Hypoplastic Left Heart Syndrome: A Review.

Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.

Risk factors for high-risk human papillomavirus infection and cofactors for high-grade cervical disease in Peru.

OBJECTIVE: To evaluate the association between potential risk factors for high-risk human papillomavirus (HR-HPV) infection and cofactors for cervical intraepithelial lesions grade 2 or worse (CIN2+) in women attending cervical screening in Amazonian Peru. MATERIALS AND METHODS: Participants completed a risk factor questionnaire before screening. High-risk human papillomavirus infection was determined by Hybrid Capture II. Logistic regression was used to evaluate associations between potential risk factors for HR-HPV infection and between cofactors and risk of CIN2+ among women with HR-HPV infection. RESULTS: Screening and questionnaires were completed by 5435 women aged 25 to 49 years. The prevalence of HR-HPV was 12.6% (95% confidence interval [CI], 11.8%-13.6%) and decreased by age. Early age at first sexual intercourse and several lifetime sexual partners increased the risk of having HR-HPV (age-adjusted odds ratio [AOR] of age at first sexual intercourse <18 vs ≥20, 1.5; 95% CI, 1.2-2.0; AOR of ≥5 lifetime sexual partners vs 1, 2.1; 95% CI, 1.4-3.2). Among women with HR-HPV infection, those with no schooling (AOR relative to 1-5 years of schooling, 3.2; 95% CI, 1.3-8.3) and those with parity ≥3 (AOR relative to parity <3, 2.6; 95% CI, 1.4-4.9) were at increased risk of CIN2+. The effect of parity was stronger for cancer (AOR of parity ≥3 vs <3, 8.3; 95% CI, 1.0-65.6). Further analysis showed that the association between parity and CIN2+ was restricted to women younger than 40. Most women (83%) had previously been screened. Sixty-four percent of CIN2+ cases detected in this study occurred in women who reported having had a Papanicolaou test in the previous 3 years. Only 4 of 20 cancers were detected in women never screened before. Having had a previous abnormal Papanicolaou test increased the risk of CIN2+ (OR, 16.1; 95% CI, 6.2-41.9). CONCLUSION: Among women with HR-HPV, high parity (in young women), no schooling, lack of good-quality screening and of adequate follow-up care are the main risk factors for high-grade cervical disease in Peru.

Assessing participation of women in a cervical cancer screening program in Peru.

OBJECTIVE: To assess systemic and individual factors influencing participation of women in a screening program for cervical cancer. METHODS: In November 2000, a new cervical cancer screening program was introduced in the Region of San Martin, Peru. A total of 107 683 women, ages 25-49, were eligible for screening. This report covers the initial period from program inception through 31 October 2003. We used data from the program information system to identify systemic factors and individual characteristics influencing women's participation. We conducted a three-step analysis: we assessed systemic factors at the level of micronetworks or group of health centers, we estimated the odds of being a new user (never screened or not screened in the past 5 years) according to sociodemographic characteristics, and we assessed how women learned about the availability of screening services while controlling for influential factors identified in previous analyses. RESULTS: During the 3-year period, 36 759 eligible women attended screening services, for a participation rate of 32.3%. While attendance varied by area and time period, the program attracted 12 208 new users. Health care micronetworks with available static screening services had higher participation. New users were more likely than regular users to have less education and to report low use of family-planning services. All other factors being equal, they were also more likely than regular users to hear about screening services from a health care provider. CONCLUSION: In this setting, the presence of and contact with health services played a role in increasing the participation in screening of women not previously screened or not screened in the past 5 years.

Assessing participation of women in a cervical cancer screening program in Peru / Análisis de la participación de las mujeres en un programa de tamizaje de cáncer cervicouterino en Perú

OBJECTIVE: To assess systemic and individual factors influencing participation of women in a screening program for cervical cancer. METHODS: In November 2000, a new cervical cancer screening program was introduced in the Region of San Martin, Peru. A total of 107 683 women, ages 25-49, were eligible for screening. This report covers the initial period from program inception through 31 October 2003. We used data from the program information system to identify systemic factors and individual characteristics influencing women's participation. We conducted a three-step analysis: we assessed systemic factors at the level of micronetworks or group of health centers, we estimated the odds of being a new user (never screened or not screened in the past 5 years) according to sociodemographic characteristics, and we assessed how women learned about the availability of screening services while controlling for influential factors identified in previous analyses. RESULTS: During the 3-year period, 36 759 eligible women attended screening services, for a participation rate of 32.3 percent. While attendance varied by area and time period, the program attracted 12 208 new users. Health care micronetworks with available static screening services had higher participation. New users were more likely than regular users to have less education and to report low use of family-planning services. All other factors being equal, they were also more likely than regular users to hear about screening services from a health care provider. CONCLUSION: In this setting, the presence of and contact with health services played a role in increasing the participation in screening of women not previously screened or not screened in the past 5 years.

OBJETIVOS: Evaluar los factores sistémicos e individuales que influyen en la participación de las mujeres en un programa de tamizaje de cáncer cervicouterino. MÉTODOS: En noviembre de 2000 se implementó un nuevo programa de tamizaje de cáncer cervicouterino en la región de San Martín, Perú. En total, 107 683 mujeres de 25 a 49 años eran elegibles para el tamizaje. Este informe cubre el período inicial desde el establecimiento del programa hasta el 31 de octubre de 2003. Se utilizaron los datos del sistema de información del programa para identificar los factores sistémicos y las características individuales que influían en la participación de las mujeres. Se realizó un análisis en tres etapas: se evaluaron los factores sistémicos a nivel de las microrredes o grupos de centros de salud, se estimaron las probabilidades de ser una nueva usuaria (nunca tamizada o no tamizada en los últimos 5 años) según las características sociodemográficas y se evaluó la vía por la que las mujeres habían conocido de la disponibilidad de los servicios de tamizaje, controlado por factores de influencia identificados en análisis previos. RESULTADOS: En el período de tres años, 36 759 mujeres elegibles recibieron este servicio, para una tasa de participación de 32,3 por ciento. Aunque la asistencia varió según la zona y el momento, el programa atrajo a 12 208 nuevas usuarias. Las microrredes sanitarias con servicios de tamizaje estáticos tuvieron una mayor participación. Las nuevas usuarias tenían menor nivel educacional y utilizaban menos los servicios de planificación familiar que las mujeres que se habían realizado la prueba con regularidad. Sin diferencias en el resto de los factores, las nuevas usuarias habían oído sobre los servicios de tamizaje más frecuentemente de los trabajadores sanitarios que las usuarias habituales. CONCLUSIONES: En este escenario, la presencia de servicios de salud y el contacto con ellos influyeron en el aumento de la participación...

Population-based prevalence and age distribution of human papillomavirus among women in Santiago, Chile.

UNLABELLED: More than 18 types of human papillomavirus (HPV) are associated with cervical cancer, the relative importance of the HPV types may vary in different populations. OBJECTIVE: To investigate the types of HPV, age distribution, and risk factors for HPV infection in women from Santiago, Chile. METHODS: We interviewed and obtained two cervical specimens from a population-based random sample of 1,038 sexually active women (age range, 15-69 years). Specimens were tested for the presence of HPV DNA using a GP5+/6+ primer-mediated PCR and for cervical cytologic abnormalities by Papanicolaou smears. RESULTS: 122 women tested positive for HPV DNA, 87 with high risk types (HR), and 35 with low risks (LR) only. Standardized prevalence of HPV DNA was 14.0% [95% confidence interval (95% CI), 11.5-16.4]. HR HPV by age showed a J reverse curve, whereas LR HPV showed a U curve, both statistically significant in comparison with no effect or with a linear effect. We found 34 HPV types (13 HR and 21 LR); HPV 16, 56, 31, 58, 59, 18, and 52 accounted for 75.4% of HR infections. Thirty-four (3.6%) women had cytologic lesions. Main risk factor for HPV and for cytologic abnormalities was number of lifetime sexual partners, odds ratios for > or =3 versus 1 were 2.8 (95% CI, 1.6-5.0) and 3.8 (95% CI, 1.3-11.4), respectively. CONCLUSIONS: LR HPV presented a clear bimodal age pattern; HR HPV presented a J reverse curve. HPV prevalence was similar to that described in most Latin American countries.

A public health framework for chronic disease prevention and control.

Chronic noncommunicable diseases are leading causes of death and disability in many developing countries. Several low-income countries lack mortality and morbidity data and do not yet know their burden of noncommunicable diseases. Cost studies are scarce, but in middle-income countries such as those of Latin America and the Caribbean, the cost of illness not only represents much of the direct costs of medical care, but also has an impact on family disposable income. Studies have reported that in low-resource settings, given incomplete health coverage and partial insurance, out-of-pocket expenses are high. Persons with chronic conditions, in many instances, have to forego care because of their inability to pay. Poverty and chronic noncommunicable diseases have a two-way interaction. These conditions warrant attention from poverty-reduction programs. Evidence shows that to have an impact on the burden of chronic diseases, action must occur at three levels: population-wide policies, community activities, and health services. The latter includes both preventive services and appropriate care for persons with chronic conditions. A public health approach embodies a systems perspective, containing the continuum of prevention and control, from determinants to care. In this framework it is critical to identify and address interactions and interventions that connect between and among the three levels of action.

Follow-up care of women with an abnormal cytology in a low-resource setting.

STUDY PURPOSE: We ascertained the follow-up care after an abnormal cytology (Papanicolaou) screening in the San Marti;n region of Perú and assessed the status of women who had not received adequate care. BASIC PROCEDURES: We identified women with an abnormal cytology and assessed their medical records, laboratory registries, death certificates and interviewed them at home. Re-screening, diagnosis and treatment were offered. MAIN FINDINGS: Only 46 (25%) of the 183 women identified received appropriate follow-up care. At re-screening 31 (34%) had a normal result, 9 (10%) were diagnosed with CIN1 and 50 (56%) had CIN2 or worse. PRINCIPAL CONCLUSIONS: In this setting, follow-up care after an abnormal cytology was very poor and could explain the lack of impact of cervical cancer screening. Women with an abnormal cytology constitute a high-risk group that should be a priority for health services.

Breast cancer in Latin America and the Caribbean.

As recently as two decades ago breast cancer was not a significant public health concern in Latin America and the Caribbean (LAC). However, mortality rates from breast cancer have been increasing for at least 40 years in most LAC countries. Socioeconomic development and consequent changes in reproductive behaviors over the past 50 years are thought to have contributed to the increased risk of breast cancer. Socioeconomic development has also increased women's health awareness and therefore the demand for quality services. In industrialized countries, screening and widely available, high-quality treatment protocols are being implemented as the main strategy for breast cancer control. Studies show that out of three available screening methods (mammography, clinical breast examination, and breast self-examination), only mammography for women 50-69 years of age has been effective at reducing mortality, and has done so by an estimated 23%. While there is much controversy about the benefits and cost-effectiveness of mammography screening for women aged 40-49, some countries, including Australia, the United States of America, and four European nations, recommend that physicians assess the need for it on an individual basis. A survey that we conducted of LAC countries shows that most of their breast cancer screening policies are not justified by available scientific evidence. Moreover, as seen by relatively high mortality/incidence ratios, breast cancer cases are not being adequately managed in many LAC countries. Before further developing screening programs, these countries need to evaluate the feasibility of designing and implementing appropriate treatment guidelines and providing wide access to diagnostic and treatment services. Given the relevance of breast cancer in Latin America and the Caribbean today, it is crucial that both women and health care providers have access to up-to-date information on which to base their decisions.