Reach and effectiveness of a HEARTS hypertension pilot project in Guatemala.

The World Health Organization Global Hearts initiative (HEARTS) and technical package aim to improve the primary health care management of hypertension and other risk factors for cardiovascular disease at the population level. This study describes the first HEARTS implementation pilot project in Guatemala's Ministry of Health (MOH) primary health care system. This pilot began in April 2022 in six primary health care facilities in three rural indigenous municipalities. The project consisted of HEARTS-aligned strategies adapted to enhance program sustainability in Guatemala. Outcomes were defined using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. The primary reach outcome was treatment count, defined as the absolute number of patients per month receiving medication treatment for hypertension. The primary effectiveness outcomes were mean systolic blood pressure (BP), mean diastolic BP, and proportion of patients with BP control (<130/80 mmHg). In the first month of the post-implementation period, there was a statistically significant increase of 25 patients treated per month above the baseline of 20 to 25 patients (P = .002), followed by a significant increase of 2.4 additional patients treated each month (P = .005) thereafter. The mean change in systolic BP was -4.4 (95% CI, -8.2 to -0.5; P = 0.028) mmHg, and the mean change in diastolic BP was -0.9 (95% CI, -2.8 to 1.1; P = .376) mmHg. The proportion of the cohort with BP control increased from 33.4% at baseline to 47.1% at 6 months (adjusted change, 13.7%; 95% CI, 2.2% to 25.2%; P = .027). These findings support the feasibility of implementing the HEARTS model for BP control throughout the MOH primary health care system, which is where most Guatemalans with hypertension seek care.

El paquete técnico de la Iniciativa Global Hearts ("HEARTS") de la Organización Mundial de la Salud tiene como objetivo mejorar el control de la hipertensión y de otros factores de riesgo de enfermedades cardiovasculares a nivel poblacional en el ámbito de la atención primaria de salud de salud. Este estudio describe el primer proyecto piloto de implementación de HEARTS en el sistema de atención primaria de salud del Ministerio de Salud de Guatemala. El proyecto, que comenzó en abril del 2022 en seis centros de atención primaria de salud pertenecientes a tres municipios rurales indígenas, consistió en estrategias alineadas con HEARTS y adaptadas para mejorar la sostenibilidad del programa en Guatemala. Los criterios de valoración de los resultados se definieron mediante el marco estandarizado de evaluación de cobertura, efectividad, adopción, implementación y mantenimiento (RE-AIM, por su sigla en inglés). El criterio principal de la cobertura fue la cantidad de tratamientos, definida como el número absoluto de pacientes por mes que recibían tratamiento farmacológico para la hipertensión. Los criterios principales de la efectividad fueron la media de presión arterial (PA) sistólica, la media de PA diastólica y la proporción de pacientes con un control de la PA (<130/80 mmHg). En el primer mes del período posterior a la implementación, se registró un aumento estadísticamente significativo de 25 pacientes tratados al mes por encima del valor inicial de 20 a 25 pacientes (n = 25; p = 0,002), seguido de un aumento significativo de 2,4 pacientes adicionales tratados al mes (p = 0,005) posteriormente. El cambio en la media de la PA sistólica fue de -4,4 (IC del 95%: -8,2 a -0,5); p = 0,028) mmHg, en tanto que el cambio en la media de la PA diastólica fue de -0,9 (IC del 95%, -2,8 a 1,1); p = 0,376) mmHg. La proporción de la cohorte con control de la PA aumentó del 33,4% al inicio al 47,1% a los seis meses (cambio ajustado, 13,7%; IC del 95%, 2,2% a 25,2%; p = 0,027). Estos resultados respaldan la viabilidad de la implementación del modelo HEARTS para el control de la PA en la totalidad del sistema de atención primaria de salud del Ministerio de Salud de Guatemala, al que acude en busca de atención la mayoría de las personas con hipertensión.

O pacote de medidas técnicas da iniciativa Global Hearts ("HEARTS") da Organização Mundial da Saúde tem como objetivo melhorar o controle da hipertensão arterial e de outros fatores de risco para doenças cardiovasculares na atenção primária à saúde em nível populacional. Este estudo descreve o primeiro projeto-piloto de implementação da iniciativa HEARTS no sistema de atenção primária à saúde do Ministério da Saúde da Guatemala. O projeto-piloto começou em abril de 2022 em seis estabelecimentos de atenção primária à saúde em três municípios indígenas rurais. O projeto consistiu em estratégias alinhadas à iniciativa HEARTS e adaptadas para melhorar a sustentabilidade do programa na Guatemala. Os desfechos foram definidos usando a estrutura de avaliação RE-AIM (sigla em inglês para alcance, efetividade, adoção, implementação e manutenção). O desfecho primário de alcance foi a quantidade de tratamentos, definida como o número absoluto de pacientes por mês que receberam tratamento medicamentoso para hipertensão. Os desfechos primários de efetividade foram pressão arterial (PA) sistólica média, PA diastólica média e proporção de pacientes com controle da PA (<130/80 mmHg). No primeiro mês do período pós-implementação, houve um aumento estatisticamente significante de 25 pacientes tratados por mês acima da linha de base de 20 a 25 pacientes (n = 25; P = 0,002), seguido de um aumento significante de 2,4 pacientes adicionais tratados a cada mês (P = 0,005) depois disso. A mudança média na PA sistólica foi de −4,4 (intervalo de confiança [IC] de 95%: −8,2 a −0,5; P = 0,028) mmHg, e a mudança média na PA diastólica foi de −0,9 (IC de 95%: −2,8 a 1,1; P = 0,376) mmHg. A proporção da coorte com controle da PA aumentou de 33,4% na linha de base para 47,1% após 6 meses (mudança ajustada, 13,7%; IC de 95%: 2,2% a 25,2%; P = 0,027). Esses achados apoiam a viabilidade da implementação do modelo HEARTS para o controle da PA em todo o sistema de atenção primária à saúde do Ministério da Saúde da Guatemala, no qual a maioria dos indivíduos com hipertensão arterial procura atendimento.

Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system.

BACKGROUND: The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. METHODS: A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. DISCUSSION: This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

Case report: From monkeypox pharyngitis to myopericarditis and atypical skin lesions.

Background: A global outbreak of the human monkeypox virus (HMPXV), first identified in May 2022, was declared a health emergency of international concern on 23 July 2022. Before the global outbreak, monkeypox cases were mostly confined to central and west African countries, where this virus is prevalent. Close contact, mainly sexual contact, is supposed to be the main route of transmission, and it is remarkable that the incidence is higher in men who have sexual relationships with other men. Case summary: A 40-year-old Caucasian man arrived at the emergency department complaining of oppressive epigastric pain extending to the chest after a diagnosis of pharyngitis, which was suspected to be caused by the human monkeypox virus. Based on the clinical symptoms, physical examination, serum cardiac biomarkers, and electrocardiographic findings, he was diagnosed with myopericarditis. The real-time PCR for human monkeypox in skin lesions, urine, plasma, and the oropharyngeal swab was positive. The peak of troponin I was 20.6 ng/ml, and the electrocardiogram showed an upward concavity in the ST segment in diffuse leads, which was in agreement with the previous diagnosis. The presence of edema, subepicardial, and myocardial late gadolinium enhancement, and increased values on T1 mapping in the cardiac MRI were in agreement with the diagnosis of myopericarditis. Antiviral treatment with tecovirimat was started with excellent tolerability. After 6 days, the patient recovered and was discharged. Discussion: To our knowledge, this is one of the first reported cases of myopericarditis due to human monkeypox infection, which was confirmed by a cardiac MRI following modified Lake Louise criteria. The short span between the onset of the mucocutaneous symptoms and the myocardial damage suggests a pathogenic association. Furthermore, the active viral replication in plasma samples and the negative results on real-time PCR for other viruses support this clinical association.

[Variability in HIV viral tropism determination using different genotypic algorithms in patients infected with B versus non-B HIV-1 subtypes]. / Variabilidad en la determinación del tropismo viral del VIH utilizando diferentes algoritmos genotípicos de interpretación en pacientes VIH-1 infectados con subtipos B versus no-B.

BACKGROUND: Genotypic tools based on the analysis of the V3 region are seen as an alternative to phenotypic assays for viral tropism determination before prescribing maraviroc. The concordance between different genotypic algorithms has been evaluated in HIV+ patients infected with B versus non-B subtypes. METHODS: HIV-infected patients on regular follow up at Hospital Universitario de Santiago de Compostela (Spain) were selected. The env-V3 region was sequenced from plasma samples and viral tropism was estimated using 8 different genotypic algorithms. Concordance among predictors was statistically evaluated by the calculation of the kappa index. Phylogenetic analyses were performed to determine the genetic subtype. RESULTS: A total of 92 HIV-infected patients were selected, 72 B and 20 non-B subtypes. Regarding the B subtype group, significant kappa values were obtained among all 28 possible combinations between the genotypic predictors evaluated. The best concordance among non-related predictors was observed for webPSSM(SINSI)/Wetcat(PART) (k: 0.771) and webPSSM(SINSI)/geno2pheno (k: 0.574). Conversely, among non-B subtypes, a significative kappa index was only obtained for 13 combinations. Among non-B subtypes, the best concordance values were obtained for webPSSM(X4R5)/Wetcat(PART) (k: 0.600) and webPSSM(SINSI)/Charge rule (k: 0.590). CONCLUSION: A high concordance was observed between different genotypic algorithms to determine viral tropism among HIV-1 B subtypes infected patients, especially between webPSSM(SINSI) and geno2pheno or Wetcat. Conversely, the overall concordance among non-B subtypes was lower. This heterogeneity could be justified by the low prevalence of non B subtypes in the datasets in which the genotypic tropism predictors were trained.

Design and validation of new genotypic tools for easy and reliable estimation of HIV tropism before using CCR5 antagonists.

BACKGROUND: Genotypic tools may allow easier and less expensive estimation of HIV tropism before prescription of CCR5 antagonists compared with the Trofile assay (Monogram Biosciences, South San Francisco, CA, USA). METHODS: Paired genotypic and Trofile results were compared in plasma samples derived from the maraviroc expanded access programme (EAP) in Europe. A new genotypic approach was built to improve the sensitivity to detect X4 variants based on an optimization of the webPSSM algorithm. Then, the new tool was validated in specimens from patients included in the ALLEGRO trial, a multicentre study conducted in Spain to assess the prevalence of R5 variants in treatment-experienced HIV patients. RESULTS: A total of 266 specimens from the maraviroc EAP were tested. Overall geno/pheno concordance was above 72%. A high specificity was generally seen for the detection of X4 variants using genotypic tools (ranging from 58% to 95%), while sensitivity was low (ranging from 31% to 76%). The PSSM score was then optimized to enhance the sensitivity to detect X4 variants changing the original threshold for R5 categorization. The new PSSM algorithms, PSSM(X4R5-8) and PSSM(SINSI-6.4), considered as X4 all V3 scoring values above -8 or -6.4, respectively, increasing the sensitivity to detect X4 variants up to 80%. The new algorithms were then validated in 148 specimens derived from patients included in the ALLEGRO trial. The sensitivity/specificity to detect X4 variants was 93%/69% for PSSM(X4R5-8) and 93%/70% for PSSM(SINSI-6.4). CONCLUSIONS: PSSM(X4R5-8) and PSSM(SINSI-6.4) may confidently assist therapeutic decisions for using CCR5 antagonists in HIV patients, providing an easier and rapid estimation of tropism in clinical samples.

Utilidade da técnica de fechamento cirúrgico "ponto em alfa" na onicocriptose / Benefits of the alpha stitch technique in surgical closure in onychocryptosis

Introdução: Aspecto pouco avaliado da onicocriptose ­ principal causa de cirurgia do aparelho ungueal ­ é como deve ser realizado o fechamento cirúrgico. Descreve-se nova técnica denominada "ponto alfa" que permite a retificação da dobra ungueal por posicioná-la no nível da placa ou abaixo dela. Objetivo: Demonstrar a utilidade da técnica de fechamento cirúrgico "ponto alfa" na matricectomia cirúrgica da onicocriptose. Métodos: Selecionados 20 pacientes com onicocriptose graus II e III, submetidos à matricectomia cirúrgica com acompanhamento durante seis meses. O fechamento cirúrgico foi realizado com a técnica "ponto alfa". Resultados: No total, 27 dobras ungueais laterais foram operadas, 81,8% delas com resultado esperado, e 18,1% com resultado duvidoso. Conclusões: O "ponto alfa" permite correta cicatrização da dobra ungueal retificada, posicionada no nível da placa ungueal ou abaixo dela, com bons resultados estéticos, rápida recuperação, mínima morbidade e baixo número de recidivas. Poderá ser usado em procedimentos cirúrgicos de outras afecções ungueais.

Introduction: A poorly described aspect of onychocryptosis ­ the main cause for nail unit surgeries ­ is how to perform its surgical closure. The present article describes a new technique denominated alpha stitch that allows the straightening out of the nail fold by positioning it at or below the nail plate's level.Objective: To demonstrate the benefits of the alpha stitch surgical closure technique in the surgical matricectomy for onychocryptosis.Methods: Twenty patients with onychocryptosis grades II and III underwent surgicalmatricectomy and were followed up for six months. The surgical closure was performed using the alpha stitch technique.Results: A total of 27 lateral nail folds were operated, with 81.8% yielding the expected result, and 18.1% presenting uncertain outcomes.Conclusions: The alpha stitch allows the proper healing of the straightened out nail fold, which is positioned at or below the nails plate's level, with good results, fast recovery, minimal morbidity and a small number of recurrences. The technique can also be used in surgical procedures involving other nail disorders.

Comparación del transporte radicular en conductos radiculares curvos utilizando las técnicas Twisted File(R) y Reciproc(R) / Evaluation of transportation incurved root canals using Reciproc(R) and TwistedFile(R) techniques

Objetivo: La preparación del conducto radicular con un solo instrumento con movimiento reciprocante está generando preocupación acerca de su comportamiento en la preparación de los conductos. El propósito de este estudio fue comparar qué sistema (TwistedFiles(R) oReciproc(R)) produce menos transporte radicular en conductos curvos. Metodología: Se utilizaron 40 molares inferiores humanos recién extraídos con curvaturas entre 25 y 35 grados, siguiendo la técnica de Schneider. Los molares fueron divididos aleatoriamente en dos grupos de 20 molares cada uno; Grupo 1: se prepararon usando movimiento de rotación continua con limas Twisted Files(R) mientras que en el Grupo 2 se prepararon con movimiento reciprocante con limas Reciproc(R). Se determinó el transporte del conducto radicular a través de CTScan midiendo la curvatura exterior e interior antes y después de la preparación. Resultados: En ambos grupos se encontró transporte del conducto radicular. Los resultados se analizaron mediante la prueba t de Student. No hubo diferencias significativas en los grados y las direcciones de transporte entre TF y grupos RP (p <.05). Conclusiones: La instrumentación con movimiento reciprocante no aumentó el transporte del conducto radicular cuando se comparacon el movimiento de rotación continua. El movimiento recíproco podría ser un método alternativo en la configuración del conducto radicular

Objective: The single-file root canal instrumentation technique using reciprocating motion is generating concern abou this behavior in root canals preparation. The purpose of this study was to compare which system Twisted Files(R) and Reciproc(R) produces less root transportation in curved root canal. Methodology: 40 extracted human mandibular molars with curvature between 25-35 degrees following Schneider’s technique. All teeth were randomly divided into 2 groups of 20 root canals each. Group 1 were prepared by using continuous rotation motion with Twisted File(R) Group 2 were prepared with reciprocating motion with Reciproc(R) files, the root canal transportation was determined through CT Scan measuring the external and internal curvature before and after preparation. Results: Both studied preparations systems created root canal transportation. The results were analysed by the t Student test. There were no significant differences in both the degrees and directions of transportation between TF and RP groups (P > .05). Conclusions: The reciprocating motion instrumentation did not increased root canal transportation when compared with continuous rotation motion. Reciprocating motion might be an alternative method in root canal shaping

Variabilidad en la determinación del tropismo viral del VIH utilizando diferentes algoritmos genotípicos de interpretación en pacientes VIH-1 infectados con subtipos B versus no-B / Variability in HIV viral tropism determination using different genotypic algorithms in patients infected with B versus non-B HIV-1 subtypes

Antecedentes Las herramientas genotípicas basadas en el análisis de la región V3 de la envuelta viral se perfilan como la alternativa a los ensayos fenotípicos para la determinación del tropismo del VIH por los receptores de quimiocinas CCR5 y CXCR4 en la práctica clínica. Este trabajo evalúa la concordancia entre los distintos algoritmos de interpretación genotípica actualmente disponibles en pacientes VIH infectados con subtipo B versus subtipos no-B .Métodos Se seleccionaron pacientes VIH positivos, procedentes del Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), España. A partir de muestras de plasma, se amplificó y secuenció la región V3 de la envuelta viral. El tropismo viral se determinó usando 8 algoritmos genotípicos distintos. La concordancia entre los distintos predictores se evaluó calculando el índice de concordancia kappa. El subtipo genético fue determinado por análisis filogenético. Resultados Se incluyeron un total de 92 pacientes, 72 infectados por subtipo B y 20 por no-B. En pacientes con subtipo B, se obtuvieron valores significativos de kappa para todas combinaciones posibles (n=28) entre los algoritmos genotípicos analizados. La mejores valores entre predictores no relacionados se obtuvieron para webPSSMSINSI/WetcatPART (k: 0,771) y webPSSMSINSI/geno2pheno (k: 0,574). En subtipos no-B solo se obtuvieron valores significativos para 13 combinaciones, correspondiendo los mejores a PSSMX4R5/WetcatPART (k: 0,600) y PSSMSINSI/Charge rule (k: 0,590) (..) (AU)

Background Genotypic tools based on the analysis of the V3 region are seen as an alternative to phenotypic assays for viral tropism determination before prescribing maraviroc. The concordance between different genotypic algorithms has been evaluated in HIV+ patients infected with B versus non-B subtypes. Methods HIV-infected patients on regular follow up at Hospital Universitario de Santiago de Compostela (Spain) were selected. The env-V3 region was sequenced from plasma samples and viral tropism was estimated using 8 different genotypic algorithms. Concordance among predictors was statistically evaluated by the calculation of the kappa index. Phylogenetic analyses were performed to determine the genetic subtype. Results A total of 92 HIV-infected patients were selected, 72 B and 20 non-B subtypes. Regarding the B subtype group, significant kappa values were obtained among all 28 possible combinations between the genotypic predictors evaluated. The best concordance among non-related predictors was observed for webPSSMSINSI/WetcatPART (k: 0.771) and webPSSMSINSI/geno2pheno (k: 0.574). Conversely, among non-B subtypes, a significative kappa index was only obtained for 13 combinations. Among non-B subtypes, the best concordance values were obtained for webPSSMX4R5/WetcatPART (k: 0.600) and webPSSMSINSI/Charge rule (k: 0.590).Conclusion A high concordance was observed between different genotypic algorithms to determine viral tropism among HIV-1 B subtypes infected patients, especially between webPSSMSINSI and geno2pheno or Wetcat. Conversely, the overall concordance among non-B subtypes was lower. This heterogeneity could be justified by the low prevalence of non B subtypes in the datasets in which the genotypic tropism predictors were trained (AU)