Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Priority setting for pandemic preparedness and response: A comparative analysis of COVID-19 pandemic plans in 12 countries in the Eastern Mediterranean Region.

Background: The COVID-19 pandemic has significantly disrupted health systems and exacerbated pre-existing resource gaps in the Eastern Mediterranean Region (WHO-EMRO). Active humanitarian and refugee crises have led to mass population displacement and increased health system fragility, which has implication for equitable priority setting (PS). We examine whether and how PS was included in national COVID-19 pandemic plans within EMRO. Methods: An analysis of COVID-19 pandemic response and preparedness planning documents from a sample of 12/22 countries in WHO-EMRO. We assessed the degree to which documented PS processes adhere to twenty established quality parameters of effective PS. Results: While all reviewed plans addressed some aspect of PS, none included all quality parameters. Yemen's plan included the highest number (9) of quality parameters, while Egypt's addressed the lowest (3). Most plans used evidence in their planning processes. While no plans explicitly identify equity as a criterion to guide PS; many identified vulnerable populations - a key component of equitable PS. Despite high concentrations of refugees, migrants, and IDPs in EMRO, only a quarter of the plans identified them as vulnerable. Conclusion: PS setting challenges are exacerbated by conflict and the resulting health system fragmentation. Systematic and quality PS is essential to tackle long-term health implications of COVID-19 for vulnerable populations in this region, and to support effective PS and equitable resource allocation.

Strategies to adapt and implement health system guidelines and recommendations: a scoping review.

BACKGROUND: Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries. METHODS: We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS: A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level. CONCLUSIONS: The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.

Clinical Impact of Initiation of U-500 Insulin vs Continuation of U-100 Insulin in Subjects With Diabetes.

BACKGROUND: The prevalence of obesity and diabetes mellitus (DM) has each increased drastically according to the Centers for Disease Control and Prevention. Growth of severe insulinresistant DM is predicted. U-500 insulin is highly concentrated and can replace less concentrated formulations in patients that need high insulin dosages. The aim of this study was to compare clinical outcomes of U-500 and U-100 insulin regimens in veterans with obesity and insulin resistance. METHODS: A single-site retrospective chart analysis of adult subjects was conducted from July 2002 to June 2011. Data for repeated measures spanned a period from 3 months before the intervention (baseline) through 12 months afterward. The main outcome was the variation in hemoglobin A1c (HbA1c). Other outcomes included incidence of severe hypoglycemia, weight changes, cardiovascular events, and number of injections. RESULTS: A total of 142 subjects (68 taking U-500 and 74 taking U-100) were included. Baseline characteristics were similar between the groups, except for weight, which was higher among U-500 subjects. Mean HbA1c was reduced by 0.84% and 0.56% in U-500 and U-100, respectively (P = .003). Severe hypoglycemia occurred in 5 subjects in the U-500 group and 1 in the U-100 group (P = .08). No significant difference was noted in the number of cardiovascular events. The mean number of daily injections was 2 in the U-500 group, and 4 in the U-100 group (P < .001). CONCLUSIONS: U-500 insulin, when compared with U-100 insulin regimens, led to a statistically significant reduction in HbA1c and number of insulin injections. Additional research is necessary to assess the risk of severe hypoglycemia in U-500 users. Neither regimen was associated with increased cardiovascular risk.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis.

BACKGROUND: Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries. METHODS: A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation. RESULTS: We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors). CONCLUSIONS: It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing. TRIAL REGISTRATION: The protocol was registered with PROSPERO, ID=CRD42017057049 .

Micosis fungoide foliculotropa de presentación grave y letal / Severe and Lethal Presentation of Folliculotropic Mycosis Fungoides

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Clinical characteristics, prevalence, and factors related to delirium in children of 5 to 14 years of age admitted to intensive care. / Características clínicas, prevalencia y factores asociados al delirium en niños de 5 a 14 años de edad ingresados en cuidados intensivos.

OBJECTIVE: To evaluate the clinical characteristics, prevalence and factors associated with delirium in critical patients from 5 to 14 years of age. DESIGN: An analytical, cross-sectional observational study was made. Delirium was assessed with the Pediatric-Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU) and motor classification was established with the Delirium Rating Scale Revised-98. SETTING: A pediatric Intensive Care Unit. PATIENTS: All those admitted over a one-year period were assessed during the first 24-72h, or when possible in deeply sedated patients. EXCLUSION CRITERIA: Patients in stupor or coma, with severe communication difficulty, subjected to deep sedation throughout admission, and those with denied consent. RESULTS: Twenty-nine of the 156 assessed patients suffered delirium (18.6%) and 55.2% were hypoactive. The neurocognitive alterations evaluated by the pCAM-ICU were similar in the three motor groups. Intellectual disability (OR=17.54; 95%CI: 3.23-95.19), mechanical ventilation (OR=18.80; 95%CI: 4.29-82.28), liver failure (OR=54.88; 95%CI: 4.27-705.33), neurological disease (OR=4.41; 95%CI: 1.23-15.83), anticholinergic drug use (OR=3.23; 95%CI: 1.02-10.26), different psychotropic agents (OR=4.88; 95%CI: 1.42-16.73) and tachycardia (OR=4.74; 95%CI: 1.21-18.51) were associated to delirium according to the logistic regression analysis. CONCLUSION: The frequency of delirium and hypoactivity was high. It is therefore necessary to routinely evaluate patients with standardized instruments. All patients presented with important neurocognitive alterations. Several factors related with the physiopathology of delirium were associated to the diagnosis; some of them are modifiable through the rationalization of medical care.

Utility of state-level influenza disease burden and severity estimates to investigate an apparent increase in reported severe cases of influenza A(H1N1) pdm09 - Arizona, 2015-2016.

The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015-2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015-2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015-2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.

αvß3 Integrin and fibronectin expressions and their relation to estrogen and progesterone during placentation in swine.

Mammalian pregnancy requires specific interactions between the conceptus and its mother that involve the endocrine system and adhesion molecules. The relation between adhesion molecules and their ligands at the fetal-maternal interface is crucial for developing a successful implantation. Progesterone (P4) and estrogen (E2) secreted by the porcine conceptus are required for the relation to be established. We investigated the expression of αvß3 integrin and its ligand, fibronectin (FN), at the placental interface, and E2 and P4 concentrations in both serum and maternal and fetal placental extracts during placentation in swine. Placental and serum samples of crossbred sows at 17, 30, 60, 70, and 114 days gestation and no pregnant uteri were used. The presence of αvß3 and FN were determined by immunohistochemistry, and E2 and P4 by chemiluminescence in homogenates of nonpregnant uterus (HoU), swine maternal placenta (HoPM), swine fetal placenta (HoPF) and serum. The expression of αvß3 and FN increased at the interface at 17, 30 and 60 days gestation. Immunostaining decreased by 70 days. Serum E2 levels peaked at 17 days, then decreased, then increased again near term. The highest concentration of P4 occurred in HoPF at 70 days gestation, then decreased coincident with a decline in integrin and FN expression at the placental interface. High P4 levels during swine gestation may regulate the expression of αvß3 integrin and FN at the placental interface for up to 70 days gestation. Other adhesion molecules and their ligands likely maintain the fetal-placental interface after 70 days.

Construcción y validación de un registro clínico para la atención asistencial de enfermería / Building and validation of a clinical register for nursing assisting attention / Construção e validação de um registro clínico para a atenção assistencial de enfermagem

Introducción: El registro clínico de enfermería debe reflejar la actuación del profesional en la atención del paciente, con la finalidad de poder evidenciar el rol autónomo de la disciplina y diferenciar sus actividades del resto de los profesionales del equipo multidisciplinario de salud. Metodología: El proyecto que se describe a continuación se desarrolló en una institución de carácter privado de la ciudad de Xalapa, Veracruz, México. Estuvo conformado de cuatro etapas que dieron como resultado el formato Registro Clínico de Enfermería, el cual se encuentra respaldado por la legislación vigente de los organismos reguladores. Se utilizó la Cédula de Evaluación del Registro Clínico de Enfermería como instrumento para determinar el nivel de cumplimiento del formato obtenido. Resultados: Se obtuvo un nivel de cumplimiento del 95.59%. Conclusión: Los resultados obtenidos representan un avance significativo en la mejora de la calidad del registro clínico, y ello ayuda a mejorar la calidad en la atención de los pacientes. El producto final se une a los esfuerzos que se han realizado previamente para la mejora del cuidado y la calidad de la atención tanto en el ámbito público como en el sector privado del sistema de salud.

Introduction: Nursing clinical register should reflect the professional's performance regarding patient attention while evidencing the discipline's autonomous role differentiating the nursing specific activities within the health multidisciplinary team. Methodology: This project was developed in a private institution in the city of Jalapa, Veracruz, Mexico, and was carried out in four stages which, ultimately, produced a Nursing Clinical Register which has been supported by the current laws of the corresponding regulatory bodies. The Nursing Clinical Register Assessment Chart was used to determine the degree of fulfillment of this new format. Results: A fulfillment level of 95.59% was determined. Conclusion: Obtained results suggest a significant advance towards quality improvement in the clinical register which, consequently, can enhance the quality of patient attention. This final product contributes to previous efforts to improve health care both in the public as well as the private sectors.

Introdução: O registro clínico de enfermagem deve refletir a atuação do profissional na atenção do paciente, isto com a finalidade de poder evidenciar o rolo autónomo da disciplina e diferenciar suas atividades do resto dos profissionais da equipe multidisciplinar de saúde. Metodologia: O projeto que se descreve a continuação desenvolveu-se em uma instituição de carácter privado da cidade de Xalapa, Veracruz, México. Esteve conformado de quatro etapas que deram como resultado o formato Registro Clínico de Enfermagem, o qual se encontra respaldado pela legislação vigente dos organismos reguladores. Utilizou-se a Cédula de Avaliação do Registro Clínico de Enfermagem como instrumento para determinar o nível de cumprimento do formato obtido. Resultados: Obteve-se um nível de cumprimento do 95.59%. Conclusão: Os resultados obtidos representam um avanço significativo na melhoria da qualidade do registro clínico e isso ajuda a melhorar a qualidade na atenção dos pacientes. O produto final se une aos esforços que se tem realizado previamente para a melhora do cuidado e a qualidade da atenção, tanto no âmbito público como no sector privado do sistema de saúde.

Patient with disseminated tuberculosis and rare perianal involvement / Paciente con tuberculosis diseminada y un raro compromiso perianal

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Capacidad antifúngica de sobrenadantes libres de células obtenidos de la fermentación de un sustrato de "panela" con gránulos de kéfir de agua / Antifungal capacity of cell-free supernatants obtained from fermentation of a substrate of brown sugar with water kefir grains

El kéfir de agua (KA) es una bebida fermentada medianamente ácida elaborada con soluciones azucaradas y fermentada por un consorcio de microorganismos, principalmente bacterias ácido lácticas (BAL) y levaduras (LEV), embebidas en un polisacárido llamado gránulo de KA. La presencia de hongos y sus toxinas es un problema de la producción de alimentos, como Aspergillus ochraceus y sus micotoxinas especialmente en café y vino. Entre algunas alternativas que se han evaluado para su inhibición se incluyen las bacterias ácido lácticas y productos fermentados en general. El objetivo principal de esta investigación fue evaluar la capacidad del KA en inhibir o retrasar el crecimiento de A. ochraceus. Se emplearon 8 sobrenadantes libres de células (SLC) obtenidos de diferentes fermentaciones de panela con gránulos de KA y con diferentes concentraciones de ácidos orgánicos (láctico y acético). Se hicieron fermentaciones con gránulos de KA en solución de panela por periodos de 32,5 h, a 25, 30 y 37 °C. Se determinaron la cinética de acidificación; el incremento de biomasa y se hizo el recuento de los grupos de microorganismos que componen el gránulo. A 25 °C se determinó el mayor aumento de biomasa (92%). La temperatura de fermentación afectó el recuento de los microorganismos que conforman el gránulo, principalmente las BAL, disminuyendo su cantidad a la máxima temperatura de fermentación (37 °C) (1x10ˆ6 UFC ml-1), comparado con la mínima temperatura (25 °C) (6x10ˆ7 UFC ml-1). El fermento que presentó mayor actividad antifúngica fue el SLC5 (pH: 3,2; temperatura de fermentación: 30 °C). El poder inhibitorio se atribuyó a los ácidos orgánicos producidos durante la fermentación, aunque no se puede descartar que hayan actuado otras sustancias no cuantificadas. Se pudo comprobar que el KA puede fermentar y aumentar su biomasa en un sustrato como el agua de panela y que sus SLC tienen la capacidad de reducir el crecimiento de A. ochraceus.

Water kéfir (WK) is a moderately sour fermented beverage elaborated in sugar-containing solutions through fermentation by a microorganism consortium, principally lactic acid bacteria (LAB) and yeasts, embedded in a matrix of polysaccharide so-called WK grains. The presence of fungi and their toxins it is a problem for the food industry, such as Aspergillus ochraceus and their mycotoxin production especially in coffee and wine. Some alternatives that have been evaluated for their inhibition include lactic acid bacteria and generally fermented products. The main objective was to evaluate the capacity of WK to ferment a Colombian beverage made with Panela and to assess capability of this product to retard the germination of a common toxigenic fungi like Aspergillus ochraceus. 8 cell-free supernatants (CFS) were obtained from separate fermentations and with different organic acids (OA) concentrations (e. g., lactic and acetic). Different fermentations were conducted with WK in Panela broth during 32.5 h periods at 25, 30, and 37°C. We determined the kinetics of acidification of WK along with the corresponding increment in biomass and conducted a quantitation of microorganisms groups that composed the grain. The greatest biomass increase occurred at 25 °C (92%); but the fermentation temperature affected the composition of microorganisms conforming the grain, with the quantity of LAB decreasing at the highest fermentation temperatures (37 °C) (1x10ˆ6cfu ml-1), compared with the minimum temperature (25 °C) (6x10ˆ7 cfu ml-1). The CFS5 (pH 3.2; fermentation temperature 30 °C) exhibited the greatest antifungal activity. We attribute the inhibitory power of these ferments to the OA produced during fermentation, although we cannot discard the possibility of the action of other substances not specifically quantified. We concluded that WK can grow and fermentate Panela broth and that its CFS can exert an antifungal effect against A. ochraceus.

Training and capacity building evaluation: Maximizing resources and results with Success Case Method.

This article describes the use of Success Case Method (Brinkerhoff, 2003) to evaluate health promotion and public health training programs. The goal of the Office Community Research and Engagement (OCRE) of the Puerto Rico Clinical and Translational Research Consortium (PRCTRC) is to establish a stable and sustainable translational research capacity. Early efforts toward achieving this goal included sponsoring two independent research training programs. A description of the implementation of the five step Success Case Method is presented. Results reveal that SCM would deem both trainings as highly successful, based upon the overall impact of a low number of success cases. However, a traditional summative evaluation would consider this disappointing. Strengths of SCM are discussed. It was concluded that the Success Case Method is a useful and valuable evaluative method for measuring the success of health promotion and public health training initiatives and provides sufficient information for decision-making processes.

Setting priorities for a research agenda to combat drug-resistant tuberculosis in children.

SETTING: Numerous knowledge gaps hamper the prevention and treatment of childhood drug-resistant tuberculosis (TB). Identifying research priorities is vital to inform and develop strategies to address this neglected problem. OBJECTIVE: To systematically identify and rank research priorities in childhood drug-resistant TB. DESIGN: Adapting the Child Health and Nutrition Research Initiative (CHNRI) methodology, we compiled 53 research questions in four research areas, then classified the questions into three research types. We invited experts in childhood drug-resistant TB to score these questions through an online survey. RESULTS: A total of 81 respondents participated in the survey. The top-ranked research question was to identify the best combination of existing diagnostic tools for early diagnosis. Highly ranked treatment-related questions centred on the reasons for and interventions to improve treatment outcomes, adverse effects of drugs and optimal treatment duration. The prevalence of drug-resistant TB was the highest-ranked question in the epidemiology area. The development type questions that ranked highest focused on interventions for optimal diagnosis, treatment and modalities for treatment delivery. CONCLUSION: This is the first effort to identify and rank research priorities for childhood drug-resistant TB. The result is a resource to guide research to improve prevention and treatment of drug-resistant TB in children.

Contexte : De nombreuses lacunes en matière de connaissances entravent la prévention et le traitement de la tuberculose (TB) pharmacorésistante. L'identification des priorités de recherche est vitale pour informer et développer des stratégies afin de répondre à ce problème négligé.Objectif : Tenter d'identifier systématiquement et de classer par ordre les priorités en matière de recherche sur la TB pharmacorésistante de l'enfant.Schéma: Ayant adapté la méthode de Child Health and Nutrition Research Initiative (CHNRI) (Initiative de recherche en santé et en nutrition de l'enfant), nous avons compilé 53 questions de recherche dans quatre domaines, puis les avons classées en trois types de recherche différents. Nous avons invité des experts en TB pharmacorésistante de l'enfant à classer ces questions grâce à une enquête en ligne.Résultats : Un total de 81 personnes ont participé à l'enquête. La question de recherche qui a été classée première était l'identification des meilleures associations d'outils de diagnostic existants pour permettre un diagnostic précoce. Les questions considérées comme prioritaires en matière de traitement étaient centrées sur des interventions visant à améliorer les résultats du traitement, à réduire les effets secondaires des médicaments et à déterminer la durée idéale du traitement. La prévalence de la TB pharmacorésistante était la priorité dans le domaine de l'épidémiologie. Les questions relatives au développement ont été considérées comme hautement prioritaires et se sont focalisées sur des interventions d'amélioration du diagnostic, du traitement et des modalités de délivrance du traitement.Conclusion : Cette enquête est la première qui vise à identifier et à hiérarchiser les priorités de recherche relatives à la TB pharmacorésistante de l'enfant. Son résultat constitue une ressource pour guider la recherche afin d'améliorer la prévention et le traitement de la TB pharmacorésistante de l'enfant.

Marco de referencia: Numerosas lagunas de conocimiento obstaculizan la prevención y el tratamiento de la tuberculosis drogorresistente (TB-DR) en niños. Es esencial identificar cuales son las áreas prioritarias de investigación para informar y desarrollar estrategias para hacer frente a este problema descuidado.Objetivo: Identificar sistemáticamente las prioridades de investigación en la TB-DR en niños, y construir una clasificación jerárquica de ellas.Diseño: Se adaptó la metodología de la Iniciativa de Investigación en Salud y Nutrición Infantil (CHNRI). Recopilamos 53 preguntas de investigación en cuatro áreas de investigación y luego las clasificamos entre tres tipos de investigación. Invitamos a expertos en TB-DR en niños a que asignen puntajes a cada una de estas preguntas usando una encuesta en línea.Resultados: Un total de 81 individuos participaron en la encuesta. La pregunta de investigación con el puntaje más alto fue de identificar la mejor combinación de existentes herramientas de diagnosis para llegar a un diagnóstico precoz. Preguntas con altos puntajes relacionadas al tratamiento se centraron en entender las razones y las intervenciones para mejorar los resultados del tratamiento, los efectos adversos de los fármacos y la duración óptima del tratamiento. La prevalencia de la TB-DR fue la pregunta con el más alto puntaje en el área de epidemiología. Las preguntas de tipo desarrollo con puntajes más altos se centraron en las intervenciones para el diagnóstico óptimo, el tratamiento óptimo y las modalidades óptimas de prestación del tratamiento.Conclusión: Este ha sido el primer esfuerzo de identificar y clasificar jerárquicamente las prioridades de investigación en la TB-DR en niños. El resultado es un recurso para orientar la investigación para mejorar la prevención y el tratamiento de la TB-DR en niños.