Accesibilidad, disponibilidad y asequibilidad de medicamentos para Niños con Enfermedad Renal Crónica en Guatemala / Access, availability and affordability of medications for children with Advanced Chronic Kidney Disease in Guatemala

El artículo tiene como objetivo analizar la disponibilidad, acceso y asequibilidad de los medicamentos para niños con Enfermedad Renal Crónica (ERC) en tratamiento con hemodiálisis (HD) en un país de bajos a medianos ingresos. Se llevó a cabo un estudio transversal para determinar los medicamentos más utilizados en una unidad de hemodiálisis pediátrica, incluyendo el nombre del medicamento, dosis, frecuencia, forma farmacéutica y vía de administración. Dos farmacias dentro del perímetro del hospital, una pública y una privada, fueron consultadas para determinar el costoy disponibilidad de medicamentos genéricos y de marca. De un total de 30 pacientes de la unidad de hemodiálisis, 22 expedientes fueron revisados. En general 94% de marca se encontraban disponibles en las farmacias consultadas en comparación a un 52% de los medicamentos genéricos. En farmacias públicas, 41% de medicamentos de marca y 29% de medicamentos genéricos se encontraban disponibles. El costo promedio para un mes de tratamiento con medicamentos de marca adquiridos en una farmacia privada era de $495.00 vs $299.00 en una farmacia pública. Para medicamentos genéricos, el costo promedio correspondía a $414.00 y $239.00 en farmacias privadas y públicas respectivamente. En promedio, los medicamentos de marca adquiridos en una farmacia privada requieren 41 días de trabajo en un mes a comparación de 25 días si se adquieren en una farmacia pública. Los medicamentos genéricos adquiridos en farmacias privadas corresponden a 34 días de trabajo vs 20 días en farmacias públicas. En general existió un acceso limitado a medicamentos genéricos y los medicamentos poseen un costo general más elevado a comparación de otros países lo que implica un posible impacto en la adherencia terapéutica y los padecimientos secundarios de la ERC en los pacientes pediátricos en Guatemala. Esta realidad se puede aplicar a otros países de bajos a medianos ingresos.

This article aims to analyze the availability, access, and affordability of medications for children with advanced Chronic Kidney Disease (CKD) treated with hemodialysis (HD) in a low to middle income country (LMIC). A cross- sectional chart review was carried out to determine the most common medications used in an HD pediatric unit, including medication name, dose, frequency, dosage form, and route of administration. Two pharmacies within the hospital perimeter, one public and one private, were consulted to determine medication cost and availability for generic and brand-name equivalents. From 30 patients attending the HD unit, 22 records were reviewed. Overall, 94 % of brand name medications were available at pharmacies consulted, versus and 52% of generic medications. In public pharmacies, 41% of brand name, and 29% of generic medications were available. The average cost for a full month´s treatment for brand name drugs in the private pharmacy was 495.00 USD versus 299.00 USD in the public pharmacy. For generic drugs, the average cost was 414.00 USD, and 239.00 USD in private and public pharmacies respectively. On average, brand-name drugs in the private pharmacy cost 41 days' wages versus 25 in the public pharmacy. Generic drugs in the private pharmacy cost 34 days' wages versus 20 in the public pharmacy. Overall, there was limited access to generic medications, medications had an overall high cost compared to other countries both of which have the potential to impact treatment adherence and overall outcomes of CKD5 pediatric patients in Guatemala. This reality can be translated to other LMIC.

Standardizing an Experimental Murine Model of Extraparenchymal Neurocysticercosis That Immunologically Resembles Human Infection.

BACKGROUND: Neurocysticercosis (NCC) is endemic in non-developed regions of the world. Two forms of NCC have been described, for which neurological morbidity depends on the location of the lesion, which can be either within the cerebral parenchyma or in extraparenchymal spaces. The extraparenchymal form (EXP-NCC) is considered the most severe form of NCC. EXP-NCC often requires several cycles of cysticidal treatment and the concomitant use of glucocorticoids to prevent increased inflammation, which could lead to intracranial hypertension and, in rare cases, to death. Thus, the improvement of EXP-NCC treatment is greatly needed. METHODS: An experimental murine model of EXP-NCC, as an adequate model to evaluate new therapeutic approaches, and the parameters that support it are described. EXP-NCC was established by injecting 30 Taenia crassiceps cysticerci, which are less than 0.5 mm in diameter, into the cisterna magna of male and female Wistar rats. RESULTS: Cyst implantation and infection progression were monitored by detecting the HP10 antigen and anti-cysticercal antibodies in the serum and cerebral spinal fluid (CSF) of infected rats and by magnetic resonance imaging. Higher HP10 levels were observed in CSF than in the sera, as in the case of human EXP-NCC. Low cell recruitment levels were observed surrounding established cysticerci in histological analysis, with a modest increase in GFAP and Iba1 expression in the parenchyma of female animals. Low cellularity in CSF and low levels of C-reactive protein are consistent with a weak inflammatory response to this infection. After 150 days of infection, EXP-NCC is accompanied by reduced levels of mononuclear cell proliferation, resembling the human disease. EXP-NCC does not affect the behavior or general status of the rats. CONCLUSIONS: This model will allow the evaluation of new approaches to control neuroinflammation and immunomodulatory treatments to restore and improve the specific anti-cysticercal immunity in EXP-NCC.

Environmental and Social Factors Associated with High Chronic Kidney Disease Mortality Rates in Municipalities of Guatemala: An Ecological Study of Municipal-Level Mortality Data.

The purpose of this study was to determine the association between social and environmental indicators and high mortality rates from chronic kidney disease (CKD) in municipalities of Guatemala. An ecological study of municipal-level factors associated with CKD mortality in Guatemala was conducted. Crude mortality rates were calculated for the 2009-2019 period for each of the country's 340 municipalities, by gender and age groups. Municipal-level social and environmental indicators were used as independent variables. Linear regression was used for bivariate and multivariate analysis. A total of 28,723 deaths from CKD were documented for the 2009-2019 period. Average crude mortality rate for all ages for the country's 340 municipalities was 70.66 per 100,000 [0-502.99]. Very highly positive associations with high mortality rates were found in two agrarian territories where land use is mainly for permanent crops (e.g., sugar cane, coffee, rubber, banana, plantain, African palm) and pastures for cattle, with very low percentages of land covered by forests or protected areas. Social factors related to poverty and environmental factors related to agricultural use of land may play a role in the high CKD mortality rates documented in a cluster of municipalities of Guatemala.

Intranasal Methylprednisolone Ameliorates Neuroinflammation Induced by Chronic Toluene Exposure.

Inhalants are chemical substances that induce intoxication, and toluene is the main component of them. Increasing evidence indicates that a dependence on inhalants involves a state of chronic stress associated to the activation of immune cells in the central nervous system and release of proinflammatory mediators, especially in some brain areas such as the nucleus accumbens and frontal cortex, where the circuits of pleasure and reward are. In this study, anti-neuroinflammatory treatment based on a single dose of intranasal methylprednisolone was assessed in a murine model of chronic toluene exposure. The levels of proinflammatory mediators, expression levels of Iba-1 and GFAP, and histological changes in the frontal cortex and nucleus accumbens were evaluated after the treatment. The chronic exposure to toluene significantly increased the levels of TNF-α, IL-6, and NO, the expression of GFAP, and induced histological alterations in mouse brains. The treatment with intranasally administered MP significantly reduced the expression of TNF-α and NO and the expression of GFAP (p < 0.05); additionally, it reversed the central histological damage. These results indicate that intranasally administered methylprednisolone could be considered as a treatment to reverse neuroinflammation and histological damages associated with the use of inhalants.

Disponibilidad de antibióticos en tiendas de Guatemala.

No disponible.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala.

OBJECTIVE: To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. METHODS: A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER's pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis. RESULTS: The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother's education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables. CONCLUSIONS: Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother's level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala

[ABSTRACT]. Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER’s pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis. Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother’s education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables. Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother’s level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

[RESUMEN]. Objetivo. Determinar los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala. Métodos. Se realizó una encuesta transversal. La población de estudio fue la totalidad de pacientes pediátricos con enfermedad renal crónica en fase 5 ingresados en la unidad de nefrología pediátrica de Fundanier (N = 156). Mediante el muestreo aleatorio simple se dispuso de un total de 100 participantes. La recopilación de datos consistió en un cuestionario que abordaba las características individuales y del hogar, el acceso y el uso de la atención de salud y el lugar de residencia al inicio de la enfermedad. La etiología de la enfermedad renal crónica se obtuvo a partir de los expedientes médicos y los datos secundarios se recopilaron a nivel municipal. Se calcularon las estadísticas descriptivas y se empleó el método de regresión logística para el análisis bifactorial y multifactorial. Resultados. La razón de posibilidades (OR) se aproximó a 1 en casi todas las variables. Dos excepciones destacables en lo relativo a las características domésticas fueron el nivel de escolaridad de la madre hasta la educación primaria (OR 2,2727) y el lugar de residencia en un entorno urbano en la aparición de los síntomas (OR 0,4035). Las excepciones con respecto a las características municipales fueron las zonas de agricultura intensiva a pequeña escala (OR 3,8923) y las zonas de agricultura intensiva a gran escala (OR 0,3338). Los valores P y los intervalos de confianza indican que la muestra no fue lo suficientemente amplia para recoger las asociaciones estadísticamente significativas entre variables. Conclusiones. Los resultados del estudio sugieren que los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala son las prácticas agrícolas intensivas en el municipio de residencia y el nivel de escolaridad de la madre. Las futuras investigaciones con niños podrían incluir el diseño de casos o los estudios poblacionales en comunidades agrícolas. Se recomiendan intervenciones de salud pública que incorporen el tamizaje de la función renal en niños.

[RESUMO]. Objetivo. Identificar os fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Métodos. Foi realizado um estudo transversal em uma população que consistiu de todos os pacientes pediátricos com doença renal crônica ativa em estágio 5 atendidos na unidade de nefrologia pediátrica da Fundación para el Niño Enfermo Renal (FUNDANIER) (N = 156). O processo de amostragem aleatória simples determinou a obtenção de uma amostra com 100 participantes. Um questionário foi usado para a coleta de dados sobre as características pessoais e familiares dos participantes, acesso à assistência de saúde e utilização de serviços e local de residência ao início da doença. Informação sobre a etiologia da doença renal crônica foi obtida dos prontuários médicos. Também foram coletados dados secundários ao nível da localidade. Estatísticas descritivas foram estimadas e um modelo de regressão logística foi usado nas análises bivariada e multivariada. Resultados. As razões de chance (odds ratio, OR) de quase todas as variáveis se aproximaram de 1. As exceções nas variáveis relativas às características familiares foram escolaridade da mãe de nível fundamental (OR 2,2727) e residir em área urbana ao início dos sintomas (OR 0,4035). As exceções nas variáveis ao nível municipal foram áreas de agricultura intensiva em pequena escala (OR 3,8923) e em grande escala (OR 0,3338). Os valores de p e os intervalos de confiança indicam que o tamanho da amostra não foi grande o suficiente para detectar associações estatisticamente significativas entre as variáveis. Conclusões. O estudo demonstrou que práticas agrícolas intensivas na localidade de residência e nível de escolaridade da mãe são fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Outros estudos em crianças devem ser realizados como estudos de caso-controle ou estudos populacionais em comunidades agrícolas. Recomendam-se também intervenções de saúde pública com a avaliação preventiva da função renal em crianças.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala / Factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala / Fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala

ABSTRACT Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER's pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis. Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother's education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables. Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother's level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

RESUMEN Objetivo. Determinar los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala. Métodos. Se realizó una encuesta transversal. La población de estudio fue la totalidad de pacientes pediátricos con enfermedad renal crónica en fase 5 ingresados en la unidad de nefrología pediátrica de Fundanier (N = 156). Mediante el muestreo aleatorio simple se dispuso de un total de 100 participantes. La recopilación de datos consistió en un cuestionario que abordaba las características individuales y del hogar, el acceso y el uso de la atención de salud y el lugar de residencia al inicio de la enfermedad. La etiología de la enfermedad renal crónica se obtuvo a partir de los expedientes médicos y los datos secundarios se recopilaron a nivel municipal. Se calcularon las estadísticas descriptivas y se empleó el método de regresión logística para el análisis bifactorial y multifactorial. Resultados. La razón de posibilidades (OR) se aproximó a 1 en casi todas las variables. Dos excepciones destacables en lo relativo a las características domésticas fueron el nivel de escolaridad de la madre hasta la educación primaria (OR 2,2727) y el lugar de residencia en un entorno urbano en la aparición de los síntomas (OR 0,4035). Las excepciones con respecto a las características municipales fueron las zonas de agricultura intensiva a pequeña escala (OR 3,8923) y las zonas de agricultura intensiva a gran escala (OR 0,3338). Los valores P y los intervalos de confianza indican que la muestra no fue lo suficientemente amplia para recoger las asociaciones estadísticamente significativas entre variables. Conclusiones. Los resultados del estudio sugieren que los factores asociados a la enfermedad renal crónica por causas no tradicionales en niños en Guatemala son las prácticas agrícolas intensivas en el municipio de residencia y el nivel de escolaridad de la madre. Las futuras investigaciones con niños podrían incluir el diseño de casos o los estudios poblacionales en comunidades agrícolas. Se recomiendan intervenciones de salud pública que incorporen el tamizaje de la función renal en niños.

RESUMO Objetivo. Identificar os fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Métodos. Foi realizado um estudo transversal em uma população que consistiu de todos os pacientes pediátricos com doença renal crônica ativa em estágio 5 atendidos na unidade de nefrologia pediátrica da Fundación para el Niño Enfermo Renal (FUNDANIER) (N = 156). O processo de amostragem aleatória simples determinou a obtenção de uma amostra com 100 participantes. Um questionário foi usado para a coleta de dados sobre as características pessoais e familiares dos participantes, acesso à assistência de saúde e utilização de serviços e local de residência ao início da doença. Informação sobre a etiologia da doença renal crônica foi obtida dos prontuários médicos. Também foram coletados dados secundários ao nível da localidade. Estatísticas descritivas foram estimadas e um modelo de regressão logística foi usado nas análises bivariada e multivariada. Resultados. As razões de chance (odds ratio, OR) de quase todas as variáveis se aproximaram de 1. As exceções nas variáveis relativas às características familiares foram escolaridade da mãe de nível fundamental (OR 2,2727) e residir em área urbana ao início dos sintomas (OR 0,4035). As exceções nas variáveis ao nível municipal foram áreas de agricultura intensiva em pequena escala (OR 3,8923) e em grande escala (OR 0,3338). Os valores de p e os intervalos de confiança indicam que o tamanho da amostra não foi grande o suficiente para detectar associações estatisticamente significativas entre as variáveis. Conclusões. O estudo demonstrou que práticas agrícolas intensivas na localidade de residência e nível de escolaridade da mãe são fatores associados a doença renal crônica de etiologia não tradicional em crianças na Guatemala. Outros estudos em crianças devem ser realizados como estudos de caso-controle ou estudos populacionais em comunidades agrícolas. Recomendam-se também intervenções de saúde pública com a avaliação preventiva da função renal em crianças.

Indicadores de desigualdad y mortalidad por enfermedades cardiometabólicas en Guatemala / Inequality indicators and cardiometabolic diseases mortality in Guatemalahttps

La medición de las desigualdades en salud al interior de los países de ingresos bajos y medios es necesaria para la planificación, monitoreo y evaluación de intervenciones de salud pública, especialmente para problemas que contribuyen altamente a la carga de enfermedad, como las enfermedades cardiometabólicas. El objetivo de este estudio fue caracterizar los patrones de desigualdad de las tasas de mortalidad para las principales causas cardiometabólicas en Guatemala. Se usó datos del Censo Nacional de Población, y estadísticas oficiales de de-función de 2018 para calcular tasas crudas de mortalidad para diabetes (DM), infarto agudo de miocardio (IAM), y accidente cerebrovascular (ACV). Se calcularon indicadores simples y complejos de desigualdad absoluta y relativa (diferencia, razón, índice de pendiente, índice de concentración, distancia de la media, índice de Theil, riesgo atribuible poblacional, y porcentaje de riesgo atribuible poblacional) para seis dimensiones de desigualdad: sexo, pueblo de pertenencia, nivel educativo, tipo de ocupación, departamento y municipio. Se documentaron 6,445 muertes por DM, 5,761 por IAM, y 3,218 por ACV. Los indicadores mostraron marcadas desigualdades para las seis dimensiones estudiadas. El patrón de desigualdad predominante para sexo, pueblo de pertenencia y departamento fue de privación masiva. Para nivel educativo y ocupación predominó un patrón de incrementos escalonados. Se identificó exclusión marginal superpuesta en nivel educativo, ocupación y municipio. Se concluye que los patrones de desigualdad de las tasas de mortalidad para estas tres enfermedades sugieren la superposición de patrones de privación masiva, incrementos escalonados, y exclusión marginal.

Measuring health inequalities within low- and middle-income countries is needed for planning, monitoring, and evaluation of public health interventions, especially for problems that represent a high burden of disease, like cardio metabolic diseases. The goal of this study was to characterize inequality patterns in mortality rates from cardio metabolic causes in Guatemala. Data from the 2018 National Population Census, and official vital statistics were used to estimate crude mortality rates for diabetes (DM), acute myocardial infarction (IAM), and stroke (ACV). Simple and complex indicators of absolute and relative inequality (difference, ratio, slope index, concentration index, distance from the mean, Theil index, population attributable risk, and percentage of popula-tion attributable risk) were calculated for six dimensions of inequality: sex, race/ethnicity, education level, type of occupation, department, and municipality. A total of 6,445 DM deaths, 5,761 IAM deaths, and 3,218 ACV deaths were documented. Indicators showed marked inequalities for the six dimensions studied. Massive deprivation was the predominant inequality pattern for sex, race/ethnicity, and department. Staggered increments were iden-tified for education level and type of occupation. Overlapping marginal exclusion was found for education level, occupation, and municipality. We conclude that inequality patterns found for the three causes of death suggest overlapping patterns of mass deprivation, staggered increments, and marginal exclusion.

Availability of over-the-counter antibiotics in Guatemalan corner stores.

Widespread availability of antibiotics without prescription potentially facilitates overuse and contributes to selection pressure for antimicrobial resistant bacteria. Prior to this study, anecdotal observations in Guatemala identified corner stores as primary antibiotic dispensaries, where people purchase antibiotics without prescriptions. We carried out a cross sectional study to document the number and types of antibiotics available in corner stores, in four study areas in Guatemala. A total of 443 corner stores were surveyed, of which 295 (67%) sold antibiotics. The most commonly available antibiotics were amoxicillin, found in 246/295 (83%) stores, and tetracycline, found in 195/295 (66%) stores. Over the counter sales result from laissez-faire enforcement of antibiotic dispensing regulations in Guatemala combined with patient demand. This study serves as a baseline to document changes in the availability of antibiotics in informal establishments in light of new pharmacy regulations for antibiotic dispensing, which were adopted after this study was completed.

La determinación social de la enfermedad renal crónica de causas no tradicionales (ERCnT) en Guatemala / The social determination of chronic kidney disease of non-traditional causes (CKDnT) in Guatemala

La Enfermedad Renal Crónica de Causas no Tradicionales (ERCnT) ha aumentado en los últimos 20 años, convirtiéndose en un problema de salud pública importante que se observa principalmente en países de Centroamérica y Asia, afectando especialmente a trabajadores agrícolas jóvenes. La presencia de factores de riesgo relacionados con toxinas, medio ambiente y condiciones laborales sugiere una causa multifactorial, la cual puede que involucre la exposición a agroquímicos, contaminantes ambientales, y episodios repetidos de deshidratación. La comprensión de las condiciones sociales que unen estos factores en grupos específicos de población es fundamental para el desarrollo de programas de salud pública tendientes a la prevención de esta epidemia devastadora. Luego de presentar brevemente los antecedentes, este ensayo discute el paradigma de causalidad de la enfermedad implícito en la literatura disponible sobre ERCnT, concretamente la "multicausalidad", sitúa el enfoque en su contexto histórico, y presenta sus fortalezas y limitaciones. Luego, el ensayo presenta dos paradigmas de causalidad que podrían ayudar a avanzar en la investigación sobre las causas de la enfermedad, específicamente los enfoques socioecológico y de determinación social de la salud. El ensayo concluye con recomendaciones para una agenda de investigación e intervención que enfoque en explicar las causas de la ERCnT.

Chronic Kidney Disease of non-Traditional Causes (CKDnT) has increased over the past 20 years, becoming a significant public health issue observed mainly in countries in Central America and Asia, primarily affecting young male agricultural workers. The presence of toxin-, environmental-, and work-related risk factors in the affected communities suggests a multifactorial cause, which may involve exposure to agrochemicals, environmental contaminants, and repeated episodes of dehydration. An understanding of the social conditions that bring these factors together in specific groups is essential for the development of public health programs to prevent this devastating epidemic. After a brief background, this essay discusses the paradigm of disease causality implied in the available literature on CKDnT, namely "multicausality", puts it in its historical context, and presents its strengths and limitations. The essay then presents two causality paradigms that could help move forward research about the causes of this disease, specifically the socioecological and the social determination of health approaches. The essay concludes with recommendations for a research and intervention agenda that focuses on explaining the causes of CKDnT.

"Medical tourism will obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala.

BACKGROUND: Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala. METHODS: After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically. RESULTS: Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system. CONCLUSION: From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

Factors associated to acceptable treatment adherence among children with chronic kidney disease in Guatemala.

Pediatric patients with Chronic Kidney Disease face several barriers to medication adherence that, if addressed, may improve clinical care outcomes. A cross sectional questionnaire was administered in the Foundation for Children with Kidney Disease (FUNDANIER, Guatemala City) from September of 2015 to April of 2016 to identify the predisposing factors, enabling factors and need factors related to medication adherence. Sample size was calculated using simple random sampling with a confidence level of 95%, confidence interval of 0.05 and a proportion of 87%. A total of 103 participants responded to the questionnaire (calculated sample size was 96). Independent variables were defined and described, and the bivariate relationship to dependent variables was determined using Odds Ratio. Multivariate analysis was carried out using logistic regression. The mean adherence of study population was 78% (SD 0.08, max = 96%, min = 55%). The mean adherence in transplant patients was 82% (SD 7.8, max 96%, min 63%), and the mean adherence in dialysis patients was 76% (SD 7.8 max 90%, min 55%). Adherence was positively associated to the mother's educational level and to higher monthly household income. Together predisposing, enabling and need factors illustrate the complexities surrounding adherence in this pediatric CKD population. Public policy strategies aimed at improving access to comprehensive treatment regimens may facilitate treatment access, alleviating economic strain on caregivers and may improve adherence outcomes.

Providers' perspectives on inbound medical tourism in Central America and the Caribbean: factors driving and inhibiting sector development and their health equity implications.

BACKGROUND: Many governments and health care providers worldwide are enthusiastic to develop medical tourism as a service export. Despite the popularity of this policy uptake, there is relatively little known about the specific local factors prospectively motivating and informing development of this sector. OBJECTIVE: To identify common social, economic, and health system factors shaping the development of medical tourism in three Central American and Caribbean countries and their health equity implications. DESIGN: In-depth, semi-structured interviews were conducted in Mexico, Guatemala, and Barbados with 150 health system stakeholders. Participants were recruited from private and public sectors working in various fields: trade and economic development, health services delivery, training and administration, and civil society. Transcribed interviews were coded using qualitative data management software, and thematic analysis was used to identify cross-cutting issues regarding the drivers and inhibitors of medical tourism development. RESULTS: Four common drivers of medical tourism development were identified: 1) unused capacity in existing private hospitals, 2) international portability of health insurance, vis-a-vis international hospital accreditation, 3) internationally trained physicians as both marketable assets and industry entrepreneurs, and 4) promotion of medical tourism by public export development corporations. Three common inhibitors for the development of the sector were also identified: 1) the high expense of market entry, 2) poor sector-wide planning, and 3) structural socio-economic issues such as insecurity or relatively high business costs and financial risks. CONCLUSION: There are shared factors shaping the development of medical tourism in Central America and the Caribbean that help explain why it is being pursued by many hospitals and governments in the region. Development of the sector is primarily being driven by public investment promotion agencies and the private health sector seeking economic benefits with limited consideration and planning for the health equity concerns medical tourism raises.

"That's enough patients for everyone!": Local stakeholders' views on attracting patients into Barbados and Guatemala's emerging medical tourism sectors.

BACKGROUND: Medical tourism has attracted considerable interest within the Latin American and Caribbean (LAC) region. Governments in the region tout the economic potential of treating foreign patients while several new private hospitals primarily target international patients. This analysis explores the perspectives of a range of medical tourism sector stakeholders in two LAC countries, Guatemala and Barbados, which are beginning to develop their medical tourism sectors. These perspectives provide insights into how beliefs about international patients are shaping the expanding regional interest in medical tourism. METHODS: Structured around the comparative case study methodology, semi-structured interviews were conducted with 50 medical tourism stakeholders in each of Guatemala and Barbados (n = 100). To capture a comprehensive range of perspectives, stakeholders were recruited to represent civil society (n = 5/country), health human resources (n = 15/country), public health care and tourism sectors (n = 15/country), and private health care and tourism sectors (n = 15/country). Interviews were transcribed verbatim, coded using a collaborative process of scheme development, and analyzed thematically following an iterative process of data review. RESULTS: Many Guatemalan stakeholders identified the Guatemalan-American diaspora as a significant source of existing international patients. Similarly, Barbadian participants identified their large recreational tourism sector as creating a ready source of foreign patients with existing ties to the country. While both Barbadian and Guatemalan medical tourism proponents share a common understanding that intra-regional patients are an existing supply of international patients that should be further developed, the dominant perception driving interest in medical tourism is the proximity of the American health care market. In the short term, this supplies a vision of a large number of Americans lacking adequate health insurance willing to travel for care, while in the long term, the Affordable Care Act is seen to be an enormous potential driver of future medical tourism as it is believed that private insurers will seek to control costs by outsourcing care to providers abroad. CONCLUSIONS: Each country has some comparative advantage in medical tourism. Assumptions about a large North American patient base, however, are not supported by reliable evidence. Pursuing this market could incur costs borne by patients in their public health systems.

Self-medication with antibiotics in four Guatemala City pharmacies: characteristics, sources of information, perceived effects, and motives

Existen pocas regulaciones que guíen el uso racional de antibióticos en países de rentas bajas o medias, lo cual facilita la automedicación con antibióticos (AMA). Describir las fuentes de información usadas durante la práctica de AMA, los efectos percibidos, y los motivos que rodean la práctica de AMA en Guatemala. Una encuesta descriptiva transversal se administró entre quienes compraron antibióticos sin receta en cuatro farmacias de ciudad de Guatemala. Las preguntas identificaron las características demográficas de los participantes, el origen de la solicitud de antibiótico, y los efectos percibidos de la AMA. En total, 230 participantes respondieron al cuestionario en cuatro farmacias. Dos farmacias correspondieron a un contexto socioeconómico bajo (FSEB) y dos correspondieron a un contexto socioeconómico alto (FSEA). La mayoría de participantes de las FSEB (93%) y de FSEA (60%) reportaron haberse automedicado con antibióticos previamente (p < .001). Cuarenta y cuatro por ciento de participantes de FSEB y 27% de FSEA usaron viejas recetas como fuentes de información cuando practicaron AMA (p = .010); 27% de participantes de FSEA hablaron por teléfono con médicos para seleccionar el antibiótico. Setenta y tres por ciento de FSEB y 68% de FSEA percibieron mejoras en su salud (p < .001) como resultado de AMA. Veinticinco por ciento de FSEB y 35% de FSEA reportaron efectos secundarios de AMA. Los motivos para automedicarse con antibióticos incluyeron ahorro de tiempo y dinero en consultar a un médico. Los resultados contribuyen a las evidencias crecientes sobre el uso de antibióticos y tienen el potencial de servir para desarrollar prácticas y políticas sobre dispensación de antibióticos en farmacias.

Few regulations guide the rational use of antibiotics in Low to Middle Income Countries (LMIC) facilitating self-medication with antibiotics (SMA). To describe the sources of information used when practicing SMA, perceived effects of SMA, and motives surrounding SMA practice in Guatemala. A descriptive, cross sectional questionnaire was administered to those purchasing antibiotics without a prescription in four Guatemala City pharmacies. Questions identified respondent demographics, origin of antibiotic request, and the perceived effects of SMA. A total of 230 participants responded to the questionnaire in four pharmacies. Two pharmacies represented Low Socio-Economic Setting Pharmacies (LSEP) and two represented High Socio-Economic Setting Pharmacies (HSEP). The majority of LSEP pharmacy respondents (93%), and HSEP respondents (60%) reported previously carrying out SMA (p < .001). Forty-four percent of LSEP and 27% of HSEP respondents used old-prescriptions as a source of information when practicing SMA (p = .01 ); 27% of HSEP respondents spoke over the phone with physicians in order to make antibiotic selection. Seventy-three percent of LSEP and 68% of HSEP perceived improvements in health (p < .001) as a result of SMA. Twenty five percent of LSEP and 35% of HSEP reported side effects from SMA. Motives for self-medicating with antibiotics included saving time and money on visiting a physician. Results contribute to the growing body of evidence regarding antibiotic use and serve to develop antibiotic dispensing practice and policies in pharmacies.