Pediatric asthma treatment: What to do when international guideline recommendations do not agree.

BACKGROUND: There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs. OBJECTIVE: To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part. RESULTS: Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma. CONCLUSION: For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

[Mexican Asthma Guidelines: GUIMA 2017]. / Guía Mexicana del Asma: GUIMA 2017.

BACKGROUND: The need for a national guideline, with a broad basis among specialists and primary care physicians was felt in Mexico, to try unifying asthma management. As several high-quality asthma guidelines exist worldwide, it was decided to select the best three for transculturation. METHODS: Following the internationally recommended methodology for guideline transculturation, ADAPTE, a literature search for asthma guidelines, published 1-1-2007 through 31-12-2015 was conducted. AGREE-II evaluations yielded 3/40 most suitable for transculturation. Their compound evidence was fused with local reality, patient preference, cost and safety considerations to draft the guideline document. Subsequently, this was adjusted by physicians from 12 national medical societies in several rounds of a Delphi process and 3 face-to-face meetings to reach the final version. RESULTS: Evidence was fused from British Thoracic Society Asthma Guideline 2014, Global Initiative on Asthma 2015, and Guía Española del Manejo del Asma 2015 (2016 updates included). After 3 Delphi-rounds we developed an evidence-based document taking into account patient characteristics, including age, treatment costs and safety and best locally available medication. CONCLUSIONS: In cooperation pulmonologists, allergists, ENT physicians, paediatricians and GPs were able to develop an evidence-based document for the prevention, diagnosis and treatment of asthma and its exacerbations in Mexico.

Antecedentes: Con el objetivo de unificar el manejo del asma en México se estructuró una guía clínica que conjunta el conocimiento de diversas especialidades y la atención en el primer nivel de contacto. Se seleccionaron 3 guías publicadas en el ámbito internacional para su transculturación. Métodos: Conforme a la metodología ADAPTE se usó AGREE II después de la búsqueda bibliográfica de guías sobre asma publicadas entre 2007 y 2015. Se fusionó la realidad local con la evidencia de 3/40 mejores guías. El documento inicial fue sometido a la revisión de representantes de 12 sociedades médicas en varias rondas Delphi hasta llegar a la versión final. Resultados: Las guías base fueron la British Thoracic Society Asthma Guideline 2014, la Global Initiative on Asthma 2015 y la Guía Española del Manejo del Asma 2015. Después de 3 rondas Delphi se desarrolló un documento en el que se consideraron las características de los pacientes según edad, costos de los tratamientos y perfiles de seguridad de los fármacos disponibles en México. Conclusión: Con la cooperación de neumólogos, alergólogos, otorrinolaringólogos, pediatras y médicos generales se llegó a un consenso basado en evidencia, en el que se incluyeron recomendaciones sobre prevención, diagnóstico y tratamiento del asma y sus crisis.

[Facing the challenge... Towards a National Program of Adolescence Health Care in Mexico, 2001-2006]. / Enfrentando el reto.... Hacia un Programa Nacional de Atención a la Salud de la Adolescencia en México 2001-2006.

OBJECTIVE: To present the process in the design, development and implementation of Mexico's National Adolescent Health Program. MATERIALS AND METHODS: In efforts to arrive at a consensus regarding the health care priorities for Mexico's adolescent population, 37 public and private institutions dedicated to adolescent health care and social issues were invited to participate in a strategic analysis regarding a joint action plan for health promotion in adolescents with special emphasis on resilience as protective factor. The definition of the action plan involved the participation of 190 health professionals responsible for child and adolescent health programs in the discussion and drafting of the National Health Program. RESULTS: The steps and issues discussed by the 37 participating institutions leading to the development of the National Health Plan are reviewed. CONCLUSIONS: The product of this exercise led to the elaboration of a consensus document that served as the framework for Mexico's National Adolescent Health Plan and that now serves 23.5 million adolescents between 10 and 19 years of age. This action plan was been reviewed by the World Health Organization, which cited Mexico as one of the eight model countries addressing adolescent health.

Tuberculosis among indigenous municipalities in Mexico: analysis of case notification and treatment outcomes between 2009 and 2013 / Tuberculosis en municipios con poblaciones indígenas en México: análisis de la notificación de casos y los resultados del tratamiento del 2009 al 2013

Objective. To assess trends in 1) tuberculosis (TB) case notification by year and 2) cumulative treatment outcomes (stratified by type of TB) in relation to the proportion of indigenous population in municipalities in a countrywide study in Mexico for the period 2009–2013. Methods. This ecological operational research study used municipality data for the five-year study period. As no single identifier variable existed for indigenous persons, municipalities were categorized into one of three groups based on the proportion of their indigenous population (< 25% (“low”), ≥ 25% to < 50% (“medium”), and ≥ 50% (“high”)). TB case notification rates (CNRs) were standardized to a 100 000 population. Results. For the first four years of the study period (2009 through 2012), for all new TB cases reported nationally, the municipalities with a high proportion of indigenous people (≥ 50%) had the highest CNRs (ranging from 20.8 to 17.7 over that period). In 2013, however, the CNR in the high proportion municipalities dropped to 16.7, lower than the CNR for that year in the municipalities with a medium proportion of indigenous people (P < 0.001). In the municipalities with low and medium proportions of indigenous people, the CNR hovered between 15.1 and 17.3 over the study period. For the 96 195 new TB cases reported over the study period, the treatment success rate ranged between 81% and 84% for all three municipality groups. For previously treated TB cases, CNRs ranged between 1.0 and 1.7 for all three groups over the study period. The average proportion of previously treated TB cases (of all TB cases) was 9% for the three groups in 2009 but dropped to 8% by 2013. The cumulative treatment success rate for all previously treated cases (a total of 8 763 for the study period) was 64% in municipalities with a low proportion of indigenous people, 61% in those with a medium proportion, and 69% in those with a high proportion. Conclusions. Despite the slightly higher CNR in municipalities with predominantly indigenous populations, there were no stark differences in TB burden across the three municipality groups. The authors were unable to confirm if the relatively low CNRs found in this study were a reflection of good TB program performance or if TB cases were being missed. A survey of TB prevalence in indigenous people, with individualized data, is needed to inform targeted TB control strategies for this group in Mexico.

Objetivo. Evaluar las tendencias en la notificación de casos de tuberculosis por año y los desenlaces terapéuticos acumulados (estratificados por tipo de tuberculosis), con respecto a la proporción de la población indígena de los municipios, en una investigación de ámbito nacional en México del 2009 al 2013. Métodos. Estudio ecológico de investigación operativa en el que se utilizaron datos de los municipios correspondientes al período quinquenal definido. Dado que no existía una variable única de identificación de las personas indígenas, los municipios se clasificaron en tres grupos en función de la proporción de su población indígena (“baja”, menos de 25%; “intermedia”, de 25% a menos de 50%; y “alta”, 50% o más). Las tasas de notificación de casos de tuberculosis se normalizaron por 100 000 habitantes. Resultados. Durante los primeros cuatro años del período del estudio (del 2009 al 2012), los municipios con una alta proporción de indígenas presentaron las más altas tasas de notificación de todos los casos nuevos de tuberculosis (de 20,8 a 17,7 en este período). En el 2013, sin embargo, la tasa de notificación en los municipios con una alta proporción disminuyó a 16,7 casos por 100 000 habitantes y fue más baja que la tasa de los municipios con una proporción intermedia de indígenas (P < 0,001). En los municipios con una proporción baja e intermedia, la tasa de notificación de casos osciló entre 15,1 y 17,3 por 100 000 habitantes durante el período del estudio. En los 96 195 casos nuevos de tuberculosis notificados durante todo el período, la tasa de éxito del tratamiento fluctuó entre 81% y 84% en los tres grupos de municipios. En los casos de tuberculosis anteriormente tratados, las tasas de notificación oscilaron entre 1,0 y 1,7 en los tres grupos durante el período estudiado. El promedio de la proporción de casos de tuberculosis anteriormente tratados (con respecto a todos los casos de tuberculosis) fue 9% en los tres grupos en el 2009 pero disminuyó a 8% en el 2013. La tasa acumulada de éxito terapéutico en todos los casos anteriormente tratados (de un total de 8 763 durante el período del estudio) fue 64% en los municipios con una baja proporción de población indígena, 61% en los municipios con una proporción intermedia y 69% en los municipios donde la proporción era alta. Conclusiones. Pese a una tasa de notificación de casos discretamente superior en los municipios con poblaciones predominantemente indígenas, no se encontraron diferencias considerables de la carga de morbilidad por tuberculosis en los tres grupos de municipios. Los autores no pudieron verificar si las tasas de notificación relativamente bajas observadas en el presente estudio correspondían a un buen desempeño del programa contra la tuberculosis o se debía a los casos de tuberculosis pasados por alto. Es preciso realizar una encuesta de prevalencia de tuberculosis en las poblaciones indígenas que aporte datos individualizados, con el propósito de fundamentar las estrategias de control de la tuberculosis que se dirigen a este grupo de la población en México.

[The epidemiologic transition of the adolescents in Mexico]. / La transición epidemiológica de las y los adolescentes en México.

OBJECTIVE: To identify the health status of adolescents in Mexico in their demographic, social and economic context. MATERIAL AND METHODS: A literature search and review of vital statistics, and opinion surveys were performed in order to asses the impact of the epidemiologic transition on the availability and priority of health services for adolescents. The Omran epidemiologic model was used to classify the demographic, social and economic characteristics of Mexican adolescents in efforts to define their impact on the epidemiologic transition of this age group. RESULTS: Demographic data are presented in the perspective of the epidemiologic transition which permit us to make inferences on the social conditions, growth patterns and health needs of this age group in Mexico. Data are presented regarding the demand and availability of health services, the impact of education and employment opportunities and the role of family and the economy on their well being. Other important aspects presented include the role of education on the sexual and reproductive health of adolescents and the threat of the AIDS pandemic in this age group. CONCLUSIONS: These findings reveal a sequence of variables that can no longer be addressed in the traditional problem oriented approach and strongly suggest a need to profile the health needs of adolescents in an integrated, holistic fashion with emphasis in health promotion and healthy life styles to favor their integral, just and equitable development, and also help focus the societal response in an integrated manner.

La transición epidemiológica de las y los adolescentes en México / The epidemiologic transition among adolescents in Mexico

OBJETIVO: Identificar los niveles de salud de la adolescencia en México en su demografía, contexto social y económico. MATERIAL Y MÉTODOS: Se efectuó una revisión de la literatura y de estadísticas vitales, así como de encuestas de opinión, con la finalidad de evaluar el impacto de la transición epidemiológica frente a la disponibilidad y prioridades de los servicios de salud para adolescentes. El modelo epidemiológico de Omran se utilizó para clasificar las características demográficas, sociales y económicas de adolescentes mexicanos como un esfuerzo para definir su impacto en la transición epidemiológica de este grupo de edad. RESULTADOS: Los datos demográficos se presentan en una perspectiva de la transición epidemiológica, la cual nos permite realizar inferencias de las condiciones sociales, patrones de desarrollo y de necesidades en salud de este grupo poblacional en México. Los datos se presentan atendiendo a la demanda y disponibilidad de servicios de salud, el impacto de la educación, las oportunidades de empleo, el rol en la familia y el bienestar. Otros aspectos importantes presentados incluyen la educación sexual y la salud reproductiva, y los relacionados con el SIDA/VIH como pandemia en este grupo de edad. CONCLUSIONES: Los hallazgos presentados revelan que la secuencia tradicional de variables, en la explicación de la transición epidemiológica, no puede seguir manejándose como hasta ahora y nos sugieren de manera imperativa la necesidad de perfilar las necesidades de salud de la adolescencia desde un enfoque holístico, con énfasis en la promoción de estilos de vida sana, que favorezcan un desarrollo justo y equitativo y que además ayuden a enfocar la respuesta social organizada