estudo foi investigar e monitorar a remoção de cistos de Giardia spp. e oocistos de Cryptosporidium spp. por diferentes processos de uma estação de tratamento de esgoto (ETE) em escala plena, composta basicamente por tratamento preliminar, reator UASB e flotador por ar dissolvido, e verificar a ocorrência desses protozoários no lodo do reator UASB e do flotador. Além disso, avaliou-se a remoção desses parasitos pelo processo de flotação por ar dissolvido em escala de bancada (equipamento Flotateste). Analisou-se a qualidade das amostras a partir de variáveis físicas e químicas, e pela detecção de microrganismos indicadores - E. coli, coliformes totais e Clostridium perfringens. Os métodos de detecção de protozoários se basearam nas etapas de concentração (tripla centrifugação ou filtração em membrana seguida de tripla centrifugação); purificação por separação imunomagnética (IMS); detecção por reação de imunofluorescência direta (RID). As recuperações de cistos variaram de 32,6 a 67,0 % dependendo do método adotado, já para os oocistos as recuperações estiveram na faixa de 5,6 a 12,0 %. Na ETE-Monjolinho foram detectadas significativas quantidades de cistos de Giardia spp. em 100% das amostras de esgoto analisadas, com concentração média de 1,89 x 104 e 2,35 x 102 cistos.L-1 no esgoto bruto e tratado, respectivamente. Já os oocistos de Cryptosporidium spp. foram detectados em 39,0 % das amostras de esgoto, com concentração média de 1,35 x 102 oocistos.L-1 no esgoto bruto e 5,87 oocistos.L-1 em esgoto tratado (após flotador). A remoção global da ETE para remoção de Giardia spp. foi em média 2,03 log. O lodo do reator UASB e lodo do flotador apresentaram altas quantidade de (oo)cistos, constatando-se a tendência desses sistemas em concentrar os (oo)cistos por seus processos físicos. Algumas correlações significativas foram encontradas, como correlação entre a concentração de cistos no lodo e a variável sólidos totais, a concentração de cistos no esgoto bruto e as variáveis cor aparente, DQO total e particulada, e a concentração de cistos no efluente UASB e o microrganismo Clostridium perfringens. Diferentemente do flotador em escala plena, o processo do flotação por ar dissolvido em escala de bancada alcançou elevadas remoções médias de cistos de Giardia spp., entre 2,5 e 2,7 log nas diferentes condições de floculação estudadas.
Resumo:
A concentração demográfica e de sistemas coletivos de esgotamento sanitário dentro do perímetro urbano da maioria dos municípios brasileiros, dificulta a viabilização do fornecimento de serviços de tratamento de esgotos domésticos à habitações e núcleos habitacionais isolados situados em áreas periurbanas e rurais, intensificando os danos provocados pela poluição de origem antrópica ao meio ambiente e à preservação da saúde pública. Para contribuir no equacionamento deste problema, o presente estudo teve por finalidade avaliar uma wetland construída híbrida em escala real, composta por uma unidade com fluxo contínuo subsuperficial vertical seguida por uma unidade de fluxo contínuo subsuperficial horizontal, cultivadas com capim Vetiver, para o tratamento de efluente proveniente de tanque séptico. A presente configuração experimental busca uma solução de baixo custo e simplificada para o tratamento descentralizado de esgotos domésticos. A estação experimental de tratamento de esgotos, parte integrante e um dos produtos da Rede Nacional de Tratamento de Esgotos Descentralizados RENTED, foi construída no Centro Tecnológico de Hidráulica CTH / Escola Politécnica EPUSP, campus Butantã da USP, em São Paulo. O esgoto bruto foi proveniente do Conjunto Residencial da USP e do restaurante central da Cidade Universitária. As vazões média e máxima de esgoto bruto, respectivamente, de 640L.d-1 e 1600L.d-1, foram aplicadas à entrada do TS de 5.000L e deste escoaram por gravidade à entrada da wetland construída híbrida, com TDH total de 2,8d e 1,1d, respectivamente, sob aplicação das vazões média e máxima de projeto. O monitoramento do experimento em campo, incluindo o período inicial de partida, durou 6 meses consecutivos. Foram avaliados os parâmetros físico-químicos e microbiológicos do esgoto bruto e do efluente do tanque séptico e das câmaras da wetland construída híbrida durante 97 dias consecutivos. Os resultados indicaram que tanto as mudas jovens quanto as adultas de capim Vetiver adaptaram-se bem às condições ambientais. As eficiências médias de remoção no efluente tratado final quanto à matéria orgânica carbonácea foram de 96 por cento para DBO5,20 e 90 por cento para DQO, 40 por cento para N-total, 23 por cento para N-amoniacal total, 60 por cento para P-total, 52 por cento para P-PO4, 74 por cento para SST, 96 por cento para SSV, 75 por cento para sólidos sedimentáveis, 44 por cento para SDV, 88 por cento para sulfeto total, e 97 por cento para óleos e graxas totais, variando entre 73 por cento a 100 por cento . Cerca de 80 por cento da fração orgânica da matéria nitrogenada presente no esgoto bruto foi removida. A remoção de coliformes termotolerantes foi, em média, de 2 e 3 unidades log, e de Escherichia Coli, média de 1 e 3 unidades log, respectivamente, sob aplicação das vazões máxima e média, Giardia sp, média de 99,995 por cento , Cryptosporidium sp, média de 98,7 por cento , Enterovírus, média de 99,6 por cento , e Ascaris sp, média de 0,10 ovo/L. A remoção de sulfetos propiciou a geração de efluente tratado sem odores desagradáveis. A diminuição da vazão aplicada e a elevação do TDH influenciaram positivamente no desempenho do sistema com relação às remoções dos parâmetros físico-químicos e microbiológicos. Com base no presente estudo, ficou evidente o benefício da associação de wetlands construídas com fluxo vertical e horizontal no tratamento de efluente de tanque séptico. O capim Vetiver apresentou bom potencial de utilização em wetlands 8 construídas para tratamento de esgotos domésticos. O sistema experimental de tratamento apresentou flexibilidade operacional, mantendo bom desempenho inclusive nos períodos de sobrecarga. A qualidade do efluente tratado final obtido no presente estudo atende às exigências de lançamento e aos padrões de emissão de efluentes líquidos em corpos dágua e em sistemas públicos de esgotamento sanitário definidos na legislação ambiental federal e do Estado de São Paulo. A tecnologia de wetlands construídas híbridas associada ao tratamento de efluentes de tanque séptico apresentou bom potencial para o tratamento descentralizado de esgotos domésticos, inclusive em regiões com pouca disponibilidade de área livre.
Resumo:
Polyketides derived from dinoflagellates are among the most complex and unique structures identified to date. The carbon framework of all polyketides is assembled by a polyketide synthase (PKS). No studies of the biosynthesis of dinoflagellate derived polyketides at the genomic level have been reported to date. Nine strains representing seven different species of dinoflagellates were screened for the presence of type I and type II polyketide synthases (PKS) by PCR and RT-PCR. Seven of the nine strains yielded products that were homologous with known and putative type I polyketide synthases. In each case, the presence of a PKS gene was correlated with the presence of bacteria in the cultures as identified by amplification of the bacterial 16S rRNA gene. However, residual phylogenetic signals, resistance to methylation sensitive restriction enzymes and the lack of hybridization to bacterial isolates support a dinoflagellate origin for most of these genes. ^ A more detailed analysis of Karenia brevis, a toxic marine dinoflagellate endemic to the Gulf of Mexico, also supports the hypothesis that dinoflagellates have polyketide synthase genes. Blooms of this harmful alga cause fish kills, marine mammal mortalities and neurotoxic shellfish poisonings. These harmful effects are attributed to a suite of polyketide secondary metabolites known as the brevetoxins. PKS encoding genes amplified from K. brevis culture were found to be similar to PKS genes from the closely related protist, Cryptosporidium parvum. This suggested that these genes originate from the dinoflagellate. However, K. brevis has not been grown axenically. The associated bacteria might be the source of the toxins or the PKS genes. This dissertation reports the localization of these PKS encoding genes by a combination of flow cytometry/PCR and fluorescence in situ hybridization (FISH). Two genes localized exclusively to K. brevis cells while a third localized to both K. brevis and associated bacteria. While these genes have not yet been linked to toxin production, the work describes the first definitive evidence of resident PKS genes in any dinoflagellate. ^
Resumo:
The aim of this study was to determine the haematological value and biochemical blood in baby alpacas with enteric disorder. A total of 30 blood and serum samples were collected from alpacas of 1 month old with diarrhoea and 5 blood samples of clinically healthy baby alpacas (controls). The animals were from communities in the central Andes from Peru. About haematology were determined haematocrit, haemoglobin concentration, red blood count and white blood count that were not significantly different between control animals and animals with diarrhoea. Moreover, biochemical blood parameters as total protein, albumin and calcium decrease significantly (p<0.05). We conclude that our results could be considered as factors in the mortality of baby alpaca by infectious diarrhoea.
Resumo:
Although diarrhoea caused by Cryptosporidium is prevalent in livestock species throughout the world relatively little is known about the species and subtypes of Cryptosporidium found in cattle on Scottish farms. In particular, little is known about the shedding profiles (age when calves become infected and duration of shedding) of the different species found in cattle and how calves become infected. There are several theories about how neonatal calves first become infected with the parasite but the role which adult cattle play in the transmission of the parasite has not been fully addressed. It was previously thought that adult cattle did not become infected with the same species of Cryptosporidium which causes disease in the young calves. Some studies have shown that this may not be true and with the advance of new techniques to discriminate species this is an area which should be revisited. In addition, it is known that it is possible for humans to become infected with Cryptosporidium and show clinical disease early in life and then again later in adulthood. In livestock however, diarrhoea caused by the parasite is generally only seen in neonatal livestock while older animals tend to be asymptomatic. It is not known if this resistance to clinical disease at an older age is due to changes in the host with an increase in age or if prior infection “immunises” the animal and provides protection against re-infection. It is also not known if infection with one isolate of C. parvum will provide protection against infection with another or if the protection formed is species/isolate specific. The main aims of this thesis were to: determine the species and subtypes of Cryptosporidium found in calves on a study farm over a one year period from birth; assess the role which adult cattle play in the transmission of the parasite to newborn calves; develop new typing tools to enable the rapid and easy differentiation of Cryptosporidium species found in cattle and to examine the host-pathogen interactions in animals given serial experimental challenges with distinct Cryptosporidium parvum isolates to determine if the resistance seen in older animals on farms is due to an increase in age or as a result of prior infection. iii A variety of different approaches were taken to achieve these aims. Longitudinal experiments carried out on a study farm revealed that in calves <9 weeks of age the most common species of Cryptosporidium is C. parvum and that all calves in the group became infected with Cryptosporidium within the first two weeks of life. Sample collection from the same animals later in life (at 6 months of age) showed that contrary to most previous studies the most common species detected at in this age group was also C. parvum although, interestingly, the subtype which the calves were shedding was not the same subtype that they were shedding previously. The longitudinal study which investigated the role of adult cattle in the transmission of Cryptosporidium also yielded some interesting results. It was found that most of the adult cattle on this farm were shedding Cryptosporidium albeit intermittently. Speciation of the positive samples revealed that, on this farm, the most predominant species of Cryptosporidium in adult cattle was also C. parvum. This is very unusual as most previous studies have not found this level of infection in older cattle and C. parvum is not usually found in this age group. A number of different subtypes were found in adult cattle and some animals shed more than one subtype over the course of the study. This contradicts prior findings which demonstrated that only one subtype is found on a single farm. The experimental infection trial involving infection of young (<1 week old) and older (6 week old) lambs with distinct C. parvum isolates demonstrated that an increase in age at primary infection reduces the effect of clinical disease. Animals which were infected at <1 week of age were re-challenged at 6 weeks of age with either a homologous or heterologous infection. Results revealed that previous exposure does not protect against re-infection with the same or a different isolate of C. parvum. This study also demonstrated that an increase in infective dose leads to a shorter pre-patent period and that there are variations in the clinical manifestations of different isolates of the same Cryptosporidium species.
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Con el objetivo de determinar la frecuencia de cryptosporidium como causa de diarrea en los niños que ingresan al servicio o son atendidos en la emergencia del departamento de pediatría del Hospital Vicente Corral Moscoso. El estudio se realizó en los niños internados en el servicio de clínica y los atendidos en el servicio de emergencia del departamento de pediatría del hospital Vicente Corral Moscoso de Cuenca, de junio de 1991 a marzo de 1993. Sujetos a investigación (muestra) fueron 500 niños que presentaron diarrea aguda que ingresaron al servicio de clínica o fueron atendidos en la emergencia del departamento de pediatría