Special Article
Medical diagnosis in resource-poor tropical countries
El diagnóstico en medicina tropical en países con pocos recursos
J.M. Ramos-Rincóna,
, J. Cuadros-Gonzálezb, E. Malmierca-Corralc, M. de Górgolas-Hernándezd
Corresponding author
a Servicio de Medicina Interna, Hospital General Universitario de Alicante, Universidad Miguel Hernández de Elche, Elche, Alicante, Spain
b Servicio de Microbiología, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
c Servicio de Medicina Interna, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
d División de Enfermedades Infecciosas, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
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Ramos-Rincón, J. Cuadros-González, E. Malmierca-Corral, M. de Górgolas-Hernández" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Ramos-Rincón" "email" => array:1 [ 0 => "jramosrincon@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Cuadros-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Malmierca-Corral" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "de Górgolas-Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario de Alicante, Universidad Miguel Hernández de Elche, Elche, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "División de Enfermedades Infecciosas, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El diagnóstico en medicina tropical en países con pocos recursos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 843 "Ancho" => 1000 "Tamanyo" => 128150 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Pallor in the nail beds of patients with anemia (black asterisks); (B) thin blood stained according to the Wright technique (×1000 magnification): trophozoite of considerable size and amoeboid appearance with blackish brown pigmentation (hemosiderin) (black arrows), malaria by <span class="elsevierStyleItalic">Plasmodium vivax</span>; (C) examination of fresh feces (×400 magnification): <span class="elsevierStyleItalic">Giardia intestinalis</span> cysts (black arrows); and (D) chest radiography with voluminous mediastinal adenopathies (white arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Healthcare collaboration with low-income countries (especially African nations) where the availability of diagnostic resources is usually quite limited is becoming increasingly common.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this context, clinical skills are especially important. Understanding the available diagnostic tools in these circumstances provides for better clinical-therapeutic approaches. This study describes the diagnostic tools commonly available in rural tropical areas with limited diagnostic resources.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical skills</span><p id="par0010" class="elsevierStylePara elsevierViewall">Anamnesis enables clinicians to obtain relevant information and constitutes an opportunity to observe the patient's behavior and assess various characteristics to explore in more detail during the physical examination. When working in areas with a different language, it can be difficult to obtain detailed information or the exact perception of the patient. In these situations, an interpreter is needed. The physical signs observed during the physical examination are objective indications of the disease.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> When the anamnesis is limited, physical signs can confirm the functional or structural abnormalities suspected in the patient interview. In these cases, a well-performed examination can be the main clue to diagnosing the disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination tends to focus on the organ or part of the body that is damaged, according to the data obtained during the patient interview.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> In tropical countries, the examination should be performed methodically and rigorously from head to toe so as not to overlook important issues in the diagnosis. It is advisable to disrobe the patient and examine him on a bed with good lighting. During the physical examination, heightened alertness to subtle signs such as petechiae, subconjunctival jaundice and pallor in the mucous membranes of dark-skinned patients is needed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The physical examination should be repeated as many times as required for the clinical situation. The availability of a wide repertoire of complementary tests in our developed European country has limited our interest and experience in the findings of physical examinations. In regions where the availability and reliability of diagnostic tests is highly reduced, the role of anamnesis and physical examination are fundamental.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Laboratory tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">In tropical regions with few resources, the laboratory is staffed by laboratory technicians. Their certification is commonly obtained in accredited schools. Certification is achieved after a national examination after completing 1–3 years of teaching courses (Certificate in Medical Laboratory Technology).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Basic hematological determinations</span><p id="par0025" class="elsevierStylePara elsevierViewall">Anemia is common in tropical areas due to various reasons, including intestinal parasitic infections, nutritional deficiency and blood loss.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Determining the degree of anemia enables us to better define the anemic syndrome (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). To assess the degree of anemia, we have the hematocrit, hemoglobin and erythrocyte count (Appendix A). At present, there are hemoglobin analyzers (or hemoglobinometers) that enable us to determine the patient's hemoglobin levels with a single drop of capillary blood. This handheld exposure meter is portable and easy to use and has a precision similar to high-caliber analyzers.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There are a number of models that also determine hematocrit levels.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given that patients with intense anemia might require blood transfusions, determining the blood groups of potential donors and recipients is necessary. The blood is mixed with anti-A, anti-B, and anti-Rh antibodies and then checked to see if the red blood cells agglutinate (Appendix A). When the donor and recipient blood are compatible, pretransfusion crossmatch tests are performed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The leukocyte count is of considerable usefulness in many situations. The erythrocyte sedimentation rate is an indicator of inflammatory response and is of considerable usefulness in tropical countries.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Automated hematology analyzers are replacing the traditional manual method of measuring hemoglobin and hematocrit levels and the visual count of leukocytes in many tropical regions. To prevent diagnostic errors, these automated analyzers require the proper training of personnel in terms of equipment operation and maintenance. These instruments should coexist with manual techniques, given that failures are frequent due to inadequate maintenance, the characteristics of calibration liquids and the continuous electricity outages.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With the AIDS epidemic in Africa and the availability of antiretroviral treatment, there has been a push to manufacture instruments to measure CD4 counts easily in laboratories located in treatment centers for patients infected by the human immunodeficiency virus (HIV). The flow cytometers used in rural areas of Africa are, in general, easy to use but require the proper training of local technicians.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, portable instruments are already available that can perform lymphocyte subpopulation counts at the patient's bedside. These instruments are based on fluorescence and impedance techniques, although there are still few studies that have verified the precision of the instruments’ results.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Basic biochemical determinations</span><p id="par0050" class="elsevierStylePara elsevierViewall">The basic biochemical parameters are determined using photometric analyzers, which are easy to use and have cuvettes large enough to incorporate between 6 and 20 samples. Depending on the model, up to 30 types of measurements can be performed, including urea, creatinine, ion, bilirubin, transaminase, albumin, amylase, calcium, cholesterol, glucose, iron and uric acid levels. These analyzers require periodic reviews, quality controls and good technique for use. To measure glycemia levels, the same biochemical analyzers or specific meters of capillary glucose can be used.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Urine analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The urine dipstick is a basic diagnostic procedure, which is simple and fast and can determine pH and density. It can also detect the presence of proteins, glucose, ketones, hemoglobin, bilirubin, urobilinogen, nitrites and leukocytes in a urine sample. The dipstick is of considerable usefulness in the diagnosis of diabetic ketoacidosis, urinary tract infection and nephrotic syndrome (which are relatively common in pediatric and juvenile populations in many sub-Saharan countries), among others. The microscopic examination of urine sediment helps identify the presence and count of leukocytes, red blood cells and bacteria. Although they can identify hyaline casts, granules and renal epithelial cells and crystals, the dipsticks require a certain amount of experience by laboratory technicians, who in some cases have a basic level of understanding.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Combination of basic tests</span><p id="par0060" class="elsevierStylePara elsevierViewall">In our community, it is standard practice to combine several laboratory tests to guide the diagnosis. In rural tropical areas, on the other hand, individual tests must be performed in a rational manner. Auto-analyzers that simultaneously provide the result of numerous biochemical determinations are not available in these settings. When nephrotic syndrome is suspected, for example, blood levels of proteins and albumin are requested; proteinuria in urine is measured using the urine dipstick. In summary, for rural laboratories in tropical nations with scarce resources, the hemogram, urine analysis and erythrocyte sedimentation rate can provide evidence of the presence of disease.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Microbiological tests</span><p id="par0065" class="elsevierStylePara elsevierViewall">Diagnostic tests related to infectious diseases in tropical regions, in areas where resources are scarce, are currently based on the rational use of microscopy and on a number of rapid diagnostic tests. The lack of technology and laboratory personnel sufficiently qualified to perform cultures of bacteria, fungi and mycobacteria represent a significant obstacle. However, rational use focused on the high clinical cost-effectiveness of microscopy can be very useful in standard practice. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the techniques available in tropical regions.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Malaria</span><p id="par0070" class="elsevierStylePara elsevierViewall">The majority of centers exclusively use Giemsa thin-blood staining, a technique with high specificity but limited sensitivity (>1500<span class="elsevierStyleHsp" style=""></span>parasites/μL) and whose results are observer dependent. These observers are generally laboratory technicians who are significantly overburdened with microscope studies (Ziehl-Neelsen stainings, thin blood and fresh blood examinations to rule out parasites) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The thick smear is more sensitive (up to 50<span class="elsevierStyleHsp" style=""></span>parasites/μL with expert microscopists) and is the reference method. However, the technique is used in only a few rural institutions because it requires more preparation time (minimum 2<span class="elsevierStyleHsp" style=""></span>h), a high degree of observer experience and strict quality control. Due to the sensitivity problems of thin blood, the majority of physicians treat patients as having suspected malaria regardless of the results of the microscopy. Rapid diagnostic tests (rapid malaria test) have been used for years worldwide, and a number of them have been shown to have excellent sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These tests are in wide use in many tropical countries and are provided for free by a number of governments to the satellite health clinics where there are no laboratories, making it possible for nurses and assistant physicians to diagnose an episode of malaria with assurance. There are hundreds of these rapid diagnostic tests on the market. The recently published study by the World Health Organization should be consulted before choosing the most appropriate test in terms of sensitivity, specificity and cost in the diagnosis of the malaria species prevalent in the specific geographical area where the test will be used.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Tuberculosis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The diagnosis of tuberculosis in most state programs in low-income countries is currently based on the microscopic detection of acid-alcohol resistant bacilli (AARB) in clinical samples. Ziehl-Neelsen staining has a sensitivity between 30% and 70%, depending on the sample. Auramine staining can improve the sensitivity of Ziehl-Neelsen staining by 10%–15% and reduces by half the daily laboratory workload compared with tuberculosis microscopy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Until recently, the technique required the use of expensive and short-lived fluorescent lamps. The recent development of LED fluorescent lamps has considerably reduced the cost of this equipment. The Foundation for Innovative New Diagnostics finances the purchase of these fluorescent microscopes in countries with a high incidence of tuberculosis (<a id="intr0040" class="elsevierStyleInterRef" href="http://www.finddiagnostics.org/">www.finddiagnostics.org</a>).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Other more sensitive methods such as cultures and the new molecular techniques recommended by the World Health Organization (Xpert MTB/RIF®) are currently only used in major well-equipped hospital centers or in satellite centers that are privately funded. The World Health Organization recommends the use of these techniques in district hospitals or smaller ones, but their high cost (although significantly less than in high-income countries) continues to be a major obstacle for their widespread use.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The main advantages of this diagnostic method are its speed (100<span class="elsevierStyleHsp" style=""></span>min), the possibility of performing monotests and the ability to simultaneously detect rifampicin resistance.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Intestinal helminthiasis and protozoan disease</span><p id="par0085" class="elsevierStylePara elsevierViewall">The examination of fresh stools to detect parasitical forms (eggs, cysts, trophozoites and larvae) is performed systematically and in general, is useful and specific for the detection of infections with high parasite burden (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Nevertheless, for mild infections or intermittent excretion, the sensitivity of the technique is low (<50%). For centers equipped with sufficient human resources and materials, it is advisable to perform a method of parasite concentration (such as the formalin-ether method) and send up to 3 samples to ensure an appropriate negative predictive value for the technique.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Clinical microbiology</span><p id="par0090" class="elsevierStylePara elsevierViewall">Clinical microbiology is based on Gram staining and rapid tests, because the laboratories of rural centers in tropical countries do not usually have cultures techniques for biological samples. Gram staining can provide useful and rapid information for the treatment of soft tissue infections, a very common condition in tropical regions. These infections include mastitis, subcutaneous abscesses and pyomyositis. Gram staining can also provide information on the etiology of infections in typically sterile fluids (cerebrospinal, peritoneal, pleural, pericardial and synovial fluid). The morphological characteristics and color of the microorganisms observed enables the empiric treatment to be adjusted according to each clinical setting.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Fungal cultures are also rarely available. For the diagnosis of fungal infections, direct stainings are usually performed with skin flakes from the patient's lesions. The stainings are conducted using the potassium hydroxide technique (KOH), which rapidly dissolves the cells and digests the protein material, observing the fungal elements with greater clarity. The observation of hyphae suggests the presence of a fungal infection.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thanks to the recent development of immunochromatography technology, a number of rapid diagnostic tests have dropped considerably in price, facilitating their selective use in a number of patients in hospitals with scarce resources. The most useful tests among these are the tests for HIV, hepatitis B and C, syphilis, pneumococcus (in urine, cerebrospinal fluid and pleural fluid) and respiratory syncytial virus (respiratory samples) and the detection in feces of adenovirus, rotavirus and astrovirus or those that differentiate <span class="elsevierStyleItalic">Entamoeba histolytica</span> from <span class="elsevierStyleItalic">Entamoeba dispar.</span></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Imaging techniques</span><p id="par0105" class="elsevierStylePara elsevierViewall">In recent years, imaging techniques have undergone considerable progress. Technologies such as ultrasonography, scintigraphy, computed tomography and magnetic resonance have benefited many patients in the most developed countries. However, rural areas of tropical countries generally only have access to older conventional radiological techniques, although in the recent years there has been an increase in the availability of ultrasonography (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conventional radiology</span><p id="par0110" class="elsevierStylePara elsevierViewall">With physical examination and anamnesis, we can arrive at a diagnosis for numerous chest diseases such as pleural effusion, pneumonia and even tuberculosis with positive AARB detected under microscope. Conventional radiography considerably improves the diagnostic orientation for conditions such as pulmonary tuberculosis with negative smears for bacilli (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), lung masses, pulmonary fibrosis and various cardiac diseases. Abdomen radiology helps confirm the diagnosis, among other problems, of conditions such as intestinal perforation, intestinal subocclusion, or intestinal volvulus. When barium meal is available, esophagograms and intestinal transits can be performed, facilitating the diagnosis of esophageal achalasia (an unexceptional condition in sub-Saharan Africa), esophageal neoplasms, gastric ulceration and upper gastrointestinal neoplasms. Bone radiography is highly useful for locating damaged bones and determining lesion size and is essential for assessing trauma processes and is of considerable usefulness in the diagnosis of osteomyelitis and bone tumors.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Conventional radiology is of considerable usefulness, although it is not available in all basic healthcare centers. Patients sometimes have to travel 50–100<span class="elsevierStyleHsp" style=""></span>km to undergo radiography to reach a diagnosis. Clinicians who work in tropical regions should be able to interpret basic radiological examinations, given that radiologists will likely not be available. All centers with conventional radiography have to meet a series of legal requirements that demonstrate the safety of the facilities in the use of this technique.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ultrasound</span><p id="par0120" class="elsevierStylePara elsevierViewall">This is a simple and highly useful technique that is easily applicable in rural areas of countries with few resources. Typically, the same clinic performs ultrasonography to visualize the abdomen, pelvis, heart and soft tissue and identify abscesses and occupying lesions in the liver, cholecystitis and cholelithiasis, among other lesions. Gynecological-obstetric ultrasonography in this setting is of considerable usefulness. Given that there are usually no specialists in obstetrics and gynecology in rural hospitals, this technique is performed by general physicians.</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions and supplementary information</span><p id="par0125" class="elsevierStylePara elsevierViewall">The areas of diagnostic uncertainty in low-income countries, especially in rural areas of Africa, are greater than in our community, because most of the diagnostic tools common to our setting are not available in these rural areas. Reason is a basic pillar for the correct diagnosis and treatment of these diseases in tropical countries with scarce resources.</p><p id="par0130" class="elsevierStylePara elsevierViewall">To learn more about diagnostic tools in developing countries, you can read the books, manuals and web pages of interest listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres632909" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec645553" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres632910" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec645552" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical skills" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Laboratory tests" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Basic hematological determinations" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Basic biochemical determinations" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Urine analysis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Combination of basic tests" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Microbiological tests" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Malaria" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Tuberculosis" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Intestinal helminthiasis and protozoan disease" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Clinical microbiology" ] ] ] 6 => array:3 [ "identificador" => "sec0060" "titulo" => "Imaging techniques" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Conventional radiology" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Ultrasound" ] ] ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions and supplementary information" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack213260" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-16" "fechaAceptado" => "2014-05-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec645553" "palabras" => array:7 [ 0 => "Tropical medicine" 1 => "Diagnosis" 2 => "Laboratory diagnosis" 3 => "Radiological diagnosis" 4 => "Ultrasound diagnosis" 5 => "Physical examination" 6 => "Africa" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec645552" "palabras" => array:7 [ 0 => "Medicina tropical" 1 => "Diagnóstico" 2 => "Diagnóstico de laboratorio" 3 => "Diagnóstico radiológico" 4 => "Diagnóstico ultrasónico" 5 => "Exploración física" 6 => "África" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">When working in healthcare centers in developing countries where diagnostic resources are limited, clinical skills are of considerable importance. This study presents the diagnostic tools available in resource-poor areas. Anamnesis and physical examination are key components for reaching a correct diagnosis. The laboratory has at its disposal hemograms, basic blood chemistry and urinalysis. The available basic microbiological tests are the study of fresh feces, smears for malaria, direct smears for bacilli in sputum and Gram staining of clinical exudates. Basic radiography of the chest, abdomen, bones and soft tissues are of considerable usefulness but are not available in all centers. Ultrasonography can be of considerable usefulness due to its simplicity and versatility. The diagnosis in low resource conditions should sharpen our clinical skills and should be supported by the use of additional basic tests.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cuando se trabaja en centros sanitarios de países en vías de desarrollo, ante la limitación de recursos diagnósticos, las habilidades clínicas resultan de gran importancia. En este trabajo se presentan las herramientas diagnósticas disponibles en zonas de bajos recursos. La anamnesis y exploración son claves para alcanzar un diagnóstico correcto. En el laboratorio se dispone de hemograma, bioquímica sanguínea básica y uroanálisis elemental. Las pruebas microbiológicas básicas disponibles son el estudio en fresco de las heces, frotis para malaria, baciloscopia de esputo y tinción de Gram de exudados clínicos. Las radiografías elementales de tórax, abdomen, huesos y partes blandas son de gran ayuda, pero tampoco están disponibles en todos los centros. La ecografía puede resultar de gran utilidad por su sencillez y versatilidad. El diagnóstico en condiciones de bajos recursos debe agudizar nuestras habilidades clínicas y debe apoyarse en el uso de pruebas complementarias elementales.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramos-Rincón JM, Cuadros-González J, Malmierca-Corral E, de Górgolas-Hernándezd M. El diagnóstico en medicina tropical en países con pocos recursos. Rev Clin Esp. 2015;215:43–49.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0150" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Annex A" "titulo" => "Additional material" "identificador" => "sec0090" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 843 "Ancho" => 1000 "Tamanyo" => 128150 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Pallor in the nail beds of patients with anemia (black asterisks); (B) thin blood stained according to the Wright technique (×1000 magnification): trophozoite of considerable size and amoeboid appearance with blackish brown pigmentation (hemosiderin) (black arrows), malaria by <span class="elsevierStyleItalic">Plasmodium vivax</span>; (C) examination of fresh feces (×400 magnification): <span class="elsevierStyleItalic">Giardia intestinalis</span> cysts (black arrows); and (D) chest radiography with voluminous mediastinal adenopathies (white arrows).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: AARB, acid-alcoholic resistant bacilli; Cr., Cryptosporidium; CTI, immunochromatography; G., Giardia; HIV, human immunodeficiency virus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Procedure \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Basic procedures and instruments \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advanced procedures \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Hematology</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hemoglobin<br><span class="elsevierStyleHsp" style=""></span>Hematocrit<br><span class="elsevierStyleHsp" style=""></span>Leukocytes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Manual measurement of hemoglobin, hematocrit and leukocyte count;<br>Hemoglobinometer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Auto hematology analyzer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CD4 lymphocyte count \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Portable cytometer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flow cytometer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Biochemistry</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Glucometer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ions and other biochemical determinations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Auto biochemical analyzer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Qualitative urine, biochemical tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urine dipsticks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urine, Cells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urine sediment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Parasitology</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Malaria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral blood smear<br>Rapid diagnostic test for malaria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thick smear examination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Basic parasitology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Visualization in fresh feces and tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Feces concentration techniques<br>CTI of intestinal parasites (<span class="elsevierStyleItalic">G. intestinal</span> and <span class="elsevierStyleItalic">Cr. parvus</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Microbiology</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AARB of sputum and other samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mycobacteria culture and Xpert MTB/RIF<span class="elsevierStyleSup">®</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bacteriology and virology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gram staining of exudates<br>Serology using ICT (HIV, hepatitis B and C, syphilis, etc.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exudate culture, urine culture and blood culture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mycology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Direct staining with potassium hydroxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin flake cultures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Imaging techniques</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Conventional radiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chest radiography<br>Abdomen radiography<br>Bone and soft tissue radiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barium study \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal, pelvic, renal, obstetric and gynecological, cardiac \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038053.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Laboratory techniques of hematology, biochemistry, parasitology, microbiology and imaging available in rural centers in tropical regions.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">1. Books and Manuals</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1.1 General books</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Eddleston M, Davidson R, Brent A, Wilkinson R. Oxford Handbook of Tropical Medicine. 3<span class="elsevierStyleSup"><span class="elsevierStyleItalic">rd</span></span> ed. Oxford: Oxford University Press; 2008. ISBN: 978-0199204090 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1.2. Case history and examination books</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Seidel HM, Ball JW, Dains JE, Flynn JA, Solomon BS, Benedict GW. Guía Mosby de exploración física. 7<span class="elsevierStyleSup"><span class="elsevierStyleItalic">th</span></span> ed. (Spanish edition). Barcelona:Elsevier; 2011. ISBN: 978-0323065405 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Prieto Valtueña JM, Noguer-Balcells. Exploración clínica práctica. 7<span class="elsevierStyleSup"><span class="elsevierStyleItalic">th</span></span> ed. Madrid: Elsevier; 2011. ISBN: 978-8480868259 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bickley LS, Szilagyi PG. Bates’ Guide to physical examination and history taking. 11<span class="elsevierStyleSup"><span class="elsevierStyleItalic">th</span></span> ed. New York: Lippincott, Williams & Wilkins; 2012 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1.3. Laboratory books</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cheesbrough M. District laboratory practice in tropical countries. Part 1. 2<span class="elsevierStyleSup">nd</span> ed. Oxford: Cambridge University Press; 2005. ISBN: 978-0521676304 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cheesbrough M. District laboratory practice in tropical countries. Part 2. 2<span class="elsevierStyleSup">nd</span> ed. Oxford: Cambridge University Press; 2010. ISBN: 978-0521676335 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1.4. Laboratory books available online:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>WHO. Manual of basic techniques for a health laboratory. 2<span class="elsevierStyleSup">nd</span> ed. Geneva: World Health Organization; 2003. ISBN 92 4 154530. Available at <a class="elsevierStyleInterRef" id="intr0005" href="http://whqlibdoc.who.int/publications/2003/9241545305.pdf">http://whqlibdoc.who.int/publications/2003/9241545305.pdf</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Kieviet W, Frank E, Stekel H. Essentials of clinical laboratory management in developing regions. Committee on Clinical Laboratory Management (C-CLM), Education and Management Division (EMD), IFCC Available at <a class="elsevierStyleInterRef" id="intr0010" href="http://www.ifcc.org/media/185572/2008%20-%20C-CLM%20Monograph.pdf">http://www.ifcc.org/media/185572/2008%20-%20C-CLM%20Monograph.pdf</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1.5. Laboratory diagrams and protocols:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cheesbrough M. Microscopy of tropical diseases – learning bench aid series. 4<span class="elsevierStyleSup"><span class="elsevierStyleItalic">th</span></span> ed. London: Tropical Health Technology and TALC; 2011. Available at <a class="elsevierStyleInterRef" id="intr0015" href="http://www.talcuk.org/">http://www.talcuk.org/</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">2. Useful Links</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Clinical Ultrasonography Workgroup of the Spanish Society of Internal Medicine, created to stimulate interest in clinical ultrasonography within the framework of the Spanish Society of Internal Medicine. Contains manuals and offers very useful courses for working in countries with low resources. Link:</span><a class="elsevierStyleInterRef" id="intr0020" href="http://www.ecografiaclinica.org/"><span class="elsevierStyleItalic">http://www.ecografiaclinica.org/</span></a><span class="elsevierStyleItalic">.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">World Health Organization Publications. Link:</span><a class="elsevierStyleInterRef" id="intr0025" href="http://www.who.int/publications"><span class="elsevierStyleItalic">http://www.who.int/publications</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">TALC or Teaching Aids at Low Cost. This is a platform with documents (books, testcards CDs</span>, etc.<span class="elsevierStyleItalic">) for working in Africa, the Caribbean, Bangladesh, India, Nepal, Pakistan and Sri Lanka. Link:</span><a class="elsevierStyleInterRef" id="intr0030" href="http://www.talcuk.org/"><span class="elsevierStyleItalic">http://www.talcuk.org/</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038054.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Guidelines and manuals of diagnostic tools for the practice of clinical medicine in rural tropical areas.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 117723 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Profesores del Curso de Patología Tropical en Madrid y Etiopía. Formador en medicina tropical" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.M. Ramos" 1 => "M. de Górgolas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2010" "volumen" => "210" "paginaInicial" => "582" "paginaFinal" => "588" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21166077" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bates’ guide to physical examination and history taking" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.S. Bickley" 1 => "P.G. 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Marais" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(13)70008-2" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2013" "volumen" => "13" "paginaInicial" => "349" "paginaFinal" => "361" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23531388" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Freeman J, Robertes S. Approach to Gram stain and culture results in the microbiology laboratory. In: Up to date, Rose BD (ed.) Waltham, MA, 2013 [accessed 3 May 2014]. 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Last but not least, we would like the two individuals who work day to day caring for patients at Hospital Gambo: Dr. Francisco Reyes and the Reverend Renzo Meneghini, members of the Consolata Missionary Institute, for their patience. Without them, none of this would have been possible.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021500000001/v2_201605010053/S2254887414001040/v2_201605010053/en/main.assets" "Apartado" => array:4 [ "identificador" => "3982" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021500000001/v2_201605010053/S2254887414001040/v2_201605010053/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887414001040?idApp=WRCEE" ]
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