[Use of evidence in heath policies and programs contributions of the instituto nacional de salud]. / Uso de la evidencia en políticas y programas de salud aportes del instituto nacional de salud.

This article analyzes some examples about how the Ministry of Health of Peru has used evidence for policy and program formulation, implementation and evaluation. It describes the process by which health budget programs are based and strengthened with scientific evidence. Provides an overview about how the development of clinical guidelines methodology is facilitating the generation of high quality evidence based clinical guidelines.It presents some examples of specific information needs of the Ministry of Health to which the Instituto Nacional de Salud has responded, and the impact of that collaboration. Finally, the article proposes future directions for the use of research methodology especially relevant for the development and evaluation of policy and programs, as well as the development of networks of health technology assessment at the national and international level.

Uso de la evidencia en políticas y programas de salud aportes del instituto nacional de salud / Use of evidence in heath policies and programs contributions of the instituto nacional de salud

RESUMEN En el presente artículo se analizan algunos ejemplos del uso de evidencia generada por el Instituto Nacional de Salud (INS) que el Ministerio de Salud del Perú ha realizado en los últimos años en la formulación, implementación y evaluación de las políticas y programas. Presenta el proceso por el cual los programas presupuestales se sustentan y fortalecen a partir de la evidencia. Describe el progreso en el desarrollo de una metodología para generar guías de calidad a partir de la mejor evidencia disponible para orientar la práctica clínica. Presenta algunos ejemplos de requerimientos de evidencia del Ministerio de Salud al Instituto Nacional de Salud y su impacto en política. Por último, propone direcciones futuras respecto a metodologías de investigación especialmente relevantes para el desarrollo y evaluación de políticas y el fortalecimiento de redes de evaluación de tecnologías en el ámbito nacional e internacional.

ABSTRACT This article analyzes some examples about how the Ministry of Health of Peru has used evidence for policy and program formulation, implementation and evaluation. It describes the process by which health budget programs are based and strengthened with scientific evidence. Provides an overview about how the development of clinical guidelines methodology is facilitating the generation of high quality evidence based clinical guidelines.It presents some examples of specific information needs of the Ministry of Health to which the Instituto Nacional de Salud has responded, and the impact of that collaboration. Finally, the article proposes future directions for the use of research methodology especially relevant for the development and evaluation of policy and programs, as well as the development of networks of health technology assessment at the national and international level.

Relación entre nivel de conocimiento sobre factores de riesgo cardiovascular y conducta de riesgo cardiovascular referida por las enfermeras / Relationship between level of knowledge about cardiovascular risk factors and cardiovascular risk behavior referred by nurses

Objetivos: determinar la relación entre el nivel de conocimiento sobre los factores de riesgo cardiovascular modificables y la conducta de riesgo cardiovascular referida por las enfermeras del Hospital Nacional Arzobispo Loayza. Material y métodos: el estudio fue descriptivo, correlacional. La muestra estuvo conformada por 107 enfermeras del Hospital Arzobispo Loayza. El muestreo fue probabilístico aleatorio simple, la recolección de datos se hizo a través de la técnica de encuesta, cuyo instrumento fue un cuestionario elaborado por las investigadoras y pasó por un proceso de validación con la correlación de Pearson, y la prueba alfa de Cronbach, para su confiabilidad. Resultados: El 56% del personal de enfermería posee un nivel de conocimiento medio acerca de los factores de riesgo cardiovascular modificable, y el 45% tiene una conducta de alto riesgo. Conclusiones: no existe relación entre el nivel de conocimientos acerca de los factores de riesgo cardiovascular y la conducta de riesgo cardiovascular en enfermeras.

Objectives: To determine the relationship between the level of knowledge about modifiable cardiovascular risk factors and cardiovascular risk behavior referred by nurses Arzobispo Loayza National Hospital. Material and Method: The study was descriptive correlational. The sample was 107 Arzobispo Loayza Hospital nurses, selected according to the inclusion criteria of a total of 423 nurses. The simple random sampling was probabilistic, data collection was done through the survey technique, the instrument was a questionnaire developed by the researchers themselves and went through a validation process with Pearson correlation and CronbachÆs alpha test for its reliability. Results: 56% of the nurses has a medium level of knowledge about modifiable cardiovascular risk factors and 45% had high-risk behavior. Conclusion: There is no relationship between the level of knowledge about cardiovascular risk factors and cardiovascular risk behavior in nurses.

Combined measurement of N-terminal pro-B-type natriuretic peptide and highly sensitive cardiac troponin T for diagnosis and monitoring of heart injury in chronic Chagas' disease.

OBJECTIVE: Chronic Chagas disease afflicts millions of patients in Latin America of which 70% remain asymptomatic but 30% develop fatal heart injury. To evaluate the impact of laboratory medicine for diagnosis and guiding of patients with Chagas' heart disease, we measured N-terminal B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT). DESIGN AND METHODS: NT-proBNP and cTnT using the highly sensitive assay (hs-cTnT) were measured in 48 asymptomatic Chagas' patients (control group; (-) CM), and in symptomatic patients who suffered from mild/moderate (group (+/++) CM, n=62) or severe cardiomyopathy (group (+++) CM, n=27). RESULTS: Both markers were higher in (+/++) CM and (+++) CM vs. (-) CM and increased in the cardiomyopathy severity. Values of 3 ng/L cTnT and 160 ng/L NT-proBNP were calculated as optimal cut-offs to distinguish (-) CM vs. CM. The NT-proBNP cut-off of 125ng/L, as recommended by international guidelines, was additionally incorporated in the analysis. Cardiomyopathy was most successfully predicted by dual positivity of both markers (positive predictive value=1.0). Negativity of both markers effectively excluded cardiomyopathy (negative predictive value of 0.85). Positivity for at least one of the markers is the best for overall correct classification. CONCLUSIONS: Combined measurement of hs-cTnT and NT-proBNP can be used for diagnosis and monitoring of cardiomyopathy in chronic Chagas' patients. In this way, laboratory medicine increases the pre-test probability of the cardiologic diagnostics, which would reduce its time, cost, and logistical problems.

Chronic Chagas disease: from basics to laboratory medicine.

Chagas disease, caused by Trypanosoma cruzi infection, is ranked as the most serious parasitic disease in Latin America and has huge potential to become a worldwide problem, due to increasing migration, and international tourism, as well as infectant transfer by blood contact and transfusion, intrauterine transfer, and organ transplantation. Nearly 30% of chronically-infected patients become symptomatic, often with a latency of 10-30 years, developing life-threatening complications. Of those, nearly 90% develop Chagas heart disease, while the others manifest gastrointestinal disease and neuronal disorders. Besides interrupting the infection cycle and chemo therapeutic infectant elimination, starting therapy early in symptomatic patients is important for counteracting the disease. This would be essentially supported by optimized patient management, involving risk assessment, early diagnosis and monitoring of the disease and its treatment. From economic and logistic viewpoints, the tools of laboratory medicine should be especially able to guarantee this. After summarizing the basics of chronic Chagas disease, such as the epidemiological data, the pathogenetic mechanisms thought to drive symptomatic Chagas disease and also treatment options, we present tools of laboratory medicine that address patient diagnosis, risk assessment for becoming symptomatic and guidance, focusing on autoantibody estimation for risk assessment and heart marker measurement for patient guidance. In addition, increases in levels of inflammation and oxidative stress markers in chronic Chagas disease are discussed.

Chronic Chagas' heart disease: a disease on its way to becoming a worldwide health problem: epidemiology, etiopathology, treatment, pathogenesis and laboratory medicine.

Chagas' disease, caused by Trypanosoma cruzi infection, is ranked as the most serious parasitic disease in Latin America. Nearly 30% of infected patients develop life-threatening complications, and with a latency of 10-30 years, mostly Chagas' heart disease which is currently the major cause of morbidity and mortality in Latin America, enormously burdening economic resources and dramatically affecting patients' social and labor situations. Because of increasing migration, international tourism and parasite transfer by blood contact, intrauterine transfer and organ transplantation, Chagas' heart disease could potentially become a worldwide problem. To raise awareness of this problem, we reflect on the epidemiology and etiopathology of Chagas' disease, particularly Chagas' heart disease. To counteract Chagas' heart disease, in addition to the general interruption of the infection cycle and chemotherapeutic elimination of the infection agent, early and effective causal or symptomatic therapies would be indispensable. Prerequisites for this are improved knowledge of the pathogenesis and optimized patient management. From economic and logistics viewpoints, this last prerequisite should be performed using laboratory medicine tools. Consequently, we first summarize the mechanisms that have been suggested as driving Chagas' heart disease, mainly those associated with the presence of autoantibodies against G-protein-coupled receptors; secondly, we indicate new treatment strategies involving autoantibody apheresis and in vivo autoantibody neutralization; thirdly, we present laboratory medicine tools such as autoantibody estimation and heart marker measurement, proposed for diagnosis, risk assessment and patient guidance and lastly, we critically reflect upon the increase in inflammation and oxidative stress markers in Chagas' heart disease.

Cardiac troponin T measured with a highly sensitive assay for diagnosis and monitoring of heart injury in chronic Chagas disease.

CONTEXT: Chronic Chagas disease (15 million patients; annual incidence, 40, 000 patients; annual mortality, 12 ,500 patients) is the most serious parasitic disease in Latin America. Between 10 and 30 years after infection, 30% of patients with Chagas disease develop heart injury, which is the main reason for its high mortality. Consequently, frequent cardiac diagnostics are required for patients with Chagas disease. OBJECTIVE: To minimize time-intensive and cost-intensive diagnostics, such as electrocardiography, echocardiography, and radiologic imaging, we tested the effect of measuring serum cardiac troponin T (cTnT) with a highly sensitive assay. To indicate the pathophysiologic background for cTnT release in Chagas heart injury, inflammation markers, such as C-reactive protein and interleukin 6, were measured in parallel. DESIGN: Serum cTnT was measured in 26 healthy subjects and in 179 patients with chronic Chagas disease who were asymptomatic (indeterminate stage, n  =  86), who were suffering from cardiomyopathy with or without megacolon (n  =  71), or who were suffering from megacolon exclusively (n  =  22). RESULTS: Serum cTnT was significantly higher in patients with cardiomyopathy with or without megacolon than in healthy subjects, asymptomatic subjects, and patients with megacolon, and the cTnT value was correlated with the severity of the cardiomyopathy. The lower limit of detection for the highly sensitive assay (3 ng/L) was best at distinguishing patients with, and without, heart injury. C-reactive protein and interleukin 6 were found to parallel cTnT changes in both the different Chagas groups and the cardiomyopathy groups separated by disease severity. CONCLUSIONS: Highly sensitive cTnT measurement has the potential to contribute to diagnosis and monitoring of heart injury in patients with chronic Chagas disease. The highly sensitive assay of cTnT release seems to be related to Chagas heart disease-specific inflammation.

Cardiac troponin T release and inflammation demonstrated in marathon runners.

BACKGROUND: As shown on the basis of highly sensitive assays, cardiac troponin release is now observed after physiological heart stress and in mild heart pathologies: both are [corrected] considered unrelated to the irreversible cardiac alteration that is typically the source of release. Transitory cardiac membrane leakage was suggested as the basis. In our view, mild inflammation may drive this type of cardiac troponin release. To verify this hypothesis, marathon runners who demonstrated post-run inflammation were used as a model to correlate cTnT release and inflammation intensity. METHODS: In 78 male marathon runners who participated in the BERLIN-MARATHON 2006, cardiac troponin T (cTnT) was monitored [corrected] at three time points (pre-race, post-race, and after two weeks of rest). [corrected] Measurements were done with the highly sensitive assay (hs cTnT assay) and the conventional fourth-generation cTnT assay for comparison. Concurrently, [corrected] the inflammation markers (leukocyte and neutrophil counts, CRP, IL-6) were measured. RESULTS: Pre-race, the fourth-generation assay failed to demonstrate cTnT positivity (> test specific LLD). In contrast, with the [corrected] use of the highly sensitive assay, 28% of the participants were positive for cTnT (> LLD of hs cTnT assay). Post-race, cTnT as measured with the fourth-generation assay was observed to be detectable in 43% of the runners (> LLD = 99(th) percentile cut off), but all runners had detectable cTnT values (> LLD) when measured with the highly sensitive assay. Even in 94% of these cTnT-positive runners, the value exceeded the 99(th) percentile cut off determined for the highly sensitive assay (13 ng/L). cTnT release correlated significantly with inflammation intensity. Faster runners demonstrated significantly stronger cTnT releases and inflammation signs. CONCLUSIONS: As demonstrated after physiological heart stress such as marathon running, transitory inflammation is evidently one of the events contributing to the cardiac troponin release under conditions suggested as unrelated to irreversible cardiac alteration.

Distinct patterns of autoantibodies against G-protein-coupled receptors in Chagas' cardiomyopathy and megacolon. Their potential impact for early risk assessment in asymptomatic Chagas' patients.

OBJECTIVES: Distinguishing the patterns of autoantibodies (AAB) against G-protein-coupled receptors in Chagas' cardiomyopathy and megacolon and the discovery of such a pattern in patients who are as yet asymptomatic could help to identify patients at high risk of developing the life-threatening complications of Chagas' disease. BACKGROUND: Such AAB against receptors as beta 1 (beta1-AAB), beta 2 (beta2-AAB), and muscarinergic 2 (M2-AAB) are thought to be involved in the pathogenesis of Chagas' cardiomyopathy and megacolon, the predominant manifestations of Chagas' disease, which is the most serious parasitic disease in Latin America. METHODS: Beta1-AAB, beta2-AAB, and M2-AAB were measured in the serum of asymptomatic Chagas' patients and in those with cardiomyopathy and/or megacolon. RESULTS: Nearly all Chagas' patients with cardiomyopathy and/or megacolon had AAB. Predominance of beta1-AAB combined with M2-AAB in Chagas' cardiomyopathy and beta2-AAB with M2-AAB in megacolon was found. Such patterns were also found in 34% of the asymptomatic patients, of whom 85% possessed a beta1-AAB level typical for Chagas' cardiomyopathy. CONCLUSIONS: The percentage of asymptomatic Chagas' patients who had a specific AAB pattern and had a beta1-AAB level above a defined cutoff point mirrors very well the epidemiological situation, which showed that clinical manifestations develop in nearly 30% of Chagas' patients and cardiomyopathy in nearly 90% of them. We hypothesize that beta1-, beta2-, and M2-AAB measurement might be a useful tool for risk assessment in the indeterminate state of Chagas' disease to select patients for earlier involvement in care programs. However, prospective studies are needed to further evaluate this hypothesis.

Factores que inciden en la utilización del Servicio de Emergencia de la Policlínica 35 CNS-Sucre, 1998 / Incident factors in the emergency service of the policlinic 35 use, C.N.S. Sucre 1998

Los servicios de emergencia de los diferentes establecimientos de salud cualquiera sea su nivel de complejidad se ven con frecuencia congestionados por la gran cantidad de pacientes que demandan atención: sin embargo en diferentes estudios se ha observado que dichos servicios se han sobreutilizado, dado que solo una pequeña proporción de demandantes portaba problemas de salud catalogados como verdaderas emergencias médicas

Conocimiento y medidas preventivas sobre SIDA en homosexuales no organizados en los distritos de San Martín de Porres, Santa Anita, Comas, Chorrillos, La Victoria - Rímac / Knowledge and preventive measures on AIDS in homosexuals nonorganized in the districts of San Martín de Porres, Santa Anita, Comas, Chorrillos, La Victoria - Rímac

En el grupo estudiado se ha encontrado que el grado de instrucción no influye significativamente en el nivel de conocimiento sobre el SIDA. Al relacionar las variables grado de instrucción y nivel socioeconómico, no se ha encontrado asociación estadísticamente significativa. La mayoría de la población encuestada utiliza el presente preservativo como barrera para evitar las enfermedades venéreas incluyendo el SIDA. A su vez el 64 por ciento solo practica relaciones sexuales anales, las cuales constituye factor de riesgo para adquirir la enfermedad del SIDA. La gran mayoría de homosexuales No-Organizados presentarón un conocimiento bajo antes de la charla educativa (18 por ciento) después de esta, el conocimiento fué alto (52 por ciento) debido al módulo educativo utilizado.

Identificación de factores de riesgo y protectores asociados a violencias y accidentes en adolescentes y jóvenes de Córdoba / Protector and risk factors identification related to violences and accidents of adolescents and youngs in Cordoba

A fin de identificar probables factores de riesgo y protección en la mortalidad por causas violentas en los adolescentes de la ciudad de Córdoba, se revelaron los datos de 1067 historias clínicas correspondientes a egresos del Hospital Municipal de Urgencias, de jóvenes de 14 a 24 años internados durante el año 1991, y se analizaron 734 ( el 68,8 por ciento) correspondientes a causas violentas. De una muestra sistemática de 50 casos se obtuvo información por medio de entrevistas semiestructuradas sobre datos vitales, antecedentes de riesgos en el desarrollo e historia familiar, situaciones presentes en el momento del traumatismo, secuelas, pérdida de tiempo productivo y reinserción a actividades habituales de estudio y trabajo. El equipo de entrevistadores estaba compuesto por jóvenes, alumnos de psicología y medicina de la Universidad Nacional de Córdoba. Se extrajeron datos que servirán para orientar programas y políticas de prevención en el tema

Identificación de factores de riesgo y protectores asociados a violencias y accidentes en adolescentes y jóvenes de Córdoba / Protector and risk factors identification related to violences and accidents of adolescents and youngs in Cordoba

A fin de identificar probables factores de riesgo y protección en la mortalidad por causas violentas en los adolescentes de la ciudad de Córdoba, se revelaron los datos de 1067 historias clínicas correspondientes a egresos del Hospital Municipal de Urgencias, de jóvenes de 14 a 24 años internados durante el año 1991, y se analizaron 734 ( el 68,8 por ciento) correspondientes a causas violentas. De una muestra sistemática de 50 casos se obtuvo información por medio de entrevistas semiestructuradas sobre datos vitales, antecedentes de riesgos en el desarrollo e historia familiar, situaciones presentes en el momento del traumatismo, secuelas, pérdida de tiempo productivo y reinserción a actividades habituales de estudio y trabajo. El equipo de entrevistadores estaba compuesto por jóvenes, alumnos de psicología y medicina de la Universidad Nacional de Córdoba. Se extrajeron datos que servirán para orientar programas y políticas de prevención en el tema