Co-creation process of an intervention to implement a multiparameter point-of-care testing device in a primary healthcare setting for non-communicable diseases in Peru.

BACKGROUND: Point-of-care testing (POCT) devices are diagnostic tools that can provide quick and accurate results within minutes, making them suitable for diagnosing non-communicable diseases (NCDs). However, these devices are not widely implemented in healthcare systems and for this reason is relevant to understand the implementation process. AIM: To describe the process and define a strategy to implement a multiparameter POCT device for diagnosing and managing NCDs in one region of Peru. METHODS: A descriptive and non-experimental study, using the participatory methodologies of co-creation process. It was conducted in one region of Peru (Tumbes) to design an intervention for implementing a multiparameter POCT device. Two co-creation sessions were conducted involving five groups: community members, primary healthcare workers, these groups in both rural and urban settings, and regional decision-makers. These sessions included activities to understand patient journeys in receiving care for NCDs, identify facilitators and barriers to POCT devices usage, and define an implementation strategy for POCT devices in both rural and urban settings of Tumbes. The research team analysed the data and summarized key topics for discussion after each session. RESULTS: A total of 78 participants were enrolled across the five groups. Among community members: 22.2% had only diabetes, 24.1% had only hypertension, and 18.5% had both diagnoses. In the patient journey, community members mentioned that it took at least three days to receive a diagnosis and treatment for an NCD. Most of the participants agreed that the POCT devices would be beneficial for their communities, but they also identified some concerns. The strategy for POCT devices implementation included healthcare workers training, POCT devices must be placed in the laboratory area and must be able to perform tests for glucose, glycated haemoglobin, cholesterol, and creatinine. Advertising about POCT devices should be displayed at the healthcare centres and the municipality using billboards and flyers. CONCLUSIONS: The co-creation process was useful to develop strategies for the implementation of multiparameter POCT devices for NCDs, involving the participation of different groups of stakeholders guided by moderators in both, rural and urban, settings in Peru.

Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews.

BACKGROUND: The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation. OBJECTIVE: The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems. METHODS: The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach. RESULTS: A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist. CONCLUSIONS: We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.12688/f1000research.27150.2.

Assessment and management of asymptomatic COVID-19 infection: A systematic review.

BACKGROUND: COVID-19 can be asymptomatic in a substantial proportion of patients. The assessment and management of these patients constitute a key element to stop dissemination. AIM: To describe the assessment and treatment of asymptomatic infection in patients with a confirmed diagnosis of COVID-19. METHODS: We searched five databases and search engines for preprints/preproofs, up to August 22, 2020. We included cohort, cross-sectional, and case series studies, reporting the assessment and management of asymptomatic individuals. We extracted data on total discharges with negative PCR, length of hospitalization, treatment, and number of patients who remained asymptomatic. A random-effects model with inverse variance method was used to calculate the pooled prevalence. RESULTS: 41 studies (nine cross-sectional studies, five retrospective studies and 27 reports/case series; 647 asymptomatic individuals), were included, of which 47% were male (233/501). The age of patients was between 1month and 73 years. In patients who became symptomatic, length of hospitalization mean was 13.6 days (SD 6.4). Studies used lopinavir/ritonavir, hydroxychloroquine plus ritonavir/lopinavir, hydroxychloroquine with and without azithromycin, ribavirin plus interferon and interferon alfa. The proportion of individuals who remained asymptomatic was 91% (463/588 patients; 95%CI: 78.3%-98.7%); and asymptomatic individuals discharged with negative PCR was 86% (102/124 individuals; 95%CI: 58.4%-100%). CONCLUSIONS: There is no standard treatment for asymptomatic COVID-19 individuals. There are no studies of adequate design to make this decision. It has been shown that most asymptomatic individuals who were followed have recovered, but this cannot be attributed to standard treatment.

Short-term efficacy of umbilical cord milking in preterm infants: systematic review and meta-analysis.

BACKGROUND: To systematically evaluate short-term efficacy of UCM versus other interventions in preterm infants. METHODS: Six engines were searched until February 2020 for randomized controlled trials (RCTs) assessing UCM versus immediate cord clamping (ICC), delayed cord clamping (DCC), or no intervention. Primary outcomes were overall mortality, intraventricular hemorrhage (IVH), and patent ductus arteriosus (PDA); secondary outcomes were need for blood transfusion, mean blood pressure (MBP), serum hemoglobin (Hb), and ferritin levels. Random-effects meta-analyses were used. RESULTS: Fourteen RCTs (n = 1708) were included. In comparison to ICC, UCM did not decrease mortality (RR 0.5, 95% CI 0.2-1.1), IVH (RR 0.7, 95% CI 0.5-1.0), or PDA (RR 1.0, 95% CI 0.7-1.5). However, UCM reduced need of blood transfusion (RR 0.5, 95% CI 0.3-0.9) and increased MBP (MD 2.5 mm Hg, 95% CI 0.5-4.5), Hb (MD 1.2 g/dL, 95% CI 0.8-1.6), and ferritin (MD 151.4 ng/dL, 95% CI 59.5-243.3). In comparison to DCC, UCM did not reduce mortality, IVH, PDA, or need of blood transfusion but increased MBP (MD 3.7, 95% CI 0.6-6.9) and Hb (MD 0.3, 95% CI -0.2-0.8). Only two RCTs had high risk of bias. CONCLUSIONS: UCM did not decrease short-term clinical outcomes in comparison to ICC or DCC in preterm infants. Intermediate outcomes improved significantly with UCM. IMPACT: In 14 randomized controlled trials (RCTs), umbilical cord milking (UCM) did not reduce mortality, intraventricular hemorrhage, or patent ductus arteriosus compared to immediate (ICC) or delayed cord clamping (DCC). UCM improved mean blood pressure and hemoglobin levels compared to ICC or DCC. In comparison to ICC, UCM reduced the need for blood transfusion. We updated searches until February 2020, stratified by type of control, and performed subgroup analyses. There was low quality of evidence about clinical efficacy of UCM. Most of RCTs had low risk of bias. UCM cannot be recommended as standard of care for preterm infants.

Interns' perceptions about the medical internship suspension during the COVID-19 quarantine. / Percepción de los internos sobre la suspensión del internado médico durante la cuarentena por la COVID-19.

The objective of the study was to describe the medical interns' (MI) perceptions about the internship suspension during the COVID-19 quarantine in Peru. A cross-sectional descriptive study was conducted by means of a virtual survey regarding the perception of the internship suspension, return conditions and academic activities during quarantine. A total of 353 MIs participated in the study; 54.9% agreed or totally agreed with returning to their hospital sites if biosecurity measures were guaranteed, more than 90% felt uncertain about the restart and end dates, and 85.6% participated in academic virtual classes. It is concluded that the intention to return to the hospital increases when biosecurity measures are guaranteed. Hospitals should guarantee these measures and ensure health coverage for the MIs, if their return to hospitals is intended.

El objetivo del estudio fue describir las percepciones de los internos de medicina (IM) sobre la suspensión del internado durante la cuarentena por la COVID-19 en el Perú. Se realizó un estudio descriptivo transversal mediante una encuesta virtual sobre la percepción de la suspensión del internado, las condiciones de retorno y las actividades académicas durante la cuarentena. Participaron en el estudio 353 IM, el 54,9% estuvo de acuerdo o totalmente de acuerdo con retornar a sus sedes hospitalarias si se garantizaban las medidas de bioseguridad; más del 90% sentía incertidumbre sobre la fecha de reinicio y el fin de internado, y el 85,6% participaba de clases virtuales académicas. Se concluye que la intención de volver al internado aumenta cuando se garantizan las medidas de bioseguridad. Las sedes hospitalarias deberían garantizar estas medidas y la cobertura de salud de los IM si se propone su retorno a los hospitales.

Diagnostic accuracy of ADA 2020 criteria for undiagnosed diabetes in a Peruvian population.

AIMS: To assess the prevalence of undiagnosed diabetes (UDD) and the diagnostic accuracy of the American Diabetes Association (ADA) criteria to detect UDD cases in a Peruvian population. METHODS: Population-based cross-sectional study. UDD was defined using fasting plasma glucose (FPG), 2-hour post-prandial plasma glucose (2 h-PPG), and glycated hemoglobin (HbA1c) traditional cut-offs. Diagnostic accuracy was estimated using areas under the receiver-operating characteristic (ROC) curve, compared with the combination of oral glucose tolerance test (FPG plus 2 h-PPG) plus HbA1c as gold standard. RESULTS: 1609 subjects were evaluated; mean age 48.2 (SD: 10.6) years, 50.3% were women. A total of 179 (11.3%) subjects were classified as having diabetes, 41.3% of them had UDD. Area under the curve for FPG, 2 h-PPG and HbA1c was 86.5% (95% CI: 81.4-91.6%); 87.2% (95% CI: 82.2-92.2%) and 80.4% (95% CI: 74.8-86.0%), respectively. FPG sensitivity was 73.0%, whereas this value was 74.3% for 2 h-PPG and 60.8% for HbA1c. Of 74 UDD cases, 45 were positive for HbA1c, 54 for FPG and 55 for 2 h-PPG. CONCLUSIONS: 41.3% of people with diabetes do not know their diagnosis. Diagnostic accuracy of FPG and 2 h-PPG was higher than HbA1c. The most sensitive combination of two tests to detect UDD cases was FPG plus 2 h-PPG.

Volumen plaquetario medio como predictor de la mortalidad en pacientes con sepsis: revisión sistemática y metanálisis / Mean platelet volume as a predictor of mortality in patients with sepsis: systematic review and meta-analysis

Introducción: El volumen medio plaquetario (VMP) es un biomarcador utilizado en el abordaje integral de la sepsis. Objetivo: Evaluar la asociación entre VMP con la mortalidad en pacientes con sepsis. Métodos: Se realizó una revisión sistemática de estudios observacionales en cinco bases de datos. Se analizó la mortalidad asociada con la sepsis; las intervenciones consideradas fueron VMP, APACHE y lactato sérico. Resultados: Respecto a la mortalidad asociada a sepsis, se encontró un valor significativo en la VMP a las 72 horas (200 fallecidos versus 654 no fallecidos; MD 0.83 IC95% 0.53-1.13, p=< 0.0001, I2 =72.9%); así como el valor de APACHE II (220 muertos frente a 604 no fallecidos; MD 0.81 IC95% 0.62-1.0, p= 0.0001, I2 =32%). No se encontró significancia estadística para las demás variables clínicas. Conclusiones: El aumento de la VMP se asocia con mayor riesgo de mortalidad en pacientes con sepsis, especialmente después de 72 horas de evolución de las características clínicas.

Introduction: Platelet mean volume (MVP) is a biomarker used in the integral approach to sepsis. Objective: To assess the association between MVP and mortality in patients with sepsis. Methods: A systematic review of observational studies in five databases was performed. Mortality associated with sepsis was analysed; interventions considered were MPV, APACHE and serum lactate. Results: Regarding mortality associated with sepsis, a significant value was found in the MVP at 72 hours (200 deceased versus 654 not deceased; MD 0.83 IC95% 0.53-1.13, p=<0.0001, I2 =72.9%); as well as the value of APACHE II (220 dead versus 604 not deceased; MD 0.81 IC95% 0.62-1.0, p= 0.0001, I2 =32%). No statistical significance was found for the other clinical variables. Conclusions: Increased MVP is associated with increased risk of mortality in patients with sepsis, especially after 72 hours of evolution of clinical features.

Educación médica virtual en Perú en tiempos de COVID-19 / Virtual Medical Education In Peru During COVID-19

La educación médica tiene como objetivo la excelencia en la formación de profesionales de la salud. Así, la educación virtual surge ante la dificultad de acceso de muchos estudiantes a los centros educativos. La educación médica no es ajena a esta transición, por lo que es importante que tanto docentes como alumnos adopten estas herramientas para conseguir un proceso enseñanza-aprendizaje de calidad. Existe evidencia sobre la efectividad y aceptación del aprendizaje virtual dentro de la comunidad médica, donde los estudiantes describen su satisfacción a esta modalidad de educación, como una buena opción para una mejor formación. Sin embargo, algunas instituciones educativas no están preparadas para este cambio y muchas de ellas no cuentan con plataformas virtuales o no tienen la capacidad de impartirlos conocimientos adecuadamente de manera virtual; lo que expone una realidad deficiente en esta era digital. La educación virtual tiene el reto de capacitar y adaptar a sus docentes a estos nuevos métodos de enseñanza frente a sus estudiantes que ya han nacido dentro de un mundo digital. No obstante, no todos los estudiantes tienen acceso en casa a estas tecnologías o conectividad necesarias para la educación virtual, en muchos casos por falta de recursos para la adquisición de computadoras o internet, sumado a las limitaciones propias de los que viven en zonas rurales.

Medical education aims at excellence in the training of health professionals. Thus, virtual education arises from the difficulty of access of many students to educational centers. Medical education is no stranger to this transition, so it is important for both teachers and students to adopt these tools to achieve a quality teaching-learning process. There is evidence on the effectiveness and acceptance of virtual learning within the medical community, where students describe their satisfaction with this modality of education as a good option for better training. However, some educational institutions are not prepared for this change and many of them do not have virtual platforms or do not have the capacity to impart knowledge properly in a virtual way, which exposes a poor reality in this digital age. Virtual education has the challenge of training and adapting its teachers to these new teaching methods in front of its students who have already been born in a digital world. However, not all students have access at home to these technologies or connectivity necessary for virtual education, in many cases due to lack of resources for the purchase of computers or the internet, added to the limitations of those living in rural areas.

Percepción de los internos sobre la suspensión del internado médico durante la cuarentena por la COVID-19 / Interns' perceptions about the medical internship suspension during the COVID-19 quarantine

RESUMEN El objetivo del estudio fue describir las percepciones de los internos de medicina (IM) sobre la suspensión del internado durante la cuarentena por la COVID-19 en el Perú. Se realizó un estudio descriptivo transversal mediante una encuesta virtual sobre la percepción de la suspensión del internado, las condiciones de retorno y las actividades académicas durante la cuarentena. Participaron en el estudio 353IM, el 54,9% estuvo de acuerdo o totalmente de acuerdo con retornar a sus sedes hospitalarias si se garantizaban las medidas de bioseguridad; más del 90% sentía incertidumbre sobre la fecha de reinicio y el fin de internado, y el 85,6% participaba de clases virtuales académicas. Se concluye que la intención de volver al internado aumenta cuando se garantizan las medidas de bioseguridad. Las sedes hospitalarias deberían garantizar estas medidas y la cobertura de salud de los IM si se propone su retorno a los hospitales.

ABSTRACT The objective of the study was to describe the medical interns' (MI) perceptions about the internship suspension during the COVID-19 quarantine in Peru. A cross-sectional descriptive study was conducted by means of a virtual survey regarding the perception of the internship suspension, return conditions and academic activities during quarantine. A total of 353 MIs participated in the study; 54.9% agreed or totally agreed with returning to their hospital sites if biosecurity measures were guaranteed, more than 90% felt uncertain about the restart and end dates, and 85.6% participated in academic virtual classes. It is concluded that the intention to return to the hospital increases when biosecurity measures are guaranteed. Hospitals should guarantee these measures and ensure health coverage for the MIs, if their return to hospitals is intended.

Development of a framework for the implementation of synchronous e-mental health: a protocol for a realist synthesis of systematic reviews.

Background: During the COVID-19 pandemic, it has been necessary to incorporate technologies in the care of mental health problems. But there have been difficulties in the application of technology-based interventions in mental health. Some quantitative systematic reviews don't allow us to fully identify and properly describe this subject. In order to answer the question "how do electronic interventions apply in mental health and what makes the application of any of these interventions work", this study will carry out an overview of systematic reviews, which will make it possible to develop a theoretical framework on the implementation of electronic care in mental health problems. Methods: We will search MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases from 1st January 2015 to September 2020, with no language restriction. We will follow a qualitative method approach and include systematic reviews that assess primary studies relating to adults with common mental health problems using any type of mobile mental health intervention that includes a synchronic component and communication with a mental health professional. For the analysis, we will make a meta-synthesis of the systematic reviews, using an emergent grounded theory approach to synthesize the information, prioritizing the systematic reviews with the lowest risk of bias in the AMSTAR-2 tool. The meta-synthesis will be based on interpreting, integrating, and inferring the evaluation elements to understand better the e-health implementation process for patients with mental health problems. Finally, we will present the overall assessment in a Summary of Qualitative Findings table. Conclusion: Our results will allow a better understanding of the facilitator and limitations in implementing e-health interventions for mental health problems.