Cognitive and motor improvement by tummy time practice in preemies from low-income settings: a randomized clinical trial.

Introduction: Early intervention and parental education for preemies are limited in some low-income countries. Thus, this study aimed to assess whether daily tummy time (TT) associated with usual care (UC) enhances motor and cognitive development in preemies from low-income countries. The main and secondary aim was to assess prone head elevation (PHE) and motor and cognitive functions, respectively. Methods: Thirty-one preemies with a mean gestational age at birth of 33.3 ± 1.6 weeks and weighing <2,500 g were included and 18 completed all assessments. Parents from the TT group were asked to perform TT with their preemies for at least 20 min during daily activities and playtime. Motor and cognitive functions were assessed by a blinded examiner using the motor and cognitive composite scores of Bayley-III after two and four months of corrected age. PHE was given by the angle from the tragus of the ear to the supporting surface of the infant; measurements were obtained using the Kinovea® software at baseline, after two, three, and four months of corrected age. Results: The Bayley-III motor composite score of the TT group was higher than the UC group after two and four months of corrected age. The PHE angle increased over time but did not differ between groups. Discussion: Nevertheless, TT expanded the perspective of preemies to explore their bodies and environment, favoring the stimuli for motor and cognitive patterns. The loss of participants (31%) was one of the limitations of the study, illustrating the challenge of providing continued early interventions to preemies from low-income countries. In this sense, TT practice is a home intervention that may improve motor and cognitive function of preemies immediately after hospital discharge.

Development of Automated Triggers in Ambulatory Settings in Brazil: Protocol for a Machine Learning-Based Design Thinking Study.

BACKGROUND: The use of technologies has had a significant impact on patient safety and the quality of care and has increased globally. In the literature, it has been reported that people die annually due to adverse events (AEs), and various methods exist for investigating and measuring AEs. However, some methods have a limited scope, data extraction, and the need for data standardization. In Brazil, there are few studies on the application of trigger tools, and this study is the first to create automated triggers in ambulatory care. OBJECTIVE: This study aims to develop a machine learning (ML)-based automated trigger for outpatient health care settings in Brazil. METHODS: A mixed methods research will be conducted within a design thinking framework and the principles will be applied in creating the automated triggers, following the stages of (1) empathize and define the problem, involving observations and inquiries to comprehend both the user and the challenge at hand; (2) ideation, where various solutions to the problem are generated; (3) prototyping, involving the construction of a minimal representation of the best solutions; (4) testing, where user feedback is obtained to refine the solution; and (5) implementation, where the refined solution is tested, changes are assessed, and scaling is considered. Furthermore, ML methods will be adopted to develop automated triggers, tailored to the local context in collaboration with an expert in the field. RESULTS: This protocol describes a research study in its preliminary stages, prior to any data gathering and analysis. The study was approved by the members of the organizations within the institution in January 2024 and by the ethics board of the University of São Paulo and the institution where the study will take place. in May 2024. As of June 2024, stage 1 commenced with data gathering for qualitative research. A separate paper focused on explaining the method of ML will be considered after the outcomes of stages 1 and 2 in this study. CONCLUSIONS: After the development of automated triggers in the outpatient setting, it will be possible to prevent and identify potential risks of AEs more promptly, providing valuable information. This technological innovation not only promotes advances in clinical practice but also contributes to the dissemination of techniques and knowledge related to patient safety. Additionally, health care professionals can adopt evidence-based preventive measures, reducing costs associated with AEs and hospital readmissions, enhancing productivity in outpatient care, and contributing to the safety, quality, and effectiveness of care provided. Additionally, in the future, if the outcome is successful, there is the potential to apply it in all units, as planned by the institutional organization. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55466.

Estimating time-varying cholera transmission and oral cholera vaccine effectiveness in Haiti and Cameroon, 2021-2023.

In 2023, cholera affected approximately 1 million people and caused more than 5000 deaths globally, predominantly in low-income and conflict settings. In recent years, the number of new cholera outbreaks has grown rapidly. Further, ongoing cholera outbreaks have been exacerbated by conflict, climate change, and poor infrastructure, resulting in prolonged crises. As a result, the demand for treatment and intervention is quickly outpacing existing resource availability. Prior to improved water and sanitation systems, cholera, a disease primarily transmitted via contaminated water sources, also routinely ravaged high-income countries. Crumbling infrastructure and climate change are now putting new locations at risk - even in high-income countries. Thus, understanding the transmission and prevention of cholera is critical. Combating cholera requires multiple interventions, the two most common being behavioral education and water treatment. Two-dose oral cholera vaccination (OCV) is often used as a complement to these interventions. Due to limited supply, countries have recently switched to single-dose vaccines (OCV1). One challenge lies in understanding where to allocate OCV1 in a timely manner, especially in settings lacking well-resourced public health surveillance systems. As cholera occurs and propagates in such locations, timely, accurate, and openly accessible outbreak data are typically inaccessible for disease modeling and subsequent decision-making. In this study, we demonstrated the value of open-access data to rapidly estimate cholera transmission and vaccine effectiveness. Specifically, we obtained non-machine readable (NMR) epidemic curves for recent cholera outbreaks in two countries, Haiti and Cameroon, from figures published in situation and disease outbreak news reports. We used computational digitization techniques to derive weekly counts of cholera cases, resulting in nominal differences when compared against the reported cumulative case counts (i.e., a relative error rate of 5.67% in Haiti and 0.54% in Cameroon). Given these digitized time series, we leveraged EpiEstim-an open-source modeling platform-to derive rapid estimates of time-varying disease transmission via the effective reproduction number ( R t ). To compare OCV1 effectiveness in the two considered countries, we additionally used VaxEstim, a recent extension of EpiEstim that facilitates the estimation of vaccine effectiveness via the relation among three inputs: the basic reproduction number ( R 0 ), R t , and vaccine coverage. Here, with Haiti and Cameroon as case studies, we demonstrated the first implementation of VaxEstim in low-resource settings. Importantly, we are the first to use VaxEstim with digitized data rather than traditional epidemic surveillance data. In the initial phase of the outbreak, weekly rolling average estimates of R t were elevated in both countries: 2.60 in Haiti [95% credible interval: 2.42-2.79] and 1.90 in Cameroon [1.14-2.95]. These values are largely consistent with previous estimates of R 0 in Haiti, where average values have ranged from 1.06 to 3.72, and in Cameroon, where average values have ranged from 1.10 to 3.50. In both Haiti and Cameroon, this initial period of high transmission preceded a longer period during which R t oscillated around the critical threshold of 1. Our results derived from VaxEstim suggest that Haiti had higher OCV1 effectiveness than Cameroon (75.32% effective [54.00-86.39%] vs. 54.88% [18.94-84.90%]). These estimates of OCV1 effectiveness are generally aligned with those derived from field studies conducted in other countries. Thus, our case study reinforces the validity of VaxEstim as an alternative to costly, time-consuming field studies of OCV1 effectiveness. Indeed, prior work in South Sudan, Bangladesh, and the Democratic Republic of the Congo reported OCV1 effectiveness ranging from approximately 40% to 80%. This work underscores the value of combining NMR sources of outbreak case data with computational techniques and the utility of VaxEstim for rapid, inexpensive estimation of vaccine effectiveness in data-poor outbreak settings.

An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review.

The relation between surgery and anesthesia safety in children and a country's Human Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001‒2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700‒0.799, medium-HDI countries: 0.550‒0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15‒36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III‒V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children.

Junk food use and neurodevelopmental and growth outcomes in infants in low-resource settings.

Introduction: Feeding infants a sub-optimal diet deprives them of critical nutrients for their physical and cognitive development. The objective of this study is to describe the intake of foods of low nutritional value (junk foods) and identify the association with growth and developmental outcomes in infants up to 18 months in low-resource settings. Methods: This is a secondary analysis of data from an iron-rich complementary foods (meat versus fortified cereal) randomized clinical trial on nutrition conducted in low-resource settings in four low- and middle-income countries (Democratic Republic of the Congo, Guatemala, Pakistan, and Zambia). Mothers in both study arms received nutritional messages on the importance of exclusive breastfeeding up to 6 months with continued breastfeeding up to at least 12 months. This study was designed to identify the socio-demographic predictors of feeding infants' complementary foods of low nutritional value (junk foods) and to assess the associations between prevalence of junk food use with neurodevelopment (assessed with the Bayley Scales of Infant Development II) and growth at 18 months. Results: 1,231 infants were enrolled, and 1,062 (86%) completed the study. Junk food feeding was more common in Guatemala, Pakistan, and Zambia than in the Democratic Republic of Congo. 7% of the infants were fed junk foods at 6 months which increased to 70% at 12 months. Non-exclusive breastfeeding at 6 months, higher maternal body mass index, more years of maternal and paternal education, and higher socioeconomic status were associated with feeding junk food. Prevalence of junk foods use was not associated with adverse neurodevelopmental or growth outcomes. Conclusion: The frequency of consumption of junk food was high in these low-resource settings but was not associated with adverse neurodevelopment or growth over the study period.

Continuing Professional Development at Two Rural Hospitals in Ecuador.

Background: E-learning Continuing Professional Development (CPD) is an activity demonstrated to improve the quality of healthcare delivery. The CPD of medical and nursing staff in high income countries (HICs) is commonplace. CPD of administrative staff is less common, but increasingly frequent. In low- and middle-income countries (LMICs), CPD of any kind is infrequent, particularly in rural and remote areas. Objective: The aim of this study was to describe a hospital-based e-learning CPD program for clinical and non-clinical personnel as a unique example of a successful, ongoing educational pilot, quality improvement program involving a broad cohort of employees, in a country that does not require such activities. Methods: Using the online educational platform Chamilo, e-learning modules were created for eight groups including clinical and non-clinical employees. Upon completion of each module, one to two paragraph discussions were provided for each incorrect answer submitted. Two additional chances were offered for the employee to achieve a passing score of 70%. This study reports on the first 10-month period of the program. Findings: All participants achieved the 70% passing threshold after the first or second attempt. There was 100% participation by the employees required to complete the e-learning modules. Employee feedback suggested the modules were good for continuing education, but some felt the CPD was imposed on them. Conclusion: E-learning CPD is an important and emerging element for CPD and may provide opportunities for healthcare service quality improvement as part of broader pedagogical modalities, such as conferences and directed readings, in rural and remote areas of LMICs. These pilot programs could provide important information to develop Spanish-language e-learning CPD programs across a broader region, promote collaboration with regional professional societies, and possibly contribute to the establishment of national health program CPD standards.

Maternal and perinatal health among pregnant patients in the context of a migratory crisis.

OBJECTIVE: To compare maternal and perinatal outcomes of migrant Venezuelan women with local pregnant patients in a Colombian institution in the context of a migratory crisis. STUDY DESIGN: This cross-sectional study included 11 304 deliveries from the Clínica de Maternidad Rafael Calvo in Cartagena de Indias, Colombia, a tertiary referral center on the north coast of Colombia. Data on maternal demographics and perinatal outcomes were obtained by chart review. RESULTS: In total, 595 patients were identified as Venezuelan migrants, and their perinatal outcomes were compared against those of 10 709 local pregnant patients. Despite similar baseline maternal conditions in both groups, poorer prenatal follow-up care (3 [1-5] vs. 5 [4-7] visits; P < 0.001) and severe complications were more common in Venezuelan migrant pregnant patients and their children. In addition, maternal hypertension was significantly more common in migrants (11.4% [68/595] vs. 8.3% [887/10709]; P = 0.009). Furthermore, in the group of pregnant migrant patients, the rates of severe maternal morbidity (13.4% [80/575] vs. 9.45%, [1013/10709]; P = 0.002), neonatal respiratory distress syndrome (22/595 [3.7%] vs. 237/10709 [2.23%]; P = 0.03), and perinatal mortality (11/586 [1.88%] vs. 67/10651 [0.63%]; P = 0.003) were significantly higher than in the local pregnant population. CONCLUSION: Forced migration during pregnancy may be associated with poorer prenatal care, which may predispose women and their newborns to more frequent adverse maternal and perinatal outcomes.

Association of development quotient with nutritional status of vitamins B6, B12, and folate in 6-59-month-old children: Results from the Brazilian National Survey on Child Nutrition (ENANI-2019).

BACKGROUND: Vitamins B6, B12, and folate are essential for the formation and maintenance of the human brain, but studies evaluating these vitamins with early childhood development (ECD) in children under 5 y are limited and controversial. OBJECTIVES: To evaluate the association between vitamins B6, B12, and folate concentrations/status and ECD. METHODS: Data regarding 6520 children aged 6-59 mo from the ENANI-2019 (the Brazilian National Survey on Child Nutrition) were analyzed. ECD was assessed using the Survey of Well-being of Young Children's milestones questionnaire. Vitamin B6 concentration (nmol/L) was classified according to the tertile of the distribution and with the cutoff <20 nmol/L. Folate concentrations >45.3 nmol/L were classified as high, and vitamin B12 <150 pmol/L was deficient. The graded response model was used to estimate developmental age, and the developmental quotient (DQ) was calculated as the developmental age divided by chronological age. Multiple linear regression models were adjusted for confounders. RESULTS: The DQ mean (95% confidence interval) for Brazilian children was 0.99 (0.97-1.01). Children aged 6-23 mo [1.13 (1.10-1.16)] had a higher DQ mean than those aged 24-35 [0.99 (0.95-1.03)] and 36-59 mo [0.89 (0.86-0.92)]. Child age was inversely associated with DQ (ß = -0.007; P < 0.001). An interaction between child age and vitamin B12 deficiency in the DQ (ß = -0.005; P < 0.001) indicated that, in children aged 36-59 mo, the DQ was markedly lower in children with vitamin B12 deficiency than in those without vitamin B12 deficiency. Vitamin B6 concentrations were directly associated with the DQ (ß = 0.0004; P = 0.031) among children aged 24-59 mo in the adjusted model. No association was observed between folate status and DQ. CONCLUSIONS: In Brazil, the DQ is lower among older children and those with vitamin B12 deficiency. Vitamin B6 status was directly associated with the DQ in children aged 24-59 mo.

How should childhood acute lymphoblastic leukemia relapses in low-income and middle-income countries be managed: The AHOPCA-ALL study group experience.

BACKGROUND: Children with relapsed acute lymphoblastic leukemia (ALL) in low-income and middle-income countries rarely survive. The Pediatric Hematology-Oncology Association of Central America (AHOPCA) developed the AHOPCA-ALL REC 2014 protocol to improve outcomes in resource-constrained settings without access to stem cell transplantation. METHODS: The AHOPCA-ALL REC 2014 protocol was based on a modified frontline induction phase 1A, a consolidation therapy with six modified R-blocks derived from the ALL-Berlin-Frankfurt-Munster REZ 2002 protocol and intermittent maintenance therapy. Children with B-lineage ALL were eligible after a late medullary relapse, an early or late combined relapse, or any extramedullary relapses. Those with T-lineage ALL were eligible after early and late extramedullary relapses, as were those with both B-lineage and T-lineage relapses occurring at least 3 months after therapy abandonment. RESULTS: The study population included 190 patients with T-lineage (n = 3) and B-lineage (n = 187) ALL. Of those with B-lineage ALL, 25 patients had a very early extramedullary relapse, 40 had an early relapse (32 extramedullary and 8 combined), and 125 had a late relapse (34 extramedullary, 19 combined, and 72 medullary). The main cause of treatment failure was second relapse (52.1%). The 3-year event-free survival rate (± standard error) was 25.9% ± 3.5%, and the 3-year overall survival rate was 36.7% ± 3.8%. The 3-year event-free survival rate was 47.2% ± 4.7% for late relapses. The most frequently reported toxicity was grade 3 or 4 infection. Mortality during treatment occurred in 17 patients (8.9%), in most cases because of infectious complications. CONCLUSIONS: Selected children with relapsed ALL in Central America can be cured with second-line regimens even without access to consolidation with stem cell transplantation. Children in low-income and middle-income countries who have lower risk relapses of ALL should be treated with curative intent.

[Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean]. / Abordaje terapéutico integral de la hipertensión arterial. Recomendaciones para Centroamérica y el Caribe.

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area.

Relevance of Fluorodopa PET Scan in Dopamine Responsive Dystonia and Juvenile Parkinsonism: A Systematic Review.

BACKGROUND: Dopamine Responsive Dystonia (DRD) and Juvenile Parkinsonism (JP) are two diseases commonly presenting with parkinsonian symptoms in young patients. Current clinical guidelines offer a diagnostic approach based on molecular analysis. However, developing countries have limitations in terms of accessibility to these tests. We aimed to assess the utility of imaging equipment, usually more available worldwide, to help diagnose and improve patients' quality of life with these diseases. METHODS: We performed a systematic literature review in English using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and meta-analysis of observational studies in epidemiology (MOOSE) protocols. We only used human clinical trials about dopamine responsive dystonia and juvenile parkinsonism patients in which a fluorodopa (FD) positron emission tomography (PET) scan was performed to identify its use in these diseases. RESULTS: We included six studies that fulfilled our criteria. We found a clear pattern of decreased uptake in the putamen and caudate nucleus in JP cases. At the same time, the results in DRD were comparable to normal subjects, with only a slightly decreased marker uptake in the previously mentioned regions by the FD PET scan. CONCLUSIONS: We found a distinctive pattern for each of these diseases. Identifying these findings with FD PET scans can shorten the delay in making a definitive diagnosis when genetic testing is unavailable, a common scenario in developing countries.

Assessing Barriers Encountered by Women in Cervical Cancer Screening and Follow-Up Care in Urban Bolivia, Cochabamba.

BACKGROUND: Timely detection of cervical cells infected with high-risk human papillomavirus (HPV) improves cervical cancer prevention. In Bolivia, actual screening coverage only reaches 33.3% of the target population aged between 25 and 64 years despite free cytology screening. Furthermore, 50% to 80% screened women are lost during follow-up. This study aimed at identifying factors explaining this lack of follow-up care. METHOD: During the first phase, face-to-face semi-structured interviews were conducted with HPV-positive women. Secondly, we explored the reasons for the non-adherence to the follow-up care: knowledge, perceptions and beliefs about HPV, as well as barriers to healthcare access, using a structured survey on Cochabamba women and healthcare professionals. RESULTS: Barriers to effective follow-up of the targeted populations were associated with health system shortcomings, including poor service delivery at the front- and second-line, health providers shortage, inadequate training, waiting time, high direct and indirect costs of care seeking and care, complex procedures to obtain HPV screening results and poor patient-provider communication. The follow-up was perceived as extremely stressful by the participants. CONCLUSION: Improved communication on HPV and HPV-related cancers in terms of representation in the general population and among the health professional's population is vital to improve access for HPV infection follow-up care.

Autism Spectrum Disorder Diagnoses: A Comparison of Countries with Different Income Levels.

Purpose: This study aimed to assess whether high-income countries have a lower mean age at the time of diagnosis of autism spectrum disorder (ASD) than low- and middle-income countries. Method: We reviewed studies related to ASD diagnoses and the time of first concerns in low-, middle-, and high-income countries, published in PubMed, SciELO, Lilacs, and ScienceDirect. Thirty articles were included: 13 from low- and middle-income countries and 17 from high-income countries. Results: The average delay between initial concerns and diagnosis was 32.33 months, with initial concerns averaging 23.64 months and diagnosis at 55.97 months. No statistical differences were found between countries with low-, middle-, and high-income. Conclusions: This review found a considerable delay in ASD diagnosis despite an early presence of recognized signs and symptoms. It highlights the urgent need for standardized tools for early ASD diagnosis.

Using EmPalPed-An Educational Toolkit on Essential Messages in Palliative Care and Pain Management in Children-As a Strategy to Promote Pediatric Palliative Care.

Background: Most children needing palliative care (PC) live in low- and middle-income countries. In Colombia, pediatric palliative care (PPC) knowledge among healthcare professionals (HCPs) is lacking as PPC is not included in the educational curricula of healthcare programs. Therefore, specific training that improves knowledge of HCPs and access to PC for children and their families is needed. To address this gap, we organized and conducted the Essential Messages in Palliative Care and Pain Management in Children (EmPalPed), an educational toolkit to increase awareness and promote essential knowledge in PPC for low- and middle-income countries. Methodology: The EmPalPed toolkit consisted of a 5-h virtual workshop with small working groups of HCPs caring for children with life-threatening conditions such as cancer. The toolkit was organized along five key domains: (1) PC as it relates to the concept of quality of life (QoL), (2) effective communication, (3) addressing pain management as a top priority, (4) providing end-of-life care, and (5) access to high-quality PC as a fundamental human right. The workshop activities included different educational strategies and tools (e.g., a pocket guide for pain assessment and management, a PPC booklet, a quick guide for communicating bad news, role playing, and discussions of clinical cases). Results: A total of 145 HCPs from 22 centers were trained. The post-test analysis for HCPs showed that attitude and knowledge about communication (p < 0.001), pain assessment (p < 0.001), first-line opioid of choice in children (p < 0.001), and palliative sedation (p < 0.001) had positive and statistically significant changes from the pre-test analysis. Discussion: This study supported the notion that the EmPalPed educational toolkit is an effective mechanism for raising awareness regarding PPC as well as providing training in many of the key aspects of PPC. The EmPalPed training approach should be studied beyond this setting, and the impact should be measured longitudinally.

Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua.

BACKGROUND: The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery. METHODS: We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother's locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women's characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country. RESULTS: Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (ß = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (ß = - 0.130, 95% CI -0.23, - 0.03) more than in the comparison group. CONCLUSIONS: Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities' capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.

Breast Cancer in Jamaica: Stage, Grade and Molecular Subtype Distributions Across Age Blocks, the Implications for Screening and Treatment.

BACKGROUND: Breast cancer is the most commonly diagnosed and leading cause of cancer-related morbidity and mortality in females worldwide. Significant disparities exist in breast cancer incidence and mortalities between low- to middle- and high-income countries. The purpose of this study was to analyze the distribution of prognostic and predictive clinicopathological features of invasive breast cancer at a single institution in Jamaica across three age groups. METHODS: Data from patients diagnosed with invasive breast cancer who underwent definitive surgery between August 2017 and September 2018 were identified. The patients were divided into three age groups (< 50, 50 - 59 and > 59 years) and the distribution of tumor size, grade, molecular subtype, nodal status and anatomic stage were determined and compared with the US population registry. Comparisons of the various characteristics were performed using the Fisher's exact test. RESULTS: Ninety-nine definitive operations were performed and met the criteria for analysis. Average age at the time of diagnosis was 54 years compared to 62 years reported in the US databases. Thirty-six percent of the patients presented below age 50 years, which was twice the corresponding rate reported for Caucasian females (18%) in the USA. Fifty percent of patients in our registry had axillary lymph node metastases at presentation and they were younger than patients with negative axillary nodes (95% confidence interval (CI) -12.06 to -1.93, P = 0.007). Patients in the age group less than age 50 years were more likely to have advanced stage, high histological grade cancers compared to the older age blocks (95% CI 0.039 - 0.902, P = 0.033). CONCLUSION: Invasive breast cancer presents at an earlier age in Jamaican women and is associated with poor prognostic features such as high rates of axillary lymph node metastases, high histological grade, advanced stage, triple-negative subtypes and low luminal A subtypes.

A Bibliometric Analysis of Published Literature in Postoperative Pain in Elderly Patients in Low- and Middle-Income Countries.

Postoperative pain (POP) remains a major challenge for surgeons and anesthesiologists worldwide, especially in low- and middle-income countries. Elderly patients are at higher risk for undertreatment of pain. Despite that, there is a paucity of papers addressing POP among this population in developing countries. This study aimed to provide a bibliometric analysis of the literature concerning postoperative pain in elderly patients from low- and middle-income countries. It was performed an extensive search of papers on this subject through the Web of Science and Scopus database using a series of uniterms and, including publications from 2001 to 2021. Publication quality was assessed by using total citation frequency, average citations per item and other citation indexes. Citation indexes were low, with the highest reaching 15 citations. In conclusion, few studies of postoperative pain in the elderly in countries with medium and low income, indicating a need that has not yet been met for this population and in these areas of the world. The published studies were not specifically aimed at the elderly, had limited impact, low international visibility. They were not epidemiological studies and are not robust, weakening knowledge and decision-making towards policies directed at this vulnerable population.

Disparities in cystic fibrosis survival in Mexico: Impact of socioeconomic status.

BACKGROUND: Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin America, especially in Mexico. The aim of our study was to assess the median age of survival in CF patients and the impact of risk factors in Mexico over a 20-year period. METHODS: We conducted a retrospective study with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with Kaplan-Meier analysis. The influence of clinical, biological, and demographic factors on survival was analyzed with Cox regression model. RESULTS: Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% confidence interval [CI], 17.20-25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR], 4.21; 95% CI, 2.43-7.27), chronic Pseudomonas aeruginosa infection at 6 years (HR, 10.45; 95% CI, 5.66-19.28), and pancreatic insufficiency (HR, 3.13; 1.38-7.13) were independent risk factors for mortality. CONCLUSION: Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-middle income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.

Surface Electromyography in Clinical Practice. A Perspective From a Developing Country.

Surface electromyography (sEMG) has long been used in research, health care, and other fields such as ergonomics and brain-machine interfaces. In health care, sEMG has been employed to diagnose as well as to treat musculoskeletal disorders, pelvic floor dysfunction, and post-stroke motor deficits, among others. Despite the extensive literature on sEMG, the clinical community has not widely adopted it. We believe that in developing countries, such as Chile, this phenomenon may be explained by several interacting barriers. First, the socioeconomics of the country creates an environment where only high cost-effective treatments are routinely applied. Second, the majority of the sEMG literature on clinical applications has not extensively translated into decisive outcomes, which interferes with its applicability in low-income contexts. Third, clinical training on rehabilitation provides inadequate instruction on sEMG. And fourth, accessibility to equipment (i.e., affordability, availability, portability) may constitute another barrier, especially among developing countries. Here, we analyze socio-economic indicators of health care in Chile and comment on current literature about the use of sEMG in rehabilitation. Then we analyze the curricula of several physical therapy schools in Chile and report some estimations of the training on sEMG. Finally, we analyze the accessibility of some available sEMG devices and show that several match predefined criteria. We conclude that in developing countries, the insufficient use of sEMG in health might be explained by a shortage of evidence showing a crucial role in specific outcomes and the lack of training in rehabilitation-related careers, which interact with local socioeconomic factors that limit the application of these techniques.

Prevalence of Prefrailty and Frailty in South America: A Systematic Review of Observational Studies.

OBJECTIVES: The present study aimed at investigating the prevalence of prefrailty and frailty in South American older adults according to the setting and region. DESIGN: A literature search combining the terms "frailty", "South America" or a specific country name was performed on PubMed, EMBASE, Lilacs, and Scielo to retrieve articles published in English, Portuguese or Spanish on or before August 2019. PARTICIPANTS: Older adults aged 60+ years from any setting classified as frail according to a validated scale were included in the study. MEASUREMENTS: Frailty assessment by a validated scale. RESULTS: One-hundred eighteen reports (98 performed from Brazil, seven from Chile, five from Peru, four from Colombia, two from Ecuador, one from Argentina, and one from Venezuela) were included in the study. The mean prevalence of prefrailty in South America was 46.8% (50.7% in older in-patients, 47.6% in the community, and 29.8% in nursing-home residents). The mean prevalence of frailty in South America was 21.7% (55.8% in nursing-home residents, 39.1% in hospitalized older adults, and 23.0% in the community). CONCLUSIONS: Prefrailty and frailty are highly prevalent in South American older adults, with rates higher than those reported in Europe and Asia. In the community, almost one-in-two is prefrail and one-in-five is frail, while hospitalized persons and nursing-home residents are more frequently affected. These findings indicate the need for immediate attention to avoid frailty progression toward negative health outcomes. Our findings also highlight the need for specific guidelines for the management of frailty in South America.