Ethical considerations for genetic research in low-income countries: perceptions of informed consent, data sharing, and expectations in Nicaragua.

Genetic research presents numerous ethical, legal, and social implications (ELSI), particularly when the research involves collaborations between investigators in high and low-income countries. Some ELSI issues are universal, and others are specific to context and culture. This study investigates perceptions of genetic research in Nicaragua, Central America, where local and U.S. based researchers have collaborated for over a decade. A total of 43 residents from northwestern Nicaragua, a region with high mortality rates attributed to chronic kidney disease of non-traditional causes (CKDnt), were interviewed, including research participants in ongoing studies (n = 36), health professionals (n = 3), labor leaders (n = 2), and family members of research participants (n = 2). Questions focused on informed consent, data-sharing, and post-study expectations. Audio recordings of interviews conducted in Spanish were transcribed and translated into English. English transcripts were coded and analyzed using NVivo 12 software. The lack of familiarity with terms in the consent form presented a barrier to participant comprehension of key elements of the genetic research study, raising concerns about the validity of informed consent. Research participants often viewed their participation as access to health care. Health professionals emphasized the importance of long-term partnerships between foreign-based researchers and local health institutions. Leaders and family members recommended that they be informed of research studies and allowed the opportunity to consent, as they felt the benefits and risks of research also apply to them. Our findings identified genetic research practices to be improved upon in order to be more responsive to the contextual realities of collaborators living in low-resource settings.

Heat stress and heat strain among outdoor workers in El Salvador and Nicaragua.

BACKGROUND: There is growing attention on occupational heat stress in Central America, as workers in this region are affected by a unique form of chronic kidney disease. Previous studies have examined wet bulb globe temperatures and estimated metabolic rates to assess heat stress, but there are limited data characterizing heat strain among these workers. OBJECTIVE: The aims were to characterize heat stress and heat strain and examine whether job task, break duration, hydration practices, and kidney function were associated with heat strain. METHODS: We used data from the MesoAmerican Nephropathy Occupational Study, a cohort of 569 outdoor workers in El Salvador and Nicaragua who underwent workplace exposure monitoring, including continuous measurement of core body temperature (Tc), heart rate (HR), physical activity, and wet bulb globe temperature (WBGT), over the course of three days in January 2018 - May 2018. Participants represented five industries: sugarcane, corn, plantain, brickmaking, and construction. RESULTS: Median WBGTs were relatively high (>27 °C) at most sites, particularly when work shifts spanned the afternoon hours (e.g., 29.2 °C among plantain workers). Sugarcane workers, especially cane cutters in both countries and Nicaraguan agrichemical applicators, had the highest estimated metabolic rates (medians: 299-318 kcal/hr). Most workers spent little time on break (<10% of the shift), as determined by physical activity data. Overall, sugarcane workers-particularly those in Nicaragua-experienced the highest Tc and HR values. However, a few workers in other industries reached high Tc (>39 °C) as well. Impaired kidney function (estimated glomerular filtration rate <90 mL/min/1.73 m2) was associated with higher Tc and HR values, even after adjustment. SIGNIFICANCE: This is the largest study to-date examining heat stress and strain among outdoor workers in Central America. Workers at sugar companies regularly experienced Tc > 38°C (76.9% of monitored person-days at Nicaraguan companies; 46.5% at Salvadoran companies). Workers with impaired kidney function had higher measures of Tc and HR. IMPACT STATEMENT: This study examined levels of occupational heat stress and heat strain experienced among outdoor workers in five industries in El Salvador and Nicaragua. We characterized heat stress using wet bulb globe temperatures and estimated metabolic rate and heat strain using core body temperature and heart rate. Sugarcane workers, particularly cane cutters and Nicaraguan agrichemical applicators, performed more strenuous work and experienced greater levels of heat strain. Impaired kidney function was associated with higher heart rates and core body temperatures.

COVID-19 and CKD: Employment, Food Security and Healthcare in El Salvador.

Background: In Central America, the COVID-19 pandemic coexists with a devastating epidemic of chronic kidney disease of unknown origin. The consequences of these overlapping health crises remain largely unknown. Methods: We assessed vulnerability to and impact of the first wave of COVID-19 on participants in a cohort study of chronic kidney disease (CKD) in El Salvador (n = 229). Participants were contacted by phone during August and September 2020. We queried changes to employment, healthcare access, household income and food security due to the pandemic (from March 2020 until the time of the interview) and COVID-19-associated symptoms during that time. Findings: We reached 94% of the cohort (n = 215). Nearly 40% of participants reported an unexpected change in employment or work activities and 8.8% reported new unemployment due to the pandemic. Participants with CKD (n = 27) had higher odds of reporting new income insecurity, food insecurity, and reductions in medical care access due to the pandemic. COVID-19-associated symptoms (an approximation of disease) were reported in 7.0% (n = 15). Participants with CKD were more likely to report COVID-19-associated symptoms compared to those without CKD, although these differences were not statistically significant. Conclusions: Overall, participants with CKD suffered greater economic consequences as a result of the pandemic and may have experienced higher incidence of COVID-19 disease, although laboratory diagnostics would be required to draw this conclusion. Longitudinal analyses are required to comprehensively evaluate the implications of the pandemic for individuals with CKD in Central America.

High prevalence of chronic kidney disease of unknown etiology among workers in the Mesoamerican Nephropathy Occupational Study.

BACKGROUND: Mortality from chronic kidney disease of unknown etiology (CKDu) is extremely high along the Pacific coast of Central America, particularly among sugarcane workers. The Mesoamerican Nephropathy Occupational Study (MANOS) is a prospective cohort study of CKDu among agricultural and non-agricultural workers in El Salvador and Nicaragua. The objective of this manuscript is to describe the MANOS cohort recruitment, baseline data collection, and CKDu prevalence after two rounds. METHODS: Workers with no known diabetes, hypertension, or CKD were recruited from sugarcane, corn, plantain, brickmaking, and road construction industries (n = 569). Investigators administered questionnaires, collected biological samples, and observed workers for three consecutive workdays at the worksite. Serum specimens were analyzed for kidney function parameters, and used to calculate estimated glomerular filtration rate (eGFR). At six months, serum was collected again prior to the work shift. CKD at baseline is defined as eGFR ≤ 60 ml/min/1.73m2 at both timepoints. Age-standardized prevalence was calculated by industry, country, and demographic measures. Kidney function parameters were compared by CKD status. RESULTS: Prevalence of CKD at baseline was 7.4% (n = 42). Age-standardized prevalence was highest in Salvadoran sugarcane (14.1%), followed by Salvadoran corn (11.6%), and Nicaraguan brickmaking (8.1%). Nicaraguan sugarcane had the lowest prevalence, likely due to kidney function screenings prior to employment. CONCLUSION: Despite efforts to enroll participants without CKD, our identification of prevalent CKD among agricultural and non-agricultural workers in the MANOS cohort indicates notable kidney disease in the region, particularly among sugarcane workers.

Biomarkers of kidney injury among children in a high-risk region for chronic kidney disease of uncertain etiology.

BACKGROUND: Mesoamerican Nephropathy (MeN), a form of chronic kidney disease of uncertain etiology, is a leading cause of death in Central America. The disease often presents in young adult male agricultural workers and progresses rapidly. Given the young age at presentation, we hypothesized that children in Central America experience subclinical kidney injury prior to working life. METHODS: We assessed specimens from a cross-sectional study of youth, aged 7-17 years, predominantly residing in a high-risk region of Nicaragua (n = 210). We evaluated urinary concentrations and risk factors for kidney injury biomarkers neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), interleukin-18 (IL-18), monocyte chemoattractant protein 1 (MCP-1), and chitinase-3-like protein 1 (YKL-40). We evaluated the association between biomarkers and contemporaneous eGFR and compared biomarker concentrations with reference values from healthy children in other countries. RESULTS: Median uNGAL, uIL-18, and uKIM-1 concentrations exceeded healthy reference values. A one-year increase in age was associated with 40% increase in odds of being in the highest quartile of uNGAL (OR 1.4; (95%CI 1.2, 1.5); p < 0.0001). Youth who reported ever experiencing dysuria had 2.5 times the odds of having uNGAL concentrations in the top quartile (OR 2.5; (95%CI 1.4, 4.6); p = 0.003). Girls had significantly higher concentrations of all biomarkers than boys. Nine percent of children demonstrated low eGFR (≤ 100 ml/min/1.73 m2), while 29% showed evidence of hyperfiltration (eGFR ≥ 160 ml/min/1.73 m2), both potentially indicative of renal dysfunction. CONCLUSIONS: Children residing in regions of Nicaragua at high risk for MeN may experience subclinical kidney injury prior to occupational exposures.

Randomized clinical trial: expanded autologous bone marrow mesenchymal cells combined with allogeneic bone tissue, compared with autologous iliac crest graft in lumbar fusion surgery.

BACKGROUND CONTEXT: Although autogenous iliac crest bone graft (AICBG) is considered the gold-standard graft material for spinal fusion, new bone substitutes are being developed to avoid associated complications and disadvantages. By combining autologous bone marrow mesenchymal stromal cells (MSCs) expanded ex vivo and allogenic cancellous bone graft, we obtain a tissue-engineered product that is osteoconductive and potentially more osteogenic and osteoinductive than AICBG, owing to the higher concentration of MSCs. PURPOSE: This study aimed to evaluate the feasibility and safety of implanting a tissue-engineered product consisting of expanded bone marrow MSCs loaded onto allograft bone (MSC+allograft) for spinal fusion in degenerative spine disease, as well as to assess its clinical and radiological efficacy. STUDY DESIGN/SETTING: A prospective, multicenter, open-label, blinded-reader, randomized, parallel, single-dose phase I-II clinical trial. PATIENT SAMPLE: A total of 73 adult patients from 5 hospitals, with Meyerding grade I-II L4-L5 degenerative spondylolisthesis and/or with L4-L5 degenerative disc disease who underwent spinal fusion through transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES: Spinal fusion was assessed by plain X-ray at 3, 6, and 12 months and by computed tomography (CT) at 6 and 12 months post-treatment. An independent radiologist performed blinded assessments of all images. Clinical outcomes were measured as change from baseline value: visual analog scale for lumbar and sciatic pain at 12 days, 3, 6, and 12 months posttreatment, and Oswestry Disability Index and Short Form-36 at 3, 6, and 12 months posttreatment. METHODS: Patients who underwent L4-L5 TLIF were randomized for posterior graft type only, and received either MSC+allograft (the tissue-engineered product, group A) or AICBG (standard graft material, group B). Standard graft material was used for anterior fusion in all patients. Feasibility was measured primarily as the percentage of randomized patients who underwent surgery in each treatment group. Safety was assessed by analyzing treatment-emergent adverse events (AEs) for the full experimental phase and appraising their relationship to the experimental treatment. Outcome measures, both radiological and clinical, were compared between the groups. RESULTS: Seventy-three patients were randomized in this study, 36 from the MSC+allograft group and 37 from the AICBG group, and 65 were surgically treated (31 group A, 34 group B). Demographic and comorbidity data showed no difference between groups. Most patients were diagnosed with grade I or II degenerative spondylolisthesis. MSC+allograft was successfully implanted in 86.1% of randomized group A patients. Most patients suffered treatment-emergent AEs during the study (88.2% in group A and 97.1% in group B), none related to the experimental treatment. X-ray-based rates of posterior spinal fusion were significantly higher for the experimental group at 6 months (p=.012) and 12 months (p=.0003). CT-based posterior fusion rates were significantly higher for MSC+allograft at 6 months (92.3% vs 45.7%; p=.0001) and higher, but not significantly, at 12 months (76.5% vs 65.7%; p=.073). CT-based complete response (defined as the presence of both posterior intertransverse fusion and anterior interbody fusion) was significantly higher at 6 months for MSC+allograft than for AICBG (70.6% vs 40%; p=.0038), and remained so at 12 months (70.6% vs 51.4%; p=.023). Clinical results including patient-reported outcomes improved postsurgery, although there were no differences between groups. CONCLUSIONS: Compared with the current gold standard, our experimental treatment achieved a higher rate of posterior spinal fusion and radiographic complete response to treatment at 6 and 12 months after surgery. The treatment clearly improved patient quality of life and decreased pain and disability at rates similar to those for the control arm. The safety profile of the tissue-engineered product was also similar to that for the standard material, and no AEs were linked to the product. Procedural AEs did not increase as a result of BM aspiration. The use of expanded bone marrow MSCs combined with cancellous allograft is a feasible and effective technique for spinal fusion, with no product-related AEs found in our study.

Dirección general salud ambiental y epidemiología / General address environmental health and epidemilogy

El documento es el informe de los diferentes programas de la Dirección General Salud Ambiental y Epidemiología del Ministerio de Salud de Nicaragua. Aborda los logros, avances, fortalezas, los proyectos de capacitación de los recursos humanos en epidemiología. También incluye la mision y objetivos de la Dirección de Enfermedades Transmisibles; la Dirección de salud ambiental; Dirección de Inmunizaciones; Dirección de Emergencia en Desastres. Al final incluye algunos logros de la dirección correspondiente al año 1997-2001

Obtención, purificación y caracterización de dos formas de hormona luteinizante de la adenohipófisis caprina (gLH) / Obtention, purification and characterization of two forms of caprine luteinizing hormone from adenohypophsis (gLH)

Se describe la obtención, purificación y caracterización de dos proteínas hipofisiarias de origen caprino con carga eléctrica diferente y con características de hormona luteinizante (LH). La fracción no retenida en la cromatografía de intercambio catiónico (CM-celulosa) designada CM-lab y la correspondiente al segundo pico de dicha cromatografía (CM-2ab), se repurificaron en una cromatografía de intercambio aniónico (DEAE-celulosa) en condiciones idénticas, para obtener LH-I (CM-lab-DEAE-la) con un rendimiento de 76 mg/kg de adenohipófisis, y a la LH-II (CM2ab-DEAE-lb) con 15 mg/kg. La diferencia de carga de cada proteína se determinó por su movilidad relativa (Rf) mediante una electroforesis en geles de poliacrilamida (PAGE) en condiciones nativas. La LH-I mostró un Rf de 0.09 (banda mayoritaria) y 0.415, mientras la LH-II presentó 2 bandas de tipo catiónico con un Rf de 0.14, 0.19 (banda mayoritaria). La determinación del peso molecular relativo de LH-I y LH-II, se llevo a cabo por medio de una electroforesis en geles de poliacilamida-dodecilsulfato de sodio (SDS-PAGE). En condiciones no reductoras (NR), ambas proteínas presentaron un peso molecular relativo de 36.5 kilodaltones (KDa) correspondiente a la forma monomérica, semejante a los estándares NIDDK-oLH-26 y USDA-bLH5, mientras que en presencia de 2ß-mercaptoetanol (condiciones reducidas), las proteínas presentaron un peso molecular de 22.4 y 20.2 KDa. El análisis por inmunotransferencia (Western-blot) en condiciones NR utilizando el anti-oLH (CSU-204), permitió identificar bandas inmunorreactivas de peso molecular de 50,43, 36.5 (mayoritaria), y 22.4 KDa, tanto en los estándares como en las fracciones obtenidas en este estudio. La potencia biológica realizada en un bioensayo in vivo 3 + 3 balanceado fue de 1.03 UI/mg para la LH-I. y de 0.65 UI/mg para la LH-II con intervalos de confianza de 95 por ciento. Su actividad inmunológica se determinó con un radioinmunoensayo (RIA) homólogo de LH caprina, a la dosis esperada del 50 por ciento (ED 50). Los resultados fueron de 1.7 ng/ml y 3.5 ng/ml para LH-I y LH-II respectivamante. Se concluye que esta técnica permite la obtención de dos proteínas con carga eléctrica diferente, con actividad biológica e inmunológica de LH, y con peso molecular idéntico

Guía para el tratamiento de la rabia en el hombre

[Prólogo] La edición de la "Guía para el Tratamiento de la Rabia en el Hombre" que realiza INPPAZ recoge las observaciones que sobre una versión anterior fueron hechas por sus numerosos lectores y está destinada fundamentalmente a quienes tienen la responsabilidad de brindar atención médica en los servicios de salud y a servir como material de apoyo a las actividades de docencia y capacitación.

Malaria y movimientos de población en la Region IV / Malaria and people dislocation in IV Region

La IV Región del país presenta una evolución epidemiológica favorable, aproximándose rápidamente a un estadio de consolidación del Programa A.C.E.M. Sin embargo el Movimiento Poblacional ha incrementado los casos de origen importados. El presente estudio permite conocer el peso relativo que dicho fenómeno tiene en la Epidemiología de la Malaria en la Región, después de practicarse una revisión a todas las Historias Epidemiológicas registradas en el 1er. Semestre del año 1984 en la Oficina de Estadística Regional del Programa A.C.E.M., se encontró que el peso fundamental como origen del Movimiento Poblacional está determinado por las necesidades de la Defesa Nacional ante la Agresión externa. Se describen los casoso según origen autóctonos e importados y según variables de edad, sexo, residencia y el lugar del país en que se adquirió la infección. Se recomienda finalmente fortalecer las actividades de vigilancia epidemiológica, controles de foco y la coordinación estrecha con los Servicios Médicos del Ejército Popular Sandinista para impedir la introducción a la Región de Malaria por los combatientes

Epidemiología de la rabia en Nicaragua

Estudio descriptivo de la epidemiología de la rabia, a fin de contribuir en la restructuración de estrategias y toma de decisiones para el control de la rabia en el país; durante el período 1967-1983 se obtuvo información de fuentes secundarias. Se encontró que anualmente se registraron un promedio de 160 animales rabiosos de los que 140 son perros, 7 gatos, 6 bovinos y algunos de vida salvaje. Los animales mordedores predominantes son el perro y el vampiro. La mortalidad humana más frecuente fue en niños y en el sexo masculino. Las actividades de control de la rabia canina se han realizado hasta porcentajes de cobertura muy inferior a lo recomendado por los expertos de la OMS, y lo referido en las normas; los años 1980 y 1983 han sido los que registran los mejores porcentajes de vacunación con el apoyo de organizaciones de masas. En 5 de 16 muertes del período 1979-1983 se conoció que acudieron a los Centros de Salud, después de haber sido mordidos por perros rabiosos y en el 100 porciento se dió mal manejo a los mismos, los restantes 11 de 16 se registraron; conociéndose el problema hasta que apareció el cuadro clínico de la enfermedad.