Sociodemographic determinants and mortality of premature newborns in a medium and low-income population in Colombia, 2017-2019 / Factores determinantes sociodemográficos y de mortalidad en recién nacidos prematuros en población de medianos y bajos ingresos en Colombia, 2017-2019

Introduction. The birth of premature babies is a public health problem with a high impact on infant morbidity and mortality. About 40% of mortality in children under five years occurs in the first month of life. Objective. To identify the association between maternal sociodemographic factors, premature birth, and mortality in newborns under 37 weeks in Santiago de Cali, 2017-2019. Materials and methods. We conducted a descriptive, cross-sectional study. We evaluated the records of Cali's Municipal Public Health Office. We calculated the crude and adjusted odd ratios and confidence intervals (95%) using the logistic regression model, data processing in Stata 16, and georeferencing the cases in the QGIS software. Results. From 2017 to 2019, premature babies in Cali corresponded to 11% of births. Poor prenatal care increased 3.13 times the risk of being born before 32 weeks (adjusted OR = 3.13; 95% CI = 2.75 - 3.56) and 1.27 times among mothers from outside the city (adjusted OR = 1.27; 95% CI = 1.15-1.41). Mortality was 4.29 per 1,000 live births. The mortality risk in newborns weighing less than 1,000 g increased 3.42 times (OR = 3.42; 95% CI = 2.85-4.12), delivery by cesarean section in 1.46 (OR = 1.46; CI 95% = 1.14-1.87) and an Apgar score - five minutes after birth- lower than seven in 1.55 times (OR = 1.55; CI 95% = 1.23-1.96). Conclusions. We found that less than three prenatal controls, mothers living outside Cali, afro-ethnicity, and cesarean birth were associated with prematurity of less than 32 weeks. We obtained higher mortality in newborns weighing less than 1,000 g.

Introducción. El nacimiento de bebés prematuros es un problema de salud pública con gran impacto en la morbimortalidad infantil: cerca del 40 % de las muertes de niños menores de cinco años sucede en el primer mes de vida. Objetivo. Identificar la asociación entre los factores sociodemográficos maternos, el parto prematuro y la mortalidad en recién nacidos menores de 37 semanas en Santiago de Cali, 2017-2019. Materiales y métodos. Se hizo un estudio descriptivo transversal. Se evaluaron los registros de la Secretaría de Salud Pública Municipal de Cali. Se calcularon las razones de probabilidad y los intervalos de confianza (95 %) crudos y ajustados mediante el modelo de regresión logística, en tanto que los datos se procesaron en Stata 16 y los casos se georreferenciaron con el programa QGIS. Resultados. Entre el 2017 y el 2019, los nacimientos de bebés prematuros en Cali correspondieron al 11 %. El control prenatal deficiente aumentó 3,13 veces el riesgo de nacer con menos de 32 semanas (OR ajustado = 3,13; IC95% = 2,75-3,56) y, en madres de municipios fuera de la ciudad, 1,27 veces (OR ajustado = 1,27; IC95% = 1,15-1,41). La mortalidad fue de 4,29 por 1.000 nacidos vivos. Nacer con un peso menor de 1.000 g aumentó el riesgo de mortalidad en 3,42 veces (OR = 3,42; IC95% = 2,85-4,12) y, un puntaje Apgar menor de siete a los cinco minutos del nacimiento, en 1,55 veces (OR=1,55; IC95% = 1,23-1,96). Conclusiones. Se encontró que tener menos de tres controles prenatales, la procedencia de la madre fuera de Cali, ser afrodescendiente y el parto por cesárea, estaban asociados significativamente con la prematuridad de menos de 32 semanas. Hubo mayor mortalidad en los recién nacidos con menos de 1.000 gramos al nacer.

Assessment of Knowledge, Attitude and Practice related to Tuberculosis among Rural and Urban Community of North India

Tuberculosis is known as one of the long-standing and dominating health problems affecting people and the extent further escalates in a developing country like India. A pre-evaluated feedback structured questionnaire was validated and adopted to get their quantitative data from 424 respondents. In the present study urban respondents (60.8%) gave affirmative responses regarding awareness of TB, especially with mobile media as their major source of information, followed by information from healthcare workers. Rural respondents were less expressed and deficient on knowledge of TB transmission and preventive methods. Prevention practices toward TB are claimed to be high in urban population because 79.48% believed that early diagnosis, prompt treatment and avoiding poor hygiene and crowded environment are effective strategies to cease the transmission of TB. Effective preventive and informative strategies should be employed in rural border areas to make up for the knowledge gap found among rural and urban populations in this study.

An Assessment of Skin Diseases in People and Their Quality of Life in Bundelkhand Region of Uttar Pradesh

Background: Skin diseases occur in all age groups in developed and developing countries. Various types of skin diseases are found worldwide and depend on factors like environment, surrounding ecology, dietary habits, socioeconomic status, mental health, and literacy. Health-related quality of life (HRQOL) improves after treatment or cure of the diseases. Objectives: To estimate the pattern of skin disease. To find out the quality of life and association of skin disease with sociodemographic factors among patients. Methods: This observational cross-sectional study was done in skin OPD at the tertiary care center, Banda district of Uttar Pradesh, India from May 2022 to July 2022. All patients who attended to skin OPD during study period were included in the study after taking informed verbal consent. Results: Skin diseases had further divided in subcategories which were infectious conditions, pigmentary disorders, inflammatory dermatoses, miscellaneous skin conditions, benign tumor and other lesions with their percentage 44.8, 10.5, 28.6, 7.1, 2.9 and 6.2%, respectively in this study Classes of DQLI where major portion of patients (49.52%) were in ‘Small effect on patient’s life’ category. The relation of age, religion, education and member of household with history of skin disease were found to be highly statistically significant. Conclusion: Infectious skin diseases were found more common in study area. Male populations were more commonly affected. Skin diseases were more common in age group of 18–60 years. Study participants showed no predominant effect on quality of life. But small effect class had major effect on participant’s quality of life.

The Burden and Risk Factors of Reproductive Tract Infections among Married Women Aged 15-49 Years in Urban Slum of Agra Uttar Pradesh

Introduction: In developing countries, reproductive tract infection among women commonly goes undiagnosed and their sequel causes various complications. Objectives: To find out the prevalence of RTI/STI through a syndromic case approach and its correlates among women of reproductive age group. Material and Methods: A community-based cross-sectional study was carried out among 500 eligible married women residing in urban slums of Agra by using WHO Syndromic case approch for diagnosis of RTIs/STIs. Results: The overall prevalence of RTI/STD was found to be 32.80% where vaginal discharge (22.60%) and lower abdominal pain (8.20%) were the most common syndromes. On multivariate analysis, religion, caste, type of absorbent used during menses, and history of IUD use were found to be significantly significant. Conclusion: The result of this study highlights the high prevalence and potential risk factors that contribute to the occurrence of RTI. It also emphasizes the need of training and education session of the participants to identify the early symptoms of RTI.

Feasibility for evaluating motor aspects of Parkinson's disease through video consultations in a resource-limited setting in Southern Brazil / Viabilidade para avaliar os aspectos motores da doença de Parkinson através de consultas por vídeo em um ambiente de recursos limitados no sul do Brasil

Abstract Background Performing motor evaluations using videoconferencing for patients with Parkinson's disease (PD) is safe and feasible. However, the feasibility of these evaluations is not adequately studied in resource-limited settings. Objective To evaluate the feasibility of performing motor evaluations for patients with PD in a resource-limited setting. Methods The examiners rated motor aspects of parkinsonism of 34 patients with PD from the Brazilian public healthcare system through telemedicine with the patient's own means by using the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) rating scale. Quality measures of the video meeting were also obtained. The feasibility of rating the motor aspects was the primary outcome whereas the rating of individual motor aspects, video meeting quality and predictors of a complete evaluation served as secondary outcomes. Results The least assessable parameters were freezing of gait (52.9%), gait (70.6%), leg agility, and rest tremor (both 76.5%). Complete MDS-UPDRS part III was possible in 41.2% of patients and 62 out of 374 motor aspects evaluated (16.6%) were missed. Available physical space for a video evaluation was the worst quality measure. Incomplete evaluations were directly associated with disability (p = 0.048, r = 0.34) and inversely with available physical space (p = 0.003, r = 0.55). Conclusion A significant portion of the MDS-UPDRS part III is unable to be performed during telemedicine-based evaluations in a real-life scenario of a resource-limited setting.

Resumo Antecedentes Realizar avaliações motoras usando videoconferência para pacientes com doença de Parkinson (DP) é seguro e viável. Entretanto, a viabilidade dessas avaliações não é adequadamente estudada em cenários com recursos limitados. Objetivo Identificar a viabilidade de realizar avaliações motoras para pacientes com DP em um ambiente com recursos limitados. Métodos Os examinadores avaliaram os aspectos motores da DP de 34 pacientes do sistema público de saúde brasileiro através da telemedicina com os próprios meios do paciente usando a escala Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). Medidas de qualidade da videochamada também foram obtidas. A viabilidade da classificação dos aspectos motores foi o resultado primário, enquanto a classificação dos aspectos motores individuais, a qualidade das videoconferências e os preditores de uma avaliação completa serviram como resultados secundários. Resultados Os parâmetros menos avaliáveis foram congelamento da marcha (52,9%), marcha (70,6%), agilidade dos membros inferiores e tremor de repouso (ambos 76,5%). A parte III completa da MDS-UPDRS foi possível em 41,2% dos pacientes, mas não foi possível avaliar 62 do total de 374 aspectos motores (16,6%). O espaço físico disponível para uma avaliação em vídeo foi a pior medida de qualidade. As avaliações incompletas foram diretamente associadas ao nível de dependência (p = 0,048, r = 0,34) e inversamente ao espaço físico disponível (p = 0,003, r = 0,55). Conclusão Uma porção significativa da parte III da MDS-UPDRS é perdida durante as avaliações baseadas em telemedicina em um cenário da vida real com recursos limitados.

No seroconversion among healthcare workers exposed to SARS-CoV-2 during the early phase of the pandemic / Ausencia de seroconversión en trabajadores de la salud expuestos a SARS-CoV-2 durante la primera fase de la pandemia

BACKGROUND: The SARS-CoV-2 pandemic is associated with morbidity, hospitalizations, absenteeism, and mortality among healthcare workers (HCW). AIM: To evaluate the seroconversion rate in HCW exposed to SARS-CoV-2 in the early pandemic phase in 2020 at a regional reference hospital. MATERIAL AND METHODS: One hundred seventy-nine HCW working at a regional hospital were invited to a longitudinal study performed between April-July 2020. A serological analysis by ELISA IgG for viral nucleoprotein and protein S with a secondary analysis by ELISA IgG protein S1/S2 for samples with positive or doubtful result was carried out together with a complementary online survey to inquire about occupational or community exposures to SARS-CoV-2. RESULTS: Two cases with baseline infection were detected (1.1%, one symptomatic and one asymptomatic) and no cases of seroconversion were detected. During the study period, there were 136 patients hospitalized with COVID-19, and regional weekly COVID-19 incidence ranged from 2.7 to 24.4 per 100,000 inhabitants. No SARS-CoV-2 cases were detected by PCR among 27 HCW who consulted for respiratory symptoms in the period. Online surveys confirmed direct care of COVID-19 patients and also detected a high degree of unprotected social interaction at work. CONCLUSIONS: There was no evidence of seroconversion in this group of HCW exposed to the risk of infection by SARS-CoV-2 during the onset of the COVID-19 pandemic. Personal protective equipment and other measures used by the HCW were extremely useful for their protection in the initial phase of the pandemic.

ANTECEDENTES: La pandemia de SARS-CoV-2 está asociada a morbilidad, hospitalizaciones, ausentismo y mortalidad entre el personal de salud (PS). OBJETIVO: Evaluar la tasa de seroconversión en el PS expuesto al SARS-CoV-2 en la fase pandémica inicial el 2020 en un hospital regional de referencia. MATERIAL Y MÉTODOS: Ciento setenta y nueve trabajadores de la salud fueron invitados a un estudio longitudinal realizado entre abril-julio de 2020. Se efectuó un análisis serológico por ELISA IgG para nucleoproteína viral y proteína S con un análisis secundario por ELISA IgG proteína S1 / S2 para muestras con resultado positivo o dudoso junto a encuestas complementarias en línea para preguntar sobre exposiciones ocupacionales o comunitarias al SARS-CoV-2. RESULTADOS: Se detectaron dos casos con infección basal (1,1%, uno sintomático y uno asintomático) sin casos de seroconversión. Durante el período de estudio, hubo 136 pacientes hospitalizados con COVID-19, y la incidencia semanal regional de COVID-19 osciló entre 2,7 y 24,4 por 100.000 habitantes. No se detectaron casos de SARS-CoV-2 por PCR entre los 27 funcionarios que consultaron por síntomas respiratorios en este período. Las encuestas en línea confirmaron la atención directa de los pacientes con COVID-19 y también detectaron un alto grado de interacción social desprotegida en el trabajo. CONCLUSIONES: No hubo evidencia de seroconversión en un grupo de funcionarios expuestos al riesgo de infección por SARS-CoV-2 durante el inicio de la pandemia de COVID-19. Los equipos de protección personal y otras medidas utilizadas por el PS fueron de suma utilidad para su protección en la fase inicial de la pandemia.

A systematic review of the epidemiology of epilepsy in Mexico during 1970 to 2020 / Revision sistematica de la epidemiologia en Mexico de la epilepsia de 1970 a 2020

Abstract Background Epilepsy is the most common major neurological disorder that affects people of all ages. The prevalence varies from one country to another and even between different areas, due to a lack of access to medical care for reasons related to limited resources. Objective Epilepsy is a worldwide public health problem that affects more deeply populations living in developing countries such as Mexico, where more aggressive health policies based on epidemiological data are needed; however, this information is scarce and the evolution of this data over time remains unclear. The aim of the present study is to provide an overview of the epidemiology of epilepsy in Mexico from 1970 to 2020. Methods We searched descriptive epidemiological studies on epilepsy in rural and urban regions of Mexico from 1970 to 2020. Available data on the sociodemographic characteristics, prevalence, and incidence data were extracted. Finally, the abstract, full-text review, and data abstraction were conducted in duplicate and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Descriptive statistics was also used. Results Overall, 11 underrepresented and heterogeneous epidemiological studies were included. In total, the prevalence of epilepsy in Mexico is 3.9 to 41:1,000 inhabitants; 3.9 to 41 per 1,000 persons in rural regions, and 3.49 to 44.3 per 1,000 persons in urban regions. None of these studies addressed the incidence of epilepsy. The prevalence of epilepsy in Mexico has remained unchanged during the last 5 decades. Conclusions Our results confirm a high prevalence of epilepsy in both urban and rural settings in Mexico that remain unchanged during the last 5 decades. All studies included in the present review showed multiple methodological limitations. New and robust epidemiological studies are needed to delineate the epidemiological profile of epilepsy in Mexico.

Resumen Antecedentes La epilepsia es el trastorno neurológico más común que afecta a individuos de todas las edades. La prevalencia varía entre paises e incluso entre diferentes áreas del mismo pais debido a la falta de acceso a la atención médica. Objectivo La epilpesía es un problema de salud pública mundial que afecta de manera más importante a los países en desarrollo como México, donde hacen falta políticas en salud y datos epidemiológicos, para conocer el impacto real de esta enfermedad. El objetivo de este estudio es brindar una visión general de la epidemiología de la epilepsia en México (1970-2020). Métodos Se realizo unas búsquedas bibliografica de estudios epidemiológicos descriptivos sobre epilepsia en regiones rurales y urbanas de México desde 1970 a 2020. Se extrajeron los datos disponibles sobre las características sociodemográficas, prevalencia e incidencia. Finalmente, el resumen, la revisión completa del texto y la extracción de datos se realizaron por duplicado y se informaron utilizando PRISMA. Se utilizo estadística descriptiva. Resultados Se incluyeron 11 estudios epidemiológicos heterogeéneos. En total la prevalencia de epilepsia en México es 3.9-41: 1000 habitantes; 3,9 a 41 por 1000 personas en las regiones rurales y 3,49 a 44,3 por 1000 personas en las regiones urbanas. Ninguno de estos estudios abordó la incidencia de epilepsia. La prevalencia de la epilepsia en México se ha mantenido sin cambios durante las últimas cinco décadas. Conclusiones Nuestros resultados confirman una alta prevalencia de epilepsia en las areas urbanas y rurales de México que se mantiene sin cambios durante las últimas cinco décadas. Todos los estudios incluidos en esta revisión mostraron múltiples limitaciones metodológicas. Se necesitan estudios epidemiológicos nuevos y sólidos para delinear el perfil epidemiológico de la epilepsia en México.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

ABSTRACT OBJECTIVE To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country. METHODS The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10. RESULTS After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women. CONCLUSIONS The study's findings were consistent, but not fully similar, to the international literature.

Cáncer de cérvix en Costa Rica, barreras según las dimensiones de la asistencia sanitaria: una revisión sistemática cualitativa

Introducción: de las muertes de mujeres en el mundo por algún tipo de cáncer, el de cérvix es responsable del 7 % del total. En Costa Rica, cada año se diagnostican en promedio 320 casos y fallecen 140 mujeres por esta enfermedad. Objetivo: identificar barreras para el diagnóstico y el tratamiento del cáncer cérvico-uterino, según la disponibilidad de la asistencia sanitaria en Costa Rica. Metodología: se realizó una revisión sistemática cualitativa de literatura entre mayo y setiembre de 2021. Se examinaron estudios publicados de enero de 2010 a junio de 2021 con diseño cuantitativo, cualitativo o ambos, de fuente primaria o secundaria, que identificaran limitaciones para acceder a la atención según población general, usuarios o personal de salud en Costa Rica. Resultados: se seleccionaron 9 artículos científicos. Se identificaron 5 dimensiones del modelo de Tanahashi y 26 barreras correspondientes a cada una: 12 de disponibilidad, 5 de accesibilidad, 3 de aceptabilidad, 2 de contacto con el servicio y 4 de cobertura efectiva.Conclusiones: las dificultades en torno al servicio médico son múltiples y están presentes en todas las dimensiones descritas en el modelo de Tanahashi. Los hallazgos de este estudio destacan la importancia de abordarlas, lo cual, en algunas podría ser complejo. No obstante, otras variables son relativamente simples de solucionar a nivel de sistema, política o práctica.

Introduction: cervical cancer is responsible for 7% of deaths from some type of cancer in women in the world. In Costa Rica, an average of 320 cases is diagnosed and 140 women die from this disease each year. Objective: identify barriers to timely detection and treatment of cervical cancer according to healthcare access dimensions in Costa Rica. Methodology: a qualitative systematic review of literature was carried out between May and September 2021. Articles using quantitative, qualitative or both methods published between January 2010 to June 2021 from a primary or secondary source that identified barriers to healthcare access from general population, users or health personnel in Costa Rica were analyzed. Results: 9 scientific articles were selected. The 5 dimensions and 26 barriers of the Tanahashi model were identified: 12 corresponded to the availability, 5 to accessibility, 3 to acceptability, 2 to contact coverage and 4 to effective coverage. Conclusions: the barriers to accessing medical care are multiple and are present in all the dimensions described in the Tanahashi model. The findings of this study highlight the importance of addressing barriers in all dimensions. Addressing some access barriers can be complex. However, other variables are relatively simple to address at the system, policy, or practice level.

The positive impact of an intervention for maternal depression on child emotional and behavioral symptoms in a low-resource setting

Objectives: Children of depressed mothers are at risk of developing mental health problems. We sought to determine whether treatment for maternal depression by community-based health workers would decrease behavioral/emotional symptoms in their children. Interventions for maternal depressive symptoms in a low/middle-income country can have a high global impact. Methods: Community-based health workers were trained to deliver a psychosocial intervention for mothers with depression in a primary care setting. A total of 49 mothers and 60 children were assessed pre-intervention, post-intervention, and at 6 months follow-up. Child behavioral/emotional symptoms were evaluated according to type of change in maternal depressive symptoms: response or remission. Results: An overall decrease in maternal depressive symptoms from baseline to post-intervention and 6 months follow-up were found. Response or remission was associated with better outcomes in child behavioral/emotional symptoms at 6 months follow-up (p = 0.0247, Cohen's d: 0.76; p = 0.0224, Cohen's f: 0.44) but not at post-intervention (p = 0.1636, Cohen's d: 0.48; p = 0.0720, Cohen's f: 0.33). Conclusions: Improvement in maternal depression was related to decreased behavioral/emotional symptoms in their children. Our results suggest that providing interventions for maternal depression in primary care is a viable strategy to prevent behavioral/emotional symptoms in the next generation. Clinical Trial registration: Brazilian Clinical Trials, number RBR-5qhmb5.

Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP) / Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)

RESUMEN Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

ABSTRACT Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia Materials and Methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80 %, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus drafted five recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

Comportamiento epidemiológico de la hipertensión arterial en países en vía de desarrollo y recomendaciones de la Sociedad Internacional de Hipertensión en el año 2020 / Epidemiological behavior of hypertension in developing countries and recommendations of the International Society of Hypertension in 2020

Resumen La hipertensión arterial se considera como una de las principales causas de morbimortalidad en todo el mundo. Asimismo, su elevada prevalencia en los países en vías de desarrollo se relaciona directamente con el desconocimiento de la enfermedad, e inversamente con la prevalencia del tratamiento y el control de la hipertensión arterial. El objetivo de esta revisión es compilar la evidencia sobre los factores que influencian la prevalencia de conocimiento del diagnóstico de hipertensión arterial, el tratamiento y el control óptimo de la enfermedad dependiendo del contexto epidemiológico. Por ello, se enfatiza que gran parte del desafío en los países en vías de desarrollo consiste en evaluar la escasa evidencia epidemiológica de base poblacional para realizar recomendaciones que se adapten a los recursos disponibles en las diferentes regiones. Para este propósito se realizó una breve revisión sobre las recomendaciones de las guías de práctica clínica propuestas por la Sociedad Internacional de Hipertensión en el año 2020.

Abstract High blood pressure is one of the leading causes of morbidity and mortality worldwide. In addition, its high prevalence in developing countries is directly related to the lack of awareness of the diagnosis and conversely to the prevalence of treatment and control of high blood pressure. This literature review aims to compile evidence on the factors that influence the prevalence of knowledge of the diagnosis of high blood pressure, the treatment and optimal control of the disease depending on the epidemiological context. In this review, we emphasize that much of the challenge in developing countries is to assess the limited population-based epidemiological evidence to make recommendations that are tailored to the resources available in the different regions. For this purpose, a brief review is carried out on the recommendations of the clinical practice guides proposed by the International Hypertension Society in 2020.

A New Dawn for Brazilian Pediatric Cardiac Surgery Is on the Way - Issues Around and Outside the Operating Room

ABSTRACT In some developing countries, congenital heart disease still stands out among the leading causes of death in the first year of life. Therefore, there is a great need to develop programs designed to improve outcomes in the diagnosis and surgical treatment of congenital heart disease in these nations, where children have always been and still are severely underserved. The Brazilian Public Health Care System demands universal access to treatment as a constitutional right. Therefore, an underfunded Pediatric Cardiac Surgery program is unacceptable since it will cost lives and increase the infant mortality rate. Additionally, poor funding decreases providers' interest, impedes technological advances and multidisciplinary engagement, and reduces access to comprehensive care. Unfortunately, in most developing countries, Pediatric Cardiac Surgery progress is still the result of isolated personal efforts, dedication, and individual resilience. This article aims to present the current state of Brazilian pediatric cardiac surgery and discuss the structural and human limitations in developing a quality care system for children with congenital heart disease. Considering such constraints, quality improvement programs via International collaboration with centers of excellence, based on proper data collection and outcomes analysis, have been introduced in the country. Such initiatives should bring a new dawn to Brazilian Pediatric Cardiac Surgery.

Difficulties in the Management of Placenta Accreta Spectrum in Hospitals with Limited Resources / Dificuldades na gestão do espectro da placenta acreta em hospitais com recursos limitados

Abstract Objective Placenta accreta spectrum (PAS) is a serious diseases, and the recommendation is that the treatment is conducted in centers of excellence. Such hospitals are not easy to find in low- and middle-income countries. We seek to describe the process of prenatal diagnosis, surgical management, and postnatal histological analysis in a low-income country referral hospital with limited resources. Methods A descriptive, retrospective study was carried out including patients with a pre- or intraoperative diagnosis of PAS. The clinical results of the patients were studied as well as the results of the prenatal ultrasound and the correlation with the postnatal pathological diagnosis. Results In total, 129 patients were included. Forty-eight of them had a prenatal PAS ultrasound diagnosis (37.2%). In the remaining 81 (62.8%), the diagnosis was intraoperative. Although hysterectomy was performed in all cases, one-third of the patients (31%) did not have a histological study of the uterus. In 40% of the patients who had a histological study, PAS was not reported by the pathologist. Conclusion The frequency of prenatal diagnosis and the availability of postnatal histological studies were very low in the studied population. Surgical skill, favored by a high flow of patients, is an important factor to avoid complications in settings with limited resources.

Resumo Objetivo O espectro da placenta accreta é uma patologia grave, cujo tratamento é recomendado emcentros de excelência. Esses hospitais não são fáceis de encontrar em países de baixa e média renda. Procuramos descrever o processo de diagnóstico prénatal, tratamento cirúrgico, e análise histológica pós-natal em um hospital de referência de baixa renda com recursos limitados. Métodos Foi realizado um estudo descritivo, retrospectivo, incluindo pacientes com diagnóstico pré ou intraoperatório de espectro da placenta accreta. Foram estudados os resultados clínicos das pacientes, bem como os resultados da ultrassonografia prénatal e a correlação com o diagnóstico patológico pós-natal. Resultados No total, 129 pacientes foram incluídas. Quarenta e oito delas tiveramum diagnóstico de ultrassom do espectro da placenta accreta pré-natal (37,2%). Nos 81 (62,8%) restantes, o diagnóstico foi intraoperatório. Embora a histerectomia tenha sido realizada em todos os casos, um terço deles (31%) não tinha estudo histológico do útero. Em 40% dos pacientes que tiveram estudo histológico, o espectro da placenta accreta não foi relatado pelo patologista. Conclusão A frequência do diagnóstico pré-natal e a disponibilidade de estudos histológicos pós-natais foram muito baixas na população estudada. A habilidade cirúrgica, favorecida por um alto fluxo de pacientes, é um fator importante para evitar complicações em ambientes com recursos limitados.

Determinantes de letalidad por la COVID-19 en trabajadores de salud en la primera y segunda olas en Perú / Determinants of COVID-19 fatality among healthcare workers during the first and second waves in Peru

RESUMEN Introducción: Los trabajadores de salud presentan alto riesgo de la COVID-19, hecho especialmente importante en el Perú que tiene una de los mayores índices de letalidad por esta pandemia. Objetivo: Identificar y comparar los determinantes de letalidad por la COVID-19 en trabajadores de salud del Perú, entre la primera y segunda olas. Material y Métodos: Análisis secundario de datos de la Sala situacional de trabajadores del sector salud de COVID-19, que incluyó 95 966 casos confirmados de la COVID-19 hasta el 21 de octubre de 2021. Se calculó el índice de letalidad, así como los odds ratio -y sus intervalos de confianza a 95 %- crudo y ajustado mediante regresión logística binaria. Resultados: 65,5 % fueron mujeres, de 41,2 (D.E.=11,1) años en promedio. El índice de letalidad fue mayor durante la segunda ola (2,1 % [IC95%=2,0-2,2] vs 2,6 % [IC95 %=2,5-2,8]). El sexo masculino (3,49 [IC95 %=3,09-3,95] en la primera ola y 2,65 [IC95 %=2,32-3,02] en la segunda ola), la edad ≥40 años (9,97 [IC95 %=8,19-12,13] en la primera ola y 10,77 [IC95 %=8,56-13,54] en la segunda ola), así como ser profesional de salud (1,14 [IC95 %=1,01-1,28] en la primera ola y 1,59 [IC95 %=1,39-1,82] en la segunda ola) determinaron la letalidad por la COVID-19 en ambas olas. Conclusiones: La letalidad fue mayor en la segunda ola y se asoció a determinantes individuales, geográficos y ocupacionales de los trabajadores de salud peruanos.

ABSTRACT Introduction: Healthcare workers are at high risk of COVID-19, a fact that is especially important in Peru which has one of the highest COVID-19 case fatality rates. Objective: To identify and compare the determinants of COVID-19 case fatality among healthcare workers in Peru between the first and second waves of the pandemic. Material and Methods: Secondary analysis of data from the COVID-19 Health Sector Workers Situation Room which included 95,966 confirmed cases of COVID-19 until October 21, 2021. Case fatality rate was calculated; crude and adjusted odds ratios with 95 % confidence intervals were obtained by applying binary logistic regression. Results: The results show that 65,5 % of the workers were female, aged 41,2 (S.D.=11,1) years on average. Case fatality rate was higher in the second wave. Male sex (3,49 [95 %CI=3,09-3,95] in the first wave (2,1 % [95 %CI=2,0-2,2] vs. 2,6 % [95 %CI=2,5-2,8]), and 2,65 [95 %CI=2,32-3,02] in the second wave), ≥40 years ofage (9,97 [95 %CI=8,19-12,13] in the first wave, and 10,77 [95 %CI=8,56-13,54] in the second wave), and healthcare professionals (1,14 [95 %CI=1,01-1,28] in the first wave, and 1,59 [95 %CI=1,39-1,82] in the second wave) were determinants for COVID-19 case fatality in both waves. Conclusions: COVID-19 case fatality was higher in the second wave, and was associated with individual, geographic and occupational determinants in Peruvian healthcare workers.

Calidad de la atención en salud en ataque cerebrovascular en un hospital de referencia en Colombia / Quality of health care in stroke in a reference hospital in Colombia

RESUMEN INTRODUCCIÓN: La evaluación de la calidad de la atención del ataque cerebrovascular (ACV) es una prioridad para los sistemas de salud, debido a su relación con la disminución de la discapacidad y la muerte. En este estudio se analizan los marcadores de calidad en ACV en un hospital de referencia en Nariño, Colombia. OBJETIVO: Evaluar los marcadores de calidad de atención en ACV en el Hospital Universitario Departamental de Nariño E. S. E., entre junio del 2018 y diciembre del 2019. Como referencia se comparó con los registros de Colombia en la plataforma RES-Q. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo de pacientes con ACV atendidos intrahospitalariamente. La recolección de datos se realizó mediante la plataforma RES-Q, en tanto que el análisis se efectuó por medio de estadísticos descriptivos y frecuencias absolutas y relativas y las diferencias con pruebas analíticas. RESULTADOS: Se evaluaron 457 pacientes con predominio de ACV isquémico y se llevó a cabo trombólisis endovenosa al 7,2% en el 2018 y al 9,2 % en el 2019, el 27,7 % con tiempo puerta aguja menor a 60 minutos en el 2018 y el 42,8 % en el 2019. Entre los marcadores de calidad, se encontró mejoría en realización de NIHSS, evaluación de disfagia en las primeras 24 horas, realización de doppler carotideo en los primeros siete días. En comparación con Colombia, se encontró un porcentaje inferior en trombólisis endovenosa y trombectomía. La mayoría de los indicadores de atención en ACV es similar al promedio nacional. CONCLUSIONES: La mejoría en el cumplimiento de marcadores de calidad en ACV refleja el impacto de programas de atención en ACV. El monitoreo de los parámetros de calidad permite generar programas para fortalecer la atención integral del ataque cerebrovascular en la región.

ABSTRACT INTRODUCTION: The evaluation of the quality of care for Stroke is a priority for health systems, given its relationship with disability and death. In this study, Stroke quality markers are analyzed in stroke in a referral hospital in Narino, Colombia. OBJECTIVE: To evaluate the markers of quality of care in stroke in the Hospital Departamental Universitario de Narino E.S.E between June 2018 and December 2019. As a reference, the outcomes were compared with the Colombian registries on RES-Q platform. MATERIALS AND METHODS: A retrospective descriptive study of patients treated in-hospital with stroke, data collection was performed using the RES-Q platform. The analysis was carried out using descriptive statistics and absolute and relative frequencies and the differences with analytical tests. RESULTS: 457patients were evaluated, with ischemic stroke predominance, endovenous thrombolysis was performed in 7.2 % in 2018, and 9.2 % in 2019, 27.7 % of patients had door to needle time less than 60 minutes in 2018 and 42.8 % in 2019. Among the quality markers evaluated, an improvement was found in the performance of NIHSS, dysphagia evaluation, and carotid doppler performance in ischemic stroke. Compared with Colombian registry, a lower percentage was found in endovenous thrombolysis and thrombectomy. Most of Stroke Care Markers are similar to national average. CONCLUSIONS: The improvement in compliance of standard of Stroke Care Quality Markers reflects the impact of stroke care programs. The monitoring of quality parameters allows the generation of comprehensivestroke care programs in the region.

Quality of Clinical Guidelines for Type 2 Diabetes Mellitus from Kenya, Zimbabwe, Tanzania and Nepal

@#The objective of this study was to describe and compare the quality of clinical guidelines for Type 2 diabetes mellitus (T2D) from Kenya, Zimbabwe, Tanzania and Nepal. Alumni from “peoples-uni” were invited to review and evaluate T2D clinical management guidelines used in their settings. The “Appraisal of Guidelines for REsearch & Evaluation II” (AGREE II) instrument was used to evaluate the guidelines. Each guideline was randomly allocated to three assessors, who evaluated the guidelines separately and allocated scores for items on the AGREE II tool. The guidelines from Zimbabwe and Kenya scored generally better than the Tanzania and Nepal guidelines. The main areas that needed the most improvement across all the guidelines were rigour of development (41%), applicability (40%) and editorial independence (35%). There is a need to improve several aspects of T2D clinical guidelines, which is a useful starting point to improve management of these patients.

Hand Hygiene Compliance during COVID-19 Pandemic among Neonatal Nurses in a Federal University Teaching Hospital in Nigeria

@#Introduction: Compliance with Hand hygiene (HH) has been considered as a simple and the most efficient strategy to reduce hospital-acquired infections (HAIs). Compliance with this practice is not often assessed in Nigeria and thus posed a significant risk to the quality of care and patient safety and especially in this era of the COVID-19 pandemic. The study aimed to assess neonatal nurses’ compliance to “my five moments for HH”. Method: A cross-sectional observational study was carried out in a Nigerian federal hospital, using an adapted version of a standardized observational WHO tool of ‘’my five moments of HH’’. A Chi-square test was employed to examine the relationship of HH compliance across units, shifts, and “my five moments for HH” opportunities. Results: The observer recorded 425 HH opportunities and the total HH compliance rate was (62.8%). There was no association between the units, working shifts, and nurses’ HH compliance. Compliance to HH was dependent on the five moments of HH (p < 0.000), better compliance was seen after body fluid exposure (100%), followed by after newborn contact (86.3%), and after contact with newborn surroundings (63.4%), while compliance before newborn contact (28.5%), and before an aseptic procedure (9.1%) were poor. Conclusion: The findings of this study showed a significant gap with the HH compliance among neonatal nurses, suggesting multiple opportunities for neonatal infections despite the current awareness of HH in the Covid-19 pandemic. Hence, there is a need to intensify infection control practices in Nigeria, especially on HH practice.

Developing capacity for implementation and evaluation of vaccine trials in Uganda: Perspective of the Makerere University Walter Reed Project

Introduction: Infectious diseases and neglected tropical diseases continue to be a major challenge in resource limited settings, causing significant morbidity and mortality. Although vaccines are a key biomedical prevention tool, resource limited settings often lack the infrastructure, regulatory frameworks, and skilled human resource to conduct vaccine clinical trials. To address this gap, the Makerere University Walter Reed Project (MUWRP) was established and has contributed to vaccine research in Uganda and globally. Methods: This was achieved through training a strong vaccine clinical trial workforce; development of requisite clinical trial infrastructure for research activities and management of investigational products; conducting phase I-III vaccine trials and contribution to national ethical and regulatory frameworks that protect participants. Results: As of 2022, MUWRP had successfully conducted and completed five phase I/II HIV vaccine clinical trials, five for Ebola and Marburg, while one phase I/II Schistosomiasis and one phase III COVID-19 vaccine clinical trial are ongoing. Discussion: The completed vaccine trials provided critical scientific knowledge on the safety and immunogenicity of investigational products which informed the design of better vaccines for diseases of global health importance. Conclusion: Academia, through establishment of appropriate partnerships can contribute to the identification of solutions to complex public health challenges