Estrategia educativa intercultural para la prevención del cáncer de cuello cérvico uterino en el resguardo de Paujil, Amazonia Colombiana / Intercultural educational strategy for the prevention of cervical cancer in Paujil Resguardo Amazonía colombiana

RESUMEN Los pueblos indígenas siguen sufriendo inequidades, a pesar de los avances relacionados con la protección de la diversidad étnica y cultural, siendo las mujeres uno de los grupos de mayor riesgo, sobre todo, en lo referente a la salud sexual y reproductiva, situación contemplada como un compromiso de acción en los objetivos de desarrollo sostenible. En ese contexto, esta investigación acción participativa buscó construir una estrategia educativa intercultural, sostenible y segura culturalmente que, a propósito de la prevención del cáncer de cuello uterino, aportará al empoderamiento y la conservación de la salud de las mujeres habitantes del resguardo de Paujil -Colombia. La iniciativa surgió de mujeres indígenas preocupadas por mejorar la salud de sus congéneres y un grupo de investigadores. La construcción de una estrategia educativa intercultural representa un reto, pues la pedagogía occidental no necesariamente corresponde a las concepciones de enseñanza aprendizaje de las indígenas del resguardo. Hay dificultades lingüísticas, pues cada etnia tiene su propia lengua. Las indígenas lideresas se convirtieron en las facilitadoras del proceso que se centró más en el uso de la oralidad y encuentros entre mujeres, que se conocen entre sí. Las mujeres prefieren estrategias didácticas basadas en compartir experiencias y el uso de cartillas y videos. El trabajo permitió concluir que cualquier estrategia educativa intercultural que se proponga debe ser específica y acorde a las necesidades de las comunidades.

ABSTRACT Despite the advances related to the protection of ethnic and cultural diversity, indigenous people continue to suffer inequities, with women being one of the groups most at risk, especially concerning sexual and reproductive health, a situation considered as a problem, a commitment to action in the sustainable development goals. In this context, this Participatory action research searched to build an intercultural educational strategy, sustainable and culturally safe, which, concerning the prevention of cervical cancer, would contribute to the empowerment and conservation of the health of the women who live in the Paujil reservation-Colombia. The initiative arose from indigenous women concerned about improving the health of their peers, and a group of researchers. The construction of an intercultural educational strategy represents a challenge since western pedagogy does not necessarily correspond to the teaching-learning conceptions of the indigenous people of the reservation. There are linguistic difficulties because each ethnic group has its language. The indigenous leaders became the facilitators of the process that focused more on the use of orality and meetings between women who know each other. Women prefer a didactic strategy based on sharing experiences, and the use of primers, and videos. The work allowed to conclude that any proposed of intercultural educational strategy must be specific and according to the needs of the communities.

Albergues temporales como apoyo a la accesibilidad al tercer nivel de atención para poblaciones rurales dispersas: experiencias de pacientes y acompañantes / Temporary shelters to support accessibility to tertiary health care services for rural dispersed populations: patients and companions experiences

Introducción: los servicios de salud en zonas rurales dispersas se han focalizado en la atención primaria. Para lograr integralidad es necesario brindar accesibilidad a los servicios de tercer nivel, lo que representa un reto para los sistemas de salud por los costos y la disponibilidad de profesionales. Varios países desplazan especialistas y equipos a las zonas rurales; en Colombia son los pacientes quienes se trasladan a los centros especializados y las aseguradoras en salud administran dineros provenientes del estado para cubrir los costos. Para ello se requiere el apoyo de albergues temporales que brinden alojamiento y alimentación a pacientes y familiares de bajos recursos. Métodos: estudio cualitativo de caso con enfoque fenomenológico para conocer la experiencia de los usuarios de dos albergues que atienden pacientes y acompañantes provenientes de una zona distante 700 km de Bogotá. Resultados: los servicios de los albergues son bien percibidos por los usuarios, aunque sedestacan aspectos locativos por mejorar. El servicio se focaliza en hospedaje, transporte y alimentación quedando un vacío en otras necesidades como ocupación del tiempo libre, apoyo emocional y social. La demora en la atención en salud es la principal causa de inconformidad pues afecta la cotidianidad de las familias por el desplazamiento y la incomunicación. Conclusiones: la atención especializada trasladando pacientes de las zonas dispersas a los centros urbanos representa una experiencia innovadora que debe ser evaluada desde el punto de vista económico y emocional para analizar su relación costo beneficio y su sostenibilidad.

Introduction: health services in disperse rural areas have focused on primary care. In order to achieve comprehensive services, access to tertiary health care services needs to be provided. This represents a challenge for health systems in terms of costs and availability of healthcare professionals. In several countries, specialists and equipment are moved to rural areas; while in Colombia it is the patient who travels to the specialized centers. Health insurers administer money from the state to cover the expenses. This requires temporary shelters providing accommodation and food to low-income patients and their families. Methods: a phenomenological qualitative case study approach to learn about users experiences in two lodges serving patients and their companions who come from an area 700 km away from Bogota. Results: shelters ́ services are well qualified by users, although facilities need to be improved in some aspects. Services are centered on accommodation, transportation and food leaving a gap in other needs such as free time and leisure activities and emotional and social support. Delay in health care provision is the main cause of dissatisfaction for it affects family everyday life due to displacement and lack of communication. Conclusions: specialized assistance by transferring patients from dispersed areas to urban centers represents an innovative experience which should be evaluated from the economic and emotional perspective to enable a cost-benefit and sustainability analysis.

Partos en gestantes remitidas de un territorio disperso e indígena a un hospital universitario / Births in patients referred from dispersed indigenous areas to a university hospital

Introducción: en el marco del nuevo modelo integral de atención en salud, piloto en Colombia, el cuarto nivel de referencia para el departamento de Guainía correspondió a un hospital universitario localizado en Bogotá. Objetivo: caracterizar las gestantes procedentes de Guainía con atención del parto en el Hospital de San José entre junio 2016 y junio 2018. Metodología: serie de casos con análisis descriptivo de variables. Resultados: los 29 fueron embarazos de alto riesgo, una edad mediana de 22 años (RIQ: 19 a 30), 73% procedían de zona urbana, 72% partos por cesárea, 52% pretérmino; 45% multíparas y dos embarazos gemelares. Todos los diagnósticos de remisión y egreso coincidieron, 55% tuvieron preeclampsia, 24% amenaza de parto pretérmino y 7% restricción del crecimiento intrauterino. En los neonatos 45% tuvieron bajo peso o bajo peso extremo al nacer, 41% requirieron cuidado intensivo y 38% ingresaron a plan canguro. No hubo casos de mortalidad materna ni perinatal. Discusión: las cero muertes reflejan el beneficio clínico con la remisión extra departamental. La alta procedencia urbana puede deberse a fallas de registro y difícil acceso de las zonas dispersas. Conclusión: la remisión aérea de gestantes con riesgo alto a una institución predefinida de alta complejidad tiene beneficio clínico. Se requiere optimizar en el territorio de origen la atención prenatal y las acciones de salud pública, en especial para preeclampsia y bajo peso al nacer.

Introduction: within the framework of the new pilot model of care in Colombia the high-level referral center from the department of Guainía corresponded to a university hospital located in Bogotá. Objective: to characterize pregnant women referred from Guainía with delivery care provided at Hospital de San José between June 2016 and June 2018. Methodology:case series descriptive study. Results: All 29 were high-risk pregnancies, median age 22 years (IQR: 19 to 39), 73% came from urban areas, 72% were cesarean deliveries, 52% preterm births, 45% multiparous mothers and there were two twin pregnancies. All referral and discharge diagnoses coincided, 55% had preeclampsia, 24% threatened preterm labor and 7% intrauterine growth restriction. Forty-five percent of neonates had low weight or extremely low weight at birth, 41% needed intensive care and 38% were admitted to the kangaroo plan. There were no maternal or perinatal deaths. Discussion: zero mortality reflects the clinical benefits of referral. The high number of urban origin of patients may be due to registration failures and difficult access from dispersed areas. Conclusion: Transfer of high-risk pregnant women by air to a pre-defined high complexity institution shows clinical benefits. Prenatal care and public health actions especially for preeclampsia and low birth weight need to be optimized in the region of origin.

Ischemic conditioning protects the rat retina in an experimental model of early type 2 diabetes.

Diabetic retinopathy is a leading cause of acquired blindness in adults, mostly affected by type 2 diabetes mellitus (T2DM). We have developed an experimental model of early T2DM in adult rats which mimics some features of human T2DM at its initial stages, and provokes significant retinal alterations. We investigated the effect of ischemic conditioning on retinal changes induced by the moderate metabolic derangement. For this purpose, adult male Wistar rats received a control diet or 30% sucrose in the drinking water, and 3 weeks after this treatment, animals were injected with vehicle or streptozotocin (STZ, 25mg/kg). Retinal ischemia was induced by increasing intraocular pressure to 120 mm Hg for 5 min; this maneuver started 3 weeks after vehicle or STZ injection and was weekly repeated in one eye, while control eyes were submitted to a sham procedure. Fasting and postprandial glycemia, and glucose, and insulin tolerance tests were analyzed. At 12 weeks of treatment, animals which received a sucrose-enriched diet and STZ showed significant differences in metabolic tests, as compared with control groups. Brief ischemia pulses in one eye and a sham procedure in the contralateral eye did not affect glucose metabolism in control or diabetic rats. Ischemic pulses reduced the decrease in the electroretinogram a-wave, b-wave, and oscillatory potential amplitude, and the increase in retinal lipid peroxidation, NOS activity, TNFα, Müller cells glial fibrillary acidic protein, and vascular endothelial growth factor levels observed in diabetic animals. In addition, ischemic conditioning prevented the decrease in retinal catalase activity induced by T2DM. These results indicate that induction of ischemic tolerance could constitute a fertile avenue for the development of new therapeutic strategies to treat diabetic retinopathy associated with T2DM.

Therapeutic efficacy of melatonin in reducing retinal damage in an experimental model of early type 2 diabetes in rats.

Diabetic retinopathy (DR) is a leading cause of acquired blindness in adults, mostly affected by type 2 diabetes mellitus (T2DM). We have developed an experimental model of early T2DM in adult rats which mimics some features of human T2DM at its initial stages and provokes significant retinal alterations. The aim of this work was to analyze the effect of melatonin on retinal changes induced by the moderate metabolic derangement. For this purpose, adult male Wistar rats received a control diet or 30% sucrose in the drinking water. Three weeks after this treatment, animals were injected with vehicle or streptozotocin (STZ, 25 mg/kg). One day or 3 wk after vehicle or STZ injection, animals were subcutaneously implanted with a pellet of melatonin. Fasting and postprandial glycemia, and glucose, and insulin tolerance tests were analyzed. At 12 wk of treatment, animals which received a sucrose-enriched diet and STZ showed significant differences in metabolic tests, as compared with control groups. Melatonin, which did not affect glucose metabolism in control or diabetic rats, prevented the decrease in the electroretinogram a-wave, b-wave, and oscillatory potential amplitude, and the increase in retinal lipid peroxidation, NOS activity, TNFα, Müller cells glial fibrillary acidic protein, and vascular endothelial growth factor levels. In addition, melatonin prevented the decrease in retinal catalase activity. These results indicate that melatonin protected the retina from the alterations observed in an experimental model of DR associated with type 2 diabetes.

Alterations of locomotor activity rhythm and sleep parameters in patients with advanced glaucoma.

The aim of this study was to evaluate the effect of advanced glaucoma on locomotor activity rhythms and related sleep parameters. Nine normal subjects and nine age-matched patients with bilateral advanced primary open-angle glaucoma, >10 yrs since diagnosis, were included in this observational, prospective, case-control study. Patients were required to record the timing and duration of their sleep and daily activities, and wore an actigraph on the wrist of the nondominant arm for 20 d. Activity rhythm period, MESOR (24-h time-series mean), amplitude (one-half peak-to-trough variation), and acrophase (peak time), plus long sleep episodes during the wake state, sleep duration, efficiency, and latency, as well as mean activity score, wake minutes, and mean wake episodes during the sleep interval were assessed in controls and glaucomatous patients. Glaucomatous patients exhibited significant decrease in nighttime sleep efficiency, and significant increase in the mean activity score, wake minutes, and mean wake episode during the night. These results suggest that alterations of circadian physiology could be a risk to the quality of life of patients with glaucoma.

Retinal changes in an experimental model of early type 2 diabetes in rats characterized by non-fasting hyperglycemia.

Diabetic retinopathy is a leading cause of acquired blindness in young, but also in elder adults, mostly affected by type 2 diabetes mellitus (T2DM). The aim of this work was to develop an experimental model of early human T2DM in adult rats, and to analyze retinal functional, morphological, and biochemical changes arising during the early stages of the moderate metabolic derangement. For this purpose, animals were divided in four groups: adult male Wistar rats receiving: tap water and citrate buffer i.p. (group 1), tap water with 30% sucrose and citrate buffer i.p. (group 2), tap water and 25mg/kg i.p streptozotocin (STZ, group 3), or 30% sucrose and STZ (group 4). Fasting and postprandial glycemia, fructosamine and serum insulin levels were assessed. In addition, i.p. glucose and insulin tolerance tests were performed. Retinal function (electroretinogram, ERG) and morphology (optical microscopy), retinal nitric oxide synthase (NOS) activity (using (3)H-arginine), lipid peroxidation (thiobarbituric acid reactive substances, TBARS), and TNFα levels (ELISA) were evaluated. At 6 and 12 weeks of treatment, animals which received a sucrose-enriched diet and STZ showed significant differences in most metabolic tests, as compared with the other groups. At 12 weeks of treatment, a significant decrease in the ERG a- and b- wave and oscillatory potential amplitudes, and a significant increase in retinal NOS activity, TBARS, TNFα, glial fibrillary acidic protein in Müller cells, and vascular endothelial growth factor levels were observed. These results indicate that the combination of diet-induced insulin resistance and a slight secretory impairment resulting from a low-dose STZ treatment mimics some features of human T2DM at its initial stages, and provokes significant retinal alterations.

Therapeutic benefit of melatonin in experimental feline uveitis.

Uveitis is a frequent ophthalmic disorder which constitutes one of the main causes of blindness in domestic cats. The aim of this report was to analyze the effect of melatonin on experimentally induced uveitis in cats. Bacterial lipopolysaccharide (LPS) was injected intravitreally into one eye from intact cats, while the contralateral eye was injected with vehicle. Melatonin was orally administered every 24 hr to a group of ten cats, from 24 hr before until 45 days after intravitreal injections. Eyes were evaluated by means of clinical evaluation, intraocular pressure (IOP), blood-ocular barrier integrity (via measurement of protein concentration and cell content in samples of aqueous humor [AH]), electroretinogram (ERG), and histological examination of the retinas. In LPS-treated eyes, several clinical signs were observed until day 45 postinjection. The treatment with melatonin significantly decreased clinical signs and prevented the reduction in IOP induced by LPS. In LPS-injected eyes, melatonin significantly preserved the blood-ocular barrier integrity, as shown by a decrease in the number of infiltrating cells and protein concentration in the AH. Mean amplitudes of scotopic ERG a- and b-waves were significantly reduced in eyes injected with LPS, whereas melatonin significantly prevented the effect of LPS. At 45 days after injection, LPS induced alterations in photoreceptors and at the middle portion of the retina, whereas melatonin preserved the retinal structure. These results indicate that melatonin prevented clinical, biochemical, functional, and histological alterations induced by LPS injection. Thus, melatonin might constitute a useful tool for the treatment of feline uveitis.

Effect of ocular hypertension on retinal GABAergic activity.

Glutamate and gamma-aminobutyric acid (GABA) are major excitatory and inhibitory retinal neurotransmitters. The balance between these signals is a key principle of organization at retinal level. Although glutamate-induced excitotoxicity could mediate retinal ganglion cell death in glaucoma, the GABAergic system was not previously examined in this disease. The aim of this work was to study the retinal GABAergic activity in eyes with ocular hypertension induced by hyaluronic acid (HA). For this purpose, weekly injections of HA were performed unilaterally in the rat anterior chamber, whereas the contralateral eye was injected with saline solution. At 3 weeks of treatment with HA, GABA turnover rate, glutamic acid decarboxylase activity, and both glutamate- and high K(+)-induced GABA release significantly decreased, whereas GABA uptake increased in HA-treated eyes. The binding of t-butylbicyclophosphorothionate (TBPS) to GABA(A)/benzodiazepine Cl(-) channels significantly increased in eyes injected with HA as compared with vehicle-injected eyes. Changes in GABA uptake and TBPS binding persisted at 6 weeks of treatment with HA. These results indicate a dysfunction of the retinal GABAergic activity in hypertensive eyes, which could suggest the involvement of GABA in glaucomatous neuropathy.

Effect of ocular hypertension on retinal nitridergic pathway activity.

PURPOSE: Understanding the mechanisms of neuronal cell death in glaucoma is important for devising new treatments. Excitatory amino acids, excessive Ca(2+) influx, and formation of nitric oxide (NO) via NO synthase (NOS)-1 could be involved in glaucomatous neuropathy. The purpose of the present study was to examine the retinal nitridergic pathway activity in rats exposed to experimentally elevated intraocular pressure. METHODS: Weekly injections of HA were performed unilaterally in the rat anterior chamber, whereas the contralateral eye was injected with saline solution. At 3 or 6 weeks of treatment, retinal NOS activity was assessed through the conversion of (3)H-L-arginine to (3)H-L-citrulline, whereas NOS-1, -2, and -3 levels were assessed by Western blotting. L-Arginine uptake was measured using (3)H-l-arginine, whereas mRNA levels of L-arginine transporters were determined by semiquantitative RT-PCR. In addition, cyclic guanosine monophosphate (cGMP) levels were quantified by radioimmunoassay. RESULTS: At both 3 and 6 weeks of treatment, NOS activity significantly increased in HA-injected eyes although no changes in retinal NOS-1, -2, or -3 levels were observed in eyes injected with HA. L-Arginine influx and mRNA levels of cationic amino acid transporter type (CAT)-1 and -2 significantly increased in retinas from hypertensive eyes. Retinal cGMP levels significantly increased in eyes injected with HA for 3 but not 6 weeks. CONCLUSIONS: These results suggest a significant activation of the retinal nitridergic pathway in hypertensive eyes.

Effect of glaucoma on the retinal glutamate/glutamine cycle activity.

Glutamate-induced excitotoxicity has been proposed to mediate the death of retinal ganglion cells in glaucoma. The metabolic dependence of glutamatergic neurons upon glia via the glutamate/glutamine cycle to provide the precursor for neurotransmitter glutamate is well established. Thus, the aim of the present work was to study the retinal glutamate/glutamine activity in eyes with hypertension induced by intracameral injections of hyaluronic acid (HA). For this purpose, weekly injections of HA were performed unilaterally in the rat anterior chamber, whereas the contralateral eye was injected with saline solution. At 3 or 10 weeks of treatment, glutamate and glutamine uptake and release were assessed using [3H]-glutamate and [3H]-glutamine as radioligands, respectively. In addition, glutamine synthetase activity was assessed by a spectrophotometric assay, whereas glutaminase activity was measured through the conversion of [3H]-glutamine to [3H]-glutamate. At 3 weeks of treatment with HA, a significant decrease (P<0.01) in glutamate uptake and glutamine synthetase activity was observed. Glutamine uptake and release, as well as glutaminase activity, were significantly increased (P<0.01) in eyes injected with HA for 3 weeks compared with vehicle-injected eyes, whereas [3H]-glutamate release did not change in hypertensive eyes. Only the changes in glutamine synthetase activity persisted at 10 weeks of treatment with HA. These results indicate a significant alteration in the retinal glutamate/glutamine cycle activity in hypertensive eyes. Since these changes preceded both functional and histological alterations induced by ocular hypertension, these results support the involvement of glutamate in glaucomatous neuropathy.

Retinal oxidative stress induced by high intraocular pressure.

Glaucoma is an optic neuropathy in which retinal ganglion cells die probably through an apoptotic process. Apoptosis is known to involve free radicals in several systems including the retina. In this context, the aim of the present work was to analyze retinal oxidative damage in rats with glaucoma induced by the chronic injection of hyaluronic acid in the eye anterior chamber. The results showed a significant decrease in total retinal superoxide dismutase and catalase activities after 6 and 3 weeks of treatment with hyaluronic acid, respectively. Also, although GPX activity increased after 10 weeks of ocular hypertension, GSH levels significantly decreased at 6 weeks of treatment with hyaluronic acid. Moreover, retinal lipid peroxidation significantly increased in a time-of-hypertension-dependent manner. On the other hand, a significant decrease in both diurnal and nocturnal retinal melatonin content was detected at 3, 6, or 10 weeks of treatment with hyaluronic acid. The present results suggest that retinal oxidative stress may be involved in glaucomatous cell death. Thus, manipulation of intracellular redox status using antioxidants may be a new therapeutic tool to prevent glaucomatous neurodegeneration.

Involvement of Bax protein in the prevention of glucocorticoid-induced thymocytes apoptosis by melatonin.

The antiapoptotic effect of melatonin has been described in several systems. In this study, the antagonistic effect of the methoxyindole on dexamethasone-induced apoptosis in mouse thymocytes was examined. Melatonin decreased both DNA fragmentation, and the number of annexin V-positive cells incubated in the presence of dexamethasone. Analysis of the expression of the members of the Bcl-2 family indicated that the synthetic glucocorticoid increased Bax protein levels without affecting the levels of Bcl-2, Bcl-XL, Bcl-XS, or Bak. This effect correlated with an increase in thymocytes bax mRNA levels. Dexamethasone also increased the release of cytochrome C from mitochondria. All of these effects were reduced in the presence of melatonin, which was ineffective per se on these parameters. In addition, the involvement of cAMP on glucocorticoid/melatonin antagonism was examined. Both melatonin and dexamethasone decreased the levels of this nucleotide in mouse thymocytes, indicating that the antagonistic action between both hormones involves a cAMP-independent pathway. In summary, the present results suggest that the antiapoptotic effect of melatonin on glucocorticoid-treated thymocytes would be a consequence of an inhibition of the mitochondrial pathway, presumably through the regulation of Bax protein levels.

Evaluación del impacto de la contaminación del embalse del Muña sobre la salud humana / Assessment of the impact on human health of the contamination of Muñaïs dam

El embalse del Muña en los últimos 30 años ha incrementado el contenido de material orgánico en descomposición. La población de Sibaté ha percibido una asociación entre esta contaminación y la aparición de enfermedades respiratorias, dérmicas y cáncer. Para aclarar esta situación se realizó una evaluación ambiental preliminar, un estudio ecológico exploratorio de mortalidad, un estudio de prevalencia de morbilidad, un estudio de corte transversal de absorción de metales y la caracterización sociocultural de la población. Los resultados no muestran un perfil anormal en la morbi-mortalidad de esta población. Se explican estos hallazgos y se sugieren nuevos estudios para mejorar el entendimiento de la posible asociación entre el embalse contaminado y la salud humana.