Characterization and Implementation of Cocoa Pod Husk as a Reinforcing Agent to Obtain Thermoplastic Starches and Bio-Based Composite Materials.

When the cocoa pod husk (CPH) is used and processed, two types of flour were obtained and can be differentiated by particle size, fine flour (FFCH), and coarse flour (CFCH) and can be used as a possible reinforcement for the development of bio-based composite materials. Each flour was obtained from chopping, drying by forced convection, milling by blades, and sieving using the 100 mesh/bottom according to the Tyler series. Their physicochemical, thermal, and structural characterization made it possible to identify the lower presence of lignin and higher proportions of cellulose and pectin in FFCH. Based on the properties identified in FFCH, it was included in the processing of thermoplastic starch (TPS) from the plantain pulp (Musa paradisiaca) and its respective bio-based composite material using plantain peel short fiber (PPSF) as a reinforcing agent using the following sequence of processing techniques: extrusion, internal mixing, and compression molding. The influence of FFCH contributed to the increase in ultimate tensile strength (7.59 MPa) and higher matrix-reinforcement interaction when obtaining the freshly processed composite material (day 0) when compared to the bio-based composite material with higher FCP content (30%) in the absence of FFCH. As for the disadvantages of FFCH, reduced thermal stability (323.57 to 300.47 °C) and losses in ultimate tensile strength (0.73 MPa) and modulus of elasticity (142.53 to 26.17 MPa) during storage progress were identified. In the case of TPS, the strengthening action of FFCH was not evident. Finally, the use of CFCH was not considered for the elaboration of the bio-based composite material because it reached a higher lignin content than FFCH, which was expected to decrease its affinity with the TPS matrix, resulting in lower mechanical properties in the material.

A simple assay for measuring tannin-protein precipitation capacity offers insights into the diet and food choice of black howler monkeys (Alouatta pigra).

Phenolics, like tannins, are plant-specialized metabolites that play a protective role against herbivory. Tannins can reduce palatability and bind with proteins to reduce digestibility, acting as deterrents to feeding and impacting nutrient extraction by herbivores. Some assays measure tannin and total phenolics content in plants but lack determination of their biological effects, hindering the interpretation of tannin function in herbivory and its impacts on animal behavior and ecology. In this study, we successfully applied the radial diffusion assay to assess tannin protein precipitation (PP) capacity and evaluate the anti-nutritional effects of tannins in food plants (n = 24) consumed by free-ranging black howler monkeys (Alouatta pigra) in Tabasco, Mexico. We found PP rings in five plant species consumed by the monkeys. The mature fruit of Inga edulis was the most consumed food plant, despite having a high tannin PP capacity (56.66 mg tannic acid equivalent/g dry matter). These findings highlight the presence of tannins in the black howler diet and provide insight into the primates' resilience and potential strategies for coping with anti-nutritional aspects of the diet.

Polymerase Chain Reaction (PCR) is a Useful and Low-Cost Tool for Molecular Sexing Psittaciformes under Human Care: An Example of a Collaborative Approach in Mexico.

Sex determination in monomorphic birds is a precondition for captive breeding programs and management and conservation strategies for threatened species. Most species of the order Psittaciformes often present complications since these birds lack external sexual phenotypic traits, making it impossible to differentiate males and females. In the present study, we used molecular techniques to determine the sex of 31 individuals belonging to nine species of the order Psittaciformes kept under human care at the Akumal Monkey Sanctuary & Rescued Animals in Quintana Roo, Mexico. This is a useful and low-cost methodology based on the analysis of the conserved region of the CHD1 gene, which was amplified by PCR with two sets of primers: P8/P2 and 2550F/2718 R. All individuals were successfully sexed with the first set of primers, while only 28 out of 31 samples (90%) could be amplified with the second set. Out of the 31 individuals analyzed, fifteen are female, and seventeen are male. This information represents a handy tool for adequately managing birds under human care, resulting in their reproduction and eventual reintegration into their natural habitat.

A 4-gene prognostic index for enhancing acute myeloid leukaemia survival prediction.

Despite advancements in utilizing genetic markers to enhance acute myeloid leukaemia (AML) outcome prediction, significant disease heterogeneity persists, hindering clinical management. To refine survival predictions, we assessed the transcriptome of non-acute promyelocytic leukaemia chemotherapy-treated AML patients from five cohorts (n = 975). This led to the identification of a 4-gene prognostic index (4-PI) comprising CYP2E1, DHCR7, IL2RA and SQLE. The 4-PI effectively stratified patients into risk categories, with the high 4-PI group exhibiting TP53 mutations and cholesterol biosynthesis signatures. Single-cell RNA sequencing revealed enrichment for leukaemia stem cell signatures in high 4-PI cells. Validation across three cohorts (n = 671), including one with childhood AML, demonstrated the reproducibility and clinical utility of the 4-PI, even using cost-effective techniques like real-time quantitative polymerase chain reaction. Comparative analysis with 56 established prognostic indexes revealed the superior performance of the 4-PI, highlighting its potential to enhance AML risk stratification. Finally, the 4-PI demonstrated to be potential marker to reclassified patients from the intermediate ELN2017 category to the adverse category. In conclusion, the 4-PI emerges as a robust and straightforward prognostic tool to improve survival prediction in AML patients.

Folate induces stemness and increases oxygen consumption under glucose deprivation by notch-1 pathway activation in colorectal cancer cell.

Evidence for folate's protective effects on neural tube defects led the USA and Chile to start mandatory folic acid (FA) fortification programs, decreasing up to 50%. However, ∼30% of the population consuming fortified foods reach supraphysiologic serum levels. Although controversial, several epidemiological and clinical observations suggest that folate increases cancer risk, giving concern about the risks of FA supplementation. The Cancer stem cells (CSCs) model has been used to explain survival to anticancer therapies. The Notch-1 pathway plays a role in several cancers and is associated with the stemness process. Different studies show that modulation of metabolic pathways regulates stemness capacity in cancer. Supraphysiologic concentrations of FA increase the proliferation of HT-29 cells by Notch-1 activation. However, whether folate can induce a stemness-like phenotype in cancer is not known. We hypothesized that FA protects from glucose deprivation-induced cell death through Notch-1 activation. HT-29 cells were challenged with glucose deprivation at basal (20 nM) and supraphysiological (400 nM) FA and 5-MTHF concentrations. We analyzed changes in stemness-like gene expression, cell death and different energetic metabolic functions. Supraphysiological concentrations of FA increased stemness-like genes, and improved survival and oxygen consumption, inducing AMPK phosphorylation and HSP-70 protein expression. We evaluated the Notch-1 pathway using the DAPT and siRNA as inhibitors, decreasing the stemness-like gene expression and preventing the FA protection against glucose deprivation-induced cell death. Moreover, they decreased oxygen consumption and AMPK phosphorylation. These results suggest that FA protects against glucose deprivation. These effects were associated with AMPK activation, a critical metabolic mediator in nutrient consumption and availability that activates the Notch-1 pathway.

Experiences and perceptions of people with celiac disease, food allergies and food intolerance when dining out.

Introduction: Eating out is a common practice in modern society. Celiac disease (CeD) and food allergy (FA) are among the most common conditions responsible for adverse reactions to food. Despite their different origins, both require treatment with restrictive diets (avoidance of gluten and/or specific allergens) and this results posing similar challenges when eating out. Our objective was to learn about the experiences/perceptions of consumers with CeD and FA when dining out, as well as the challenges they face in food service environments. Methods: An ad hoc questionnaire was used to record consumer perceptions, food service characteristics and resulting adverse reactions. Results: 377 individuals living in Santiago, Chile, provided complete information and were analyzed (160 CeD, 105 FA). 301 participants (79.8%) declared eating out, 33.6% reported experiencing an adverse reaction at least once while eating out. 94.4% of the 377 participants believed that the serving staff had little or no knowledge about his/her condition. Consumers reporting symptoms as severe adverse reactions were more common among celiac than allergic patients (p < 0.001). Discussion: The study showed no significant differences based on consumer-related characteristics (p:NS). The consequences of eating out did not vary based on individual's data, including diagnosis, age, frequency of eating out, adverse reactions experienced, or intensity. These findings suggest that the most important determinants of risk associated with eating out are characteristics of the food service, like availability of information, staff training, and establishment's facilities like equipment available, exclusive utensils for customers with special dietary needs and kitchen and bathrooms organization.

Funciones ejecutivas en pacientes con apnea obstructiva del sueño: explorando el modelo prefrontal / Executive functions in patients with obstructive sleep apnea: exploring the prefrontal model

Introducción El modelo prefrontal propone que los individuos con apnea obstructiva del sueño (AOS) manifiestan conductas similares a un síndrome disejecutivo como resultado de las alteraciones de gases en la sangre y la fragmentación del sueño. Objetivo Comparar las funciones ejecutivas en pacientes con AOS con valores normativos y explorar su relación con las alteraciones de gases en la sangre y la fragmentación del sueño. Pacientes y métodos Se reclutó a pacientes de la comunidad general y de un hospital de tercer nivel. La puntuación obtenida en la evaluación neuropsicológica se contrastó con la t de Student para una muestra. Posteriormente, se estimó un análisis de regresión lineal múltiple mediante parámetros polisomnográficos de hipercapnia, hipoxemia y fragmentación del sueño como variables predictoras, y la puntuación de funciones ejecutivas como variable que se debe predecir. Resultados Pese a que el desempeño en la evaluación neuropsicológica del 26% de esta muestra se clasificó como alteración ejecutiva, los indicadores de fragmentación del sueño y alteraciones de gases no predijeron el desempeño ejecutivo. Conclusión Una fracción de los pacientes con AOS mostró un desempeño similar a un síndrome disejecutivo; no obstante, permanecen indefinidos los factores que subyacen y favorecen este tipo de manifestaciones cognitivas. La atención temprana de este problema de salud pública podría ser la mejor herramienta disponible en aras de mejorar la calidad de vida y prevenir riesgos a la salud. (AU)

INTRODUCTION According to the prefrontal model, individuals with obstructive sleep apnea (OSA) manifest behaviours mimicking dysexecutive syndrome as a result of blood gas abnormalities and sleep fragmentation. OBJECTIVE. To compare executive functions in OSA patients with normative values and explore their relationship with blood gas abnormalities and sleep fragmentation. PATIENTS AND METHODS Patients were recruited from the wider community and from a tertiary care hospital. The score obtained in the neuropsychological assessment was compared with Student’s t-test for a sample. A multiple linear regression analysis was subsequently estimated, using polysomnographic parameters of hypercapnia, hypoxemia and sleep fragmentation as the predictor variables, and the executive function score as the variable to be predicted. RESULTS Although the neuropsychological assessment performance of 26% of this sample was classified as executive impairment, indicators of sleep fragmentation and gas abnormalities failed to predict the performance of executive functions. CONCLUSION. A proportion of the patients with OSA presented performance similar to a dysexecutive syndrome; however, the factors underlying and fostering this type of cognitive manifestation remain unclear. Early treatment for this public health problem could be the best tool available for improving quality of life and preventing health risks. (AU)

Use of the CONSIDER statement by eye health researchers when conducting and reporting research involving Indigenous peoples: an online survey.

BACKGROUND: Indigenous peoples experience worse eye health compared to non-Indigenous peoples. Service providers and researchers must avoid perpetuating this inequity. To help achieve this, researchers can use the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples (CONSIDER) statement. This study aimed to identify the degree to which the CONSIDER statement has been used by eye health researchers when conducting and reporting research with an Indigenous component, and how they perceive its relevance in their future research. METHODS: We used purposive sampling to recruit eye health researchers from any country who have undertaken research with an Indigenous component. The online survey collected quantitative and qualitative data and was analysed using descriptive statistics and reflexive thematic analysis. Responses were gathered on a four-point Likert scale (1 to 4), with four being the most positive statement. RESULTS: Thirty-nine eye health researchers from nine countries completed the survey (Aotearoa New Zealand, Argentina, Australia, Brazil, Canada, Colombia, Guatemala, Panama, Peru); almost two-thirds (n = 24) undertake epidemiological research. On average, participants disclosed only 'sometimes' previously reporting CONSIDER items (2.26 ± 1.14), but they thought the items were relevant to eye health research and were motivated to use these guidelines in their future research. Some participants requested clarity about how CONSIDER aligned with existing guidelines, and when and how to apply the statement. Others shared rich experiences of the benefits to their research of Indigenous leadership and collaboration. CONCLUSIONS: The CONSIDER statement is perceived as a valuable tool by these eye health researchers, and there are opportunities to maximise uptake and use, including increasing awareness of the statement, clarity about when it applies, and availability of institutional-level support.

Lead exposure and its relationship with fecal cortisol levels in black howler monkeys (Alouatta pigra).

Efficiently detecting early environmental threats to wildlife is vital for conservation. Beyond obvious dangers like habitat loss or deforestation, our study focuses on one of the most hazardous toxic metals for wildlife: lead (Pb). Pb is a widespread, cumulative, and insidious environmental pollutant that can trigger a wide range of physiological, biochemical, and behavioral disorders. In fact, Pb can cause permanent dysfunction of the major stress system, the hypothalamic pituitary adrenal (HPA) axis. We analyzed Pb and cortisol concentrations in fecal samples from Alouatta pigra in southern Mexico. Fecal samples were collected across six sites categorized as free-ranging (n = 65; conserved and disturbed) and from captive animals (n = 58). Additionally, we collected soil samples (n = 35). We found that Pb was present in 28% of fecal samples and 83% of soil samples. There was a positive relation between fecal and soil Pb levels, and fecal Pb concentration was negatively associated with cortisol levels. However, the claim of Pb being a direct interference with HPA axis requires further investigation. Given our findings, assessing wildlife exposure can be a valuable tool for understanding potential Pb exposure levels in the environment and its possible implications for human health. It can also serve as an early warning system of these consequences.

New Cap-Holed AlP, GaP, and InP Nanotubes.

The structural, vibrational, and electronic properties of new inorganic X-phosphide nanotubes (ch-XPNT), with X = Al, Ga, or In and chirality of (5,5), are investigated. These new NTs display cap-hole ends, with the cap-hole features induced by the nonpassivated ends. Studies are based on density functional theory (DFT) using the M06-2X, PBE, and B3LYP functionals together with the LanL2DZ basis set. All nanostructures have been relaxed by minimizing the total energy, assuming a nonmagnetic nature and a total neutral charge. Note that the cap-hole NTs are terminated by a 10-atom ring, which in turn favors the geometrical ordering and yields stable structures. The (5,5) ch-XPNT are highly electrophilic and nonpolar, in addition to having high solvation energy values. Let us remark that solvation energies are produced by the intermolecular forces that involve the induced dipoles. Structural and vibrational results show that the X-P bonds are single bonds. Finally, results suggest that the inorganic nanotubes are structurally stable with semiconductor features, which means that their functionalization may yield interesting future applications.

Malignant phyllodes tumor of the breast in ayoung patient ­ case report

Phyllodes tumor (PT) is an uncommon form of breast tumor. It occurs most commonly in women aged 35 to 65 years. The benign form represents about 85­90% of cases and only 10­15% of PTs are malignant. Clinically and radiologically, malignant phyllodes tumor (MPT) presents as regular, well-delimited, mobile nodules that are difficult to distinguish from fibroadenomas of the breast. The most important differential diagnoses of MPT include fibroadenoma, metaplastic carcinoma, and sarcoma. The prognosis of MPT exhibits a higher frequency of local recurrence and metastatic rate with larger tumors and inadequate surgical margins. The case presented here refers to a 24-year-old female patient, with a vast tumor in the right breast, with rapid and progressive growth, associated to local pain, and histological diagnosis of MPT. Surgery was the initial treatment, followed by adjuvant chemotherapy and radiotherapy. The purpose of this article was to report an atypical case of MPT of the breast in a very young woman as well as to make a brief literature review on this infrequent and dangerous disease. (AU)

Fitness costs in the presence and absence of insecticide use explains abundance of two common Aedes aegypti kdr resistance alleles found in the Americas.

Aedes aegypti is the vector of viruses such as chikungunya, dengue, yellow fever and Zika that have a critical impact on human health. Control of adult mosquitoes is widely done using pyrethroids, but resistance has reduced the effectiveness of this class of insecticides. Resistance to pyrethroids in mosquitoes is commonly due to mutations in the voltage-gated sodium channel (Vgsc) gene (these mutations are known as knockdown resistance, kdr). In the Americas and the Caribbean, the most common kdr alleles are 410L+1016I+1534C and 1534C. In this study, we conducted a population cage experiment to evaluate changes in the allele and genotype frequencies of the 410L+1016I+1534C allele by crossing two congenic strains; one carrying the 410L+1016I+1534C and another with the 1534C allele. Changes in allele frequencies were measured over 10 generations in the absence of insecticide exposure. We also applied one cycle of selection with deltamethrin at F9 to evaluate the changes in allele and genotype frequencies. Our findings indicate that fitness costs were higher with the 410L+1016I+1534C allele, relative to the 1534C allele, in the absence of deltamethrin exposure, but that the 410L+1016I+1534C allele provides a stronger advantage when exposed to deltamethrin relative to the 1534C allele. Changes in genotype frequencies were not in Hardy-Weinberg equilibrium and could not be explained by drift. Our results suggest the diametrically opposed fitness costs in the presence and absence of insecticides is a reason for the variations in frequencies between the 410L+1016I+1534C and 1534C alleles in field populations.

Survival analysis over a 20-year period of a Brazilian cohort of blood donors coinfected HIV-HCV.

Among individuals coinfected with HCV and HIV, studies of mortality from non-hepatic causes have shown inconsistent results. The aim of this study was to investigate the contribution of HCV and HIV co-infection to mortality from hepatic and non-hepatic causes in Brazil. This retrospective cohort study included blood donors from Fundação Pró-Sangue de São Paulo (FPS) who were followed from 1994 to 2016 to compare mortality and its causes between HIV-HCV coinfected individuals versus those seronegative for all tested infections. Records from the FPS database and the Mortality Information System were linked through a probabilistic record Relationship (RL). The Hazard Ratio (HR) was estimated using Cox multiple regression models. HCV-HIV coinfected individuals compared to seronegative individuals had a higher risk of death from all causes (HR = 14.54), non-liver neoplasms (HR = 2.55), infections (HR = 10.37) and liver disease (HR = 7.0). In addition, HCV mono-infected individuals compared to seronegative individuals had a higher risk of death from all causes (HR = 2.23), liver cancer (HR = 32.21), liver disease (HR = 14.92), infection (HR = 3.22), and trauma (HR = 1.68). Individuals coinfected with HCV and HIV have increased overall mortality and death due to infections, liver diseases and non-liver neoplasms as compared to those uninfected with HCV and HIV.

Relación entre la Composición Corporal, Condición Física y Capacidad Operativa en Militares Chilenos / Relationship Between Body Composition, Physical Condition and Operational Capacity in Chilean Military

La composición corporal engloba una serie de variables relacionadas con la salud e influye en la condición física. A pesar de ello, existe poca evidencia sobre sus efectos en la capacidad operativa en militares. El objetivo de este estudio fue relacionar la composición corporal, la condición física y la capacidad operativa de militares chilenos. Participaron 57 militares chilenos (26,9 ± 4,8 años), con especialización operativa en infantería. La composición corporal fue evaluada con bioimpedancia octopolar estimando masa libre de grasa, tejido muscular y tejido adiposo, entre otras variables. También se realizaron las siguientes pruebas de condición física: 5000 m planos, dominadas, abdominales y flexibilidad, así como cuatro pruebas específicas de actividades operativas militares específicas (situación de combate simulado). Los resultados mostraron un porcentaje de tejido muscular de 45,4 ± 2,9 % (IC95%: 44,6 - 46,2), mientras que el porcentaje de tejido adiposo fue de 20,3 ± 4,9 % (IC95%: 14,7 - 17,3). Se encontraron correlaciones negativas de pequeña magnitud entre el tiempo de carrera (5000 m) y el tejido muscular (%) (r = -0,275) y positiva con el tejido adiposo (%) (r = 0,294). Sin embargo, se observaron correlaciones de alta magnitud entre dominadas y tejido muscular (%) (r = 0,517) y tejido adiposo (%) (r = -0,558). El tejido adiposo se relacionó negativamente con la capacidad aeróbica, fuerza de brazos(??) y fuerza resistencia abdominal, mientras que el tejido muscular se relacionó positivamente con estas mismas variables. No se apreciaron correlaciones entre la composición corporal y la capacidad operativa militar (p<0,05). Se concluye que la composición corporal y la condición física no se relacionan con la capacidad operativa militar en situación de combate en especialistas en infantería, pero si la composición corporal se relaciona con la fuerza y la capacidad cardiorrespiratoria.

SUMMARY: Body composition encompasses a series of variables that are health-related and influence physical condition. Nevertheless, there is little evidence on its effects on the operational capacity of the military. The objective of this study was to relate the body composition, the physical condition and the operational capacity of the Chilean military. Fifty-seven Chilean soldiers (26.9 ± 4.8 years) participated, with operational specialization in infantry. Body composition was evaluated with octopolar bioimpedance, estimating fat- free mass, muscle tissue, and adipose tissue, among other variables. The following physical condition tests were also carried out: 5000 m flat, pull-ups, abdominals and flexibility, as well as four specific tests of specific military operational activities (simulated combat situation). The results showed a percentage of muscle tissue of 45.4 ± 2.9 % (95%CI: 44.6 - 46.2), while the percentage of adipose tissue was 20.3 ± 4.9 % (95%CI). : 14.7-17.3). Negative correlations of small magnitude were found between race time (5000 m) and muscle tissue (%) (r = -0.275) and positive with adipose tissue (%) (r = 0.294). However, high magnitude correlations were observed between pull-ups and muscle tissue (%) (r = 0.517) and adipose tissue (%) (r = -0.558). Adipose tissue was negatively related to aerobic capacity, arm strength, and abdominal endurance strength, while muscle tissue was positively related to these same variables. No correlations were found between body composition and military operational capacity (p<0.05). It is concluded that body composition and physical condition are not related to military operational capacity in combat situations in infantry specialists, but body composition is related to strength and cardiorespiratory capacity.

Postoperative pain management in the elderly. Literature review

Timely post-operative pain management in elderly patients is critically important. Given their physiological changes and comorbidities, management in this group of patients is different from the rest of the population. Knowledge of potentially inappropriate medications (Beers criteria) is relevant because of the presence of comorbidities in this population. Although acetaminophen continues to be safe, non-steroidal anti-inflammatory agents produce several adverse effects which need to be considered before they are used. On the other hand, opioids continue to be one of the pillars in analgesia, with due consideration of their adverse affects and interactions, and the need for dose adjustments. Adequate postoperative pain management prevents adverse effects and the risk of developing chronic pain.

El manejo oportuno del dolor en la población anciana durante el periodo posoperatorio es de vital importancia. Este grupo de pacientes, dado sus cambios fisiológicos y comorbilidades, requieren un manejo diferente al resto de la población. Es relevante conocer cuáles medicamentos son potencialmente inapropiados para su uso (criterios de Beers) ante las comorbilidades de esta población. Si bien el acetaminofén continúa siendo seguro, los antiinflamatorios no esteroideos causan varios efectos adversos que ameritan consideración antes de su uso; por su parte, los opioides siguen siendo uno de los pilares analgésicos, teniendo en cuenta sus efectos adversos y valorando la necesidad de ajuste de dosis e interacciones. El adecuado manejo del dolor posoperatorio previene desenlaces adversos y el riesgo de cronificación.

Diagnóstico de la variante conductual de demencia frontotemporal basado en estadios clínicos adaptado para países con baja educación: el caso de Perú

Demencia frontotemporal (DFT) es una condición neurodegenerativa escasamente reconocida en personas menores a 65 años de edad. El diagnóstico de DFT variante conductual (DFTvc) se basa en una entrevista clínica comprehensiva, complementada por una evaluación multidimensional (neurológica, cognitiva, neuropsiquiátrica, de biomarcadores e imágenes cerebrales) adaptada y validada a la población a estudiar; sin embargo, a pesar del incremento de su prevalencia en Latinoamérica y el Caribe, existe necesidad de herramientas estandarizadas y un consenso para el diagnóstico de DFTvc. El artículo intenta realizar una aproximación del enfoque de diagnóstico de DFTvc en escenario de paises con bajos y medianos ingresos, como el Perú.

Frontotemporal dementia (FTD) is a widely recognized neurodegenerative condition in people under 65 years old. The diagnosis of behavioral variant FTD (bvFTD) is based on a comprehensive clinical assessment, complemented by a multidimensional assessment (neurological, cognitive, neuropsychiatric, biomarker and brain imaging) adapted and validated to the population to be studied; however, despite its increasing prevalence in Latin America and the Caribbean, there is a need for standardized tools and consensus for the bvFTD diagnosis. The manuscript attempts to approximate the approach for the diagnosis of bvFTD in the setting of low and middle-income countries, including Peru.