Telemedicine and Pediatric Care in Rural and Remote Areas of Middle-and-Low-Income Countries: Narrative Review.

OBJECTIVES: Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC. METHODOLOGY: A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC. RESULTS: Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency. CONCLUSION: Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care.

Effect of preterm birth on growth and blood pressure in adulthood in the Pelotas 1993 cohort.

BACKGROUND: Preterm birth has been associated with increased risk of hypertension and cardiovascular disease later in adulthood, attributed to cardiovascular and metabolic alterations in early life. However, there is paucity of evidence from low- and middle-income countries (LMICs). METHODS: We investigated the differences between preterm (<37 weeks gestational age) and term-born individuals in birth length and weight as well as adult (18 and 20 years) height, weight and blood pressure in the Brazilian 1993 Pelotas birth cohort using linear regressions. Analyses were adjusted for the maternal weight at the beginning of pregnancy and maternal education and family income at childbirth. Additional models were adjusted for body mass index (BMI) and birthweight. Separate analyses were run for males and females. The complete sample was analysed with an interaction term for sex. RESULTS: Of the 3585 babies included at birth, 3010 were followed up in adulthood at 22 years. Preterm participants had lower length and weight at birth. This difference remained for male participants in adulthood, but female participants were no shorter than their term counterparts by 18 years of age. At 22 years, females born preterm had lower blood pressures (systolic blood pressure -1.00 mmHg, 95%CI -2.7, 0.7 mmHg; diastolic blood pressure -1.1 mmHg, 95%CI -2.4, 0.3 mmHg) than females born at term. These differences were not found in male participants. CONCLUSIONS: In this Brazilian cohort we found contrasting results regarding the association of preterm birth with blood pressure in young adulthood, which may be unique to an LMIC.

Chagas Disease Diagnostic Testing in Two Academic Hospitals in New Orleans, Louisiana: A Call to Action.

Chagas disease, caused by the protozoa parasite Trypanosoma cruzi, is an anthropozoonosis that represents a major public health problem in the Americas, affecting 7 million people with at least 65 million at risk. We sought to assess the intensity of disease surveillance based on diagnostic test requests from hospitals in New Orleans, Louisiana. We extracted information from send-out labs at two major tertiary academic hospitals in New Orleans, Louisiana, USA, from 1 January 2018 to 1 December 2020. We found that in these three years there were 27 patients for whom Chagas disease testing was ordered. Most of these patients were male (70%), with a median age of 40 years old, and their most common ethnical background was Hispanic (74%). These findings demonstrate undertesting of this neglected disease in our region. Given the low Chagas disease surveillance, we need to increase awareness, health promotion, and education among healthcare workers.

Addressing bias and knowledge gaps regarding race and ethnicity in neonatology manuscript review.

A recent shift in public attention to racism, racial disparities, and health equity have resulted in an abundance of calls for relevant papers and publications in academic journals. Peer-review for such articles may be susceptible to bias, as subject matter expertise in the evaluation of social constructs, like race, is variable. From the perspective of researchers focused on neonatal health equity, we share our positive and negative experiences in peer-review, provide relevant publicly available data regarding addressing bias in peer-review from 12 neonatology-focused journals, and give recommendations to address bias and knowledge gaps in the peer review process of health equity research.

Risk factors for vertical transmission of Chagas disease: A systematic review and meta-analysis.

BACKGROUND: Vertical transmission of Trypanosoma cruzi infection from mother to infant accounts for a growing proportion of new Chagas disease cases. However, no systematic reviews of risk factors for T. cruzi vertical transmission have been performed. METHODS: We performed a systematic review of the literature in PubMed, LILACS, and Embase databases, following PRISMA guidelines. Studies were not excluded based on language, country of origin, or publication date. RESULTS: Our literature review yielded 27 relevant studies examining a wide variety of risk factors, including maternal age, parasitic load, immunologic factors and vector exposure. Several studies suggested that mothers with higher parasitic loads may have a greater risk of vertical transmission. A meta-analysis of 2 studies found a significantly higher parasitic load among transmitting than non-transmitting mothers with T. cruzi infection. A second meta-analysis of 10 studies demonstrated that maternal age was not significantly associated with vertical transmission risk. CONCLUSIONS: The literature suggests that high maternal parasitic load may be a risk factor for congenital Chagas disease among infants of T. cruzi seropositive mothers. Given the considerable heterogeneity and risk of bias among current literature, additional studies are warranted to assess potential risk factors for vertical transmission of T. cruzi infection.

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort.

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

Cough Frequency During Treatment Associated With Baseline Cavitary Volume and Proximity to the Airway in Pulmonary TB.

BACKGROUND: Cough frequency, and its duration, is a biomarker that can be used in low-resource settings without the need of laboratory culture and has been associated with transmission and treatment response. Radiologic characteristics associated with increased cough frequency may be important in understanding transmission. The relationship between cough frequency and cavitary lung disease has not been studied. METHODS: We analyzed data in 41 adults who were HIV negative and had culture-confirmed, drug-susceptible pulmonary TB throughout treatment. Cough recordings were based on the Cayetano Cough Monitor, and sputum samples were evaluated using microscopic observation drug susceptibility broth culture; among culture-positive samples, bacillary burden was assessed by means of time to positivity. CT scans were analyzed by a US-board-certified radiologist and a computer-automated algorithm. The algorithm evaluated cavity volume and cavitary proximity to the airway. CT scans were obtained within 1 month of treatment initiation. We compared small cavities (≤ 7 mL) and large cavities (> 7 mL) and cavities located closer to (≤ 10 mm) and farther from (> 10 mm) the airway to cough frequency and cough cessation until treatment day 60. RESULTS: Cough frequency during treatment was twofold higher in participants with large cavity volumes (rate ratio [RR], 1.98; P = .01) and cavities located closer to the airway (RR, 2.44; P = .001). Comparably, cough ceased three times faster in participants with smaller cavities (adjusted hazard ratio [HR], 2.89; P = .06) and those farther from the airway (adjusted HR, 3.61;, P = .02). Similar results were found for bacillary burden and culture conversion during treatment. CONCLUSIONS: Cough frequency during treatment is greater and lasts longer in patients with larger cavities, especially those closer to the airway.

The Latin America and the Caribbean search strategy proposal.

Latin America and the Caribbean's public health literature is not widely recognized. Science in this region has even been compared to a night sky with just a few specks of light. To make those lights as reachable as possible, we developed the Latin America and the Caribbean Search Strategy (LACSS). This is a new method to utilize our region's health promotion results within MEDLINE/PubMed. In contrast to a typical MeSH query, LACSS retrieves up to six times more publication results regarding non-communicable diseases, neglected tropical diseases, injuries and other important public health relevant topics in the region. We believe that global health promotion will be improved in this region by improving its visibility, and this search strategy will contribute to this.

Linking Individual Natural History to Population Outcomes in Tuberculosis.

Background: Substantial individual heterogeneity exists in the clinical manifestations and duration of active tuberculosis. We sought to link the individual-level characteristics of tuberculosis disease to observed population-level outcomes. Methods: We developed an individual-based, stochastic model of tuberculosis disease in a hypothetical cohort of patients with smear-positive tuberculosis. We conceptualized the disease process as consisting of 2 states-progression and recovery-including transitions between the 2. We then used a Bayesian process to calibrate the model to clinical data from the prechemotherapy era, thus identifying the rates of progression and recovery (and probabilities of transition) consistent with observed population-level clinical outcomes. Results: Observed outcomes are consistent with slow rates of disease progression (median doubling time: 84 days, 95% uncertainty range 62-104) and a low, but nonzero, probability of transition from disease progression to recovery (median 16% per year, 95% uncertainty range 11%-21%). Other individual-level dynamics were less influential in determining observed outcomes. Conclusions: This simplified model identifies individual-level dynamics-including a long doubling time and low probability of immune recovery-that recapitulate population-level clinical outcomes of untreated tuberculosis patients. This framework may facilitate better understanding of the population-level impact of interventions acting at the individual host level.

Dynamics of Cough Frequency in Adults Undergoing Treatment for Pulmonary Tuberculosis.

Background: Cough is the major determinant of tuberculosis transmission. Despite this, there is a paucity of information regarding characteristics of cough frequency throughout the day and in response to tuberculosis therapy. Here we evaluate the circadian cycle of cough, cough frequency risk factors, and the impact of appropriate treatment on cough and bacillary load. Methods: We prospectively evaluated human immunodeficiency virus-negative adults (n = 64) with a new diagnosis of culture-proven, drug-susceptible pulmonary tuberculosis immediately prior to treatment and repeatedly until treatment day 62. At each time point, participant cough was recorded (n = 670) and analyzed using the Cayetano Cough Monitor. Consecutive coughs at least 2 seconds apart were counted as separate cough episodes. Sputum samples (n = 426) were tested with microscopic-observation drug susceptibility broth culture, and in culture-positive samples (n = 252), the time to culture positivity was used to estimate bacillary load. Results: The highest cough frequency occurred from 1 pm to 2 pm, and the lowest from 1 am to 2 am (2.4 vs 1.1 cough episodes/hour, respectively). Cough frequency was higher among participants who had higher sputum bacillary load (P < .01). Pretreatment median cough episodes/hour was 2.3 (interquartile range [IQR], 1.2-4.1), which at 14 treatment days decreased to 0.48 (IQR, 0.0-1.4) and at the end of the study decreased to 0.18 (IQR, 0.0-0.59) (both reductions P < .001). By 14 treatment days, the probability of culture conversion was 29% (95% confidence interval, 19%-41%). Conclusions: Coughs were most frequent during daytime. Two weeks of appropriate treatment significantly reduced cough frequency and resulted in one-third of participants achieving culture conversion. Thus, treatment by 2 weeks considerably diminishes, but does not eliminate, the potential for airborne tuberculosis transmission.

A quantitative adaptation of the Wayne test for pyrazinamide resistance.

BACKGROUND: Pyrazinamide (PZA) is the most important drug against the latent stage of tuberculosis (TB) and is used in both first and second line treatment regimens. The continued increase in multi-drug resistant TB and the prevalence of PZA resistance makes the development of alternative assays for prompt identification of PZA resistance all the more important. METHODS: We standardized and evaluated a quantitative variant of the Wayne assay (QW) for determining PZA resistance in Mycobacterium tuberculosis strains. This assay quantifies M. tuberculosis metabolism of PZA and production of pyrazinoic acid (POA) using visible spectrophotometry. We evaluated this method using PZA concentrations of 400 µg/ml and 800 µg/ml at incubation periods of 3, 5 and 7 days. M. tuberculosis strains from 68 sputum samples were also tested with the standard Wayne assay, Tetrazolium Microplate Assay (TEMA), Bactec 460TB and pncA sequencing. We compared QW and standard Wayne assay against a dichotomous reference classification using concordant Bactec 460TB and pncA sequencing. Secondarily, we determined the quantitative correlation between both QW values and TEMA's minimum inhibitory concentration (MIC) against Bactec 460TB percentage growth. RESULTS: The standard Wayne showed sensitivity of 88% and specificity of 97.5%, giving a Youden Index (YI) of 0.855 against reference tests. The QW showed maximum YI of 0.934 on day 7 at 400 µg/ml PZA with 96% sensitivity and 97.4% specificity. Absorbance OD values for 400 µg/ml PZA were more accurate than 800 µg/ml PZA. Although QW showed high accuracy for PZA susceptibility, it did not correlate quantitatively with Bactec percentage growth. TEMA testing was unreliable and did not correlate with Bactec results. CONCLUSIONS: The proposed QW assay is an inexpensive method capable of providing standardization and automation of colorimetric PZA resistance testing, with better discriminatory than the standard Wayne assay.

The dream of health information for all.

In 2004, an influential report in The Lancet suggested that open health information for all could be achieved by 2015. Unfortunately, this goal has not yet been accomplished. Despite progress in obtaining quality scientific articles in Latin America, it remains difficult to reliably access new and cutting-edge research. As graduating Peruvian medical students, we have confronted many obstacles in obtaining access to quality and up-to-date information and a constant tension between accessing "what is available" rather than "what we need". As we have learned, these limitations affect not only our own education but also the choices we make in the management of our patients. In the following article, we state our point of view regarding limitations in access to scientific articles in Peru and Latin America.

Nutritional intake and weight z-scores in very low birth weight infants in Peru.

OBJECTIVES: To determine the actual nutritional intake of very low birth weight infants and their growth outcome during the first month of life. Additionally, we identified factors that account for a negative neonatal outcome in this population. METHODS: A case-series study was conducted in a tertiary hospital in Lima, Peru between 2011 and 2012 and the data was obtained from medical records. No feeding protocol was used during this study. Daily fluids, energy and protein intakes were documented and weekly weight z-scores were calculated. A logistic regression analysis was used to identify factors for an adverse outcome, defined as neonatal mortality or extra-uterine growth restriction, during the first 28 days of life. RESULTS: After applying selection criteria, 76 participants were included. The nutritional intakes were similar to standard values seen in the literature, but protein intakes were suboptimal in all of the four weeks. Birth weight z-score was associated with an adverse outcome (p=0.035). It was determined that having a birth weight z-score under -1.09 predicted a negative outcome with an area under the curve of 96.8% [93.5%, 100%] with a 95% confidence interval. CONCLUSION: Protein intakes are widely deficient in the population of this study. Nevertheless, an adverse outcome during the neonatal period is more associated with a poor birth weight z-score than nutrition-related factors.

OBJETIVOS: Determinar las ingestas nutricionales en los recién nacidos de muy bajo peso al nacer y su respectivo crecimiento en el primer mes de vida. Adicionalmente, identificar factores para un desenlace negativo en el periodo neonatal de esta población. METODOS: Estudio de serie de casos desarrollado en un hospital de tercer nivel en Lima, Perú desde 2011 a 2012. La información se obtuvo de las historias médicas. No se utilizó un protocolo de nutrición durante el estudio. La ingesta diaria del volumen, la energía y las proteínas fue registrada al igual que el puntaje z del peso de manera semanal. Se utilizó regresión logística para identificar factores asociados a un desenlace adverso, que se define como mortalidad neonatal o restricción de crecimiento extrauterino en los primeros 28 días de vida. RESULTADOS: Luego del criterio de selección, se incluyeron a 76 participantes. Las ingestas nutricionales fueron similares a los valores descritos en la literatura, pero la ingesta proteica fue sub óptima durante las cuatro semanas. El puntaje z del peso al nacer se asocia con un desenlace adverso (p=0,035). Se determinó que un puntaje z menor de 1,09 predice un desenlace negativo con un área bajo la curva ROC de 96,8% (93,5%, 100%), con un intervalo de confianza del 95%. CONCLUSIÓN: Las ingestas proteicas fueron sumamente deficientes en este estudio. Sin embargo, un desenlace adverso se asocia más a un pobre puntaje z al nacer que a factores relacionados a la nutrición.

Protocol for studying cough frequency in people with pulmonary tuberculosis.

INTRODUCTION: Cough is a key symptom of tuberculosis (TB) as well as the main cause of transmission. However, a recent literature review found that cough frequency (number of coughs per hour) in patients with TB has only been studied once, in 1969. The main aim of this study is to describe cough frequency patterns before and after the start of TB treatment and to determine baseline factors that affect cough frequency in these patients. Secondarily, we will evaluate the correlation between cough frequency and TB microbiological resolution. METHODS: This study will select participants with culture confirmed TB from 2 tertiary hospitals in Lima, Peru. We estimated that a sample size of 107 patients was sufficient to detect clinically significant changes in cough frequency. Participants will initially be evaluated through questionnaires, radiology, microscopic observation drug susceptibility broth TB-culture, auramine smear microscopy and cough recordings. This cohort will be followed for the initial 60 days of anti-TB treatment, and throughout the study several microbiological samples as well as 24 h recordings will be collected. We will describe the variability of cough episodes and determine its association with baseline laboratory parameters of pulmonary TB. In addition, we will analyse the reduction of cough frequency in predicting TB cure, adjusted for potential confounders. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the ethics committees at each participating hospital in Lima, Peru, Asociación Benéfica PRISMA in Lima, Peru, the Universidad Peruana Cayetano Heredia in Lima, Peru and Johns Hopkins University in Baltimore, USA. We aim to publish and disseminate our findings in peer-reviewed journals. We also expect to create and maintain an online repository for TB cough sounds as well as the statistical analysis employed.

[Mobile health for public health in Peru: lessons learned]. / Tecnologías móviles para la salud pública en el Perú: lecciones aprendidas.

Mobile communication technologies have become more prevalent in developed and developing countries. These coun- tries -including Peru- are becoming an ideal setting where mobile health (mHealth) projects can provide better health services. The reviewed literature shows that the mHealth interventions have enormous potential to improve access and the quality of health services, increasing the effectiveness of public health programs and reducing healthcare costs. It is noticeable that these projects have a positive impact; however, despite the current information, more research is needed to understand mHealth in-depth. These projects are the foundation for future health policies that will help the Peruvian health system to be more inclusive and more effective.

Tecnologías móviles para la salud pública en el Perú: lecciones aprendidas / Mobile health for public health in Peru: lessons learned

En los últimos años, las tecnologías de la comunicación móvil se han expandido de manera rápida tanto en los países desarrollados como en vías de desarrollo. Estos países, incluyendo a Perú, son escenarios ideales donde las herramientas de la salud móvil (mSalud) se convierten en excelentes oportunidades para brindar y hacer más inclusivo los servicios de salud. La literatura revisada muestra que las intervenciones de mSalud en nuestro país, presentan un enorme potencial para mejorar el acceso y calidad de la los servicios de salud, aumentando la efectividad de los programas de salud pública y reduciendo los costos de la asistencia sanitaria. No obstante, se requiere de mayor investigación en estas áreas para com- prender en su totalidad el potencial de la mSalud para que puedan ser base y sustento de políticas de estado innovadoras, integradas al sistema de salud y costo-efectivas para la mejora en la atención e inclusión en salud en Perú.

Mobile communication technologies have become more prevalent in developed and developing countries. These coun- tries -including Peru- are becoming an ideal setting where mobile health (mHealth) projects can provide better health services. The reviewed literature shows that the mHealth interventions have enormous potential to improve access and the quality of health services, increasing the effectiveness of public health programs and reducing healthcare costs. It is noticeable that these projects have a positive impact; however, despite the current information, more research is needed to understand mHealth in-depth. These projects are the foundation for future health policies that will help the Peruvian health system to be more inclusive and more effective.