Diarrheal disease and associations with water access and sanitation in Indigenous Shawi children along the Armanayacu River basin in Peru.

INTRODUCTION: Diarrheal disease, particularly in children under 5 years old, remains a global health challenge due to its high prevalence and chronic health consequences. Public health interventions that reduce diarrheal disease risk include improving access to water, sanitation, and hygiene. Although Peru achieved the 2015 Millennium Development Goal (MDG) indicators for water access, less progress was achieved on sanitation. Furthermore, many Indigenous Peoples were overlooked in the MDG indicators, resulting in a prioritization of Indigenous Peoples in the 2030 Sustainable Development Goals (SDGs). This study aimed to estimate the prevalence of childhood diarrhea, characterize access to water and sanitation, and determine the association of childhood diarrhea with water access and sanitation indicators in 10 Shawi Indigenous communities along the Armanayacu River in the Peruvian Amazon. METHODS: A cross-sectional survey (n=82) that captured data on diarrheal disease, sociodemographic variables, and water and sanitation exposures was conducted in 10 Shawi communities. Nutritional status of children under 5 was also assessed via physical examination. Descriptive and comparative statistics were conducted. RESULTS: A small proportion (n=7; 8.54%) of participating children reported an episode of diarrhea in the previous month. Almost half (46.30%) of participating children had stunting, wasting, or both. Although not statistically significant, children living in households that used latrines were 4.29 times (95% confidence interval (CI) 1.01-18.19) more likely to report an episode of diarrhea than children living in households that practiced open defecation. Although not statistically significant, children living in households that used water treatment methods were 4.25 times (95%CI 0.54-33.71) more likely to report an episode of diarrhea than children living in households that did not. CONCLUSION: The prevalence of childhood diarrhea was lower for Shawi than for other Amazon areas. The higher prevalence of childhood diarrhea in households that used latrines and water treatments warrants further investigation into local risk and protective factors. These Shawi communities scored low for the WHO/UNICEF Joint Monitoring Programme indicators for water and sanitation, indicating that they should be prioritized in future water, sanitation, and hygiene initiatives. Research will be required to understand and incorporate local Indigenous values and cultural practices into water, sanitation, and hygiene initiatives to maximize intervention uptake and effectiveness.

Effect of bovine lactoferrin on prevention of late-onset sepsis in infants <1500 g: a pooled analysis of individual patient data from two randomized controlled trials.

We previously conducted two randomized controlled trials with bovine lactoferrin (bLF) for the prevention of late-onset sepsis (LOS) in infants with a birth weight <2500 g (Study 1) and <2000 g (Study 2). The aim of this study was to determine the preventative effects of bLF on culture-proven or probable LOS in infants with a birth weight <1500 g from both studies, and to determine the effect of bLF in relation to intake of human milk. Both trial designs had similar inclusion and exclusion criteria, the same dose of bLF [200 mg·(kg body mass)-1·day-1], and used the same control (maltodextrin). We fitted multivariate Cox regression models to estimate the effect of bLF on the risk of development of the composite outcome, adjusting for covariates. We included 335 neonates with a mean birth weight of 1162 ± 244 g; 27.5% were <1000 g. There were 33 first episodes of LOS in the bLF treatment group and 48 in the control group (19.5% vs. 28.9%). bLF had a protective effect on the risk of development of LOS [hazard ratio (HR) = 0.64; %95 CI = 0.41-0.99; p = 0.048]; particularly among infants weighing <1000 g [HR = 0.46; %95 CI = 0.22-0.96; p = 0.039] and infants with a low intake of human milk [HR = 0.40; %95 CI = 0.19-0.84; p = 0.015]. Therefore, bLF supplementation protects infants <1500 g from LOS, particularly those infants not receiving human milk.

Thyroid cancer overdiagnosis and overtreatment: a cross- sectional study at a thyroid cancer referral center in Ecuador.

BACKGROUND: In contrast to the rapid increase in thyroid cancer incidence, the mortality has remained low and stable over the last decades. In Ecuador, however, thyroid cancer mortality has increased. The objective of this study is to determine possible drivers of high rates of thyroid cancer mortality, through a cross-sectional analysis of all patients attending a thyroid cancer referral center in Ecuador. METHODS: From June 2014 to December 2017, a cross-sectional study was conducted at the Hospital de Especialidades Eugenio Espejo, a regional reference public hospital for endocrine neoplasia in adults in Quito, Ecuador. We identified the mechanism of detection, histopathology and treatment modalities from a patient interview and review of clinical records. RESULTS: Among 452 patients, 74.8% were young adults and 94.2% (426) were female. 13.7% had a family history of thyroid cancer, and patients' median tumor size was 2 cm. The incidental finding was 54.2% whereas 45.8% was non-incidental. Thyroid cancer histology reported that 93.3% had papillary thyroid cancer (PTC), 2.7% follicular, 1.5% Hurtle cells, 1.6% medullary, 0.7% poor differentiated, and 0.2% anaplastic carcinoma. The mean MACIS (metastasis, age, completeness, invasion, and size) score was 4.95 (CI 4.15-5.95) with 76.2% of the thyroid cancer patients having MACIS score less than or equal to 6. The very low and low risk of recurrence was 18.1% (79) and 62% (271) respectively. An analysis of 319 patients with non-metastatic thyroid cancer showed that 10.7% (34) of patients had surgical complications. Moreover, around 62.5% (80 from 128 patients with thyroglobulin laboratory results) of TC patients had a stimulated-thyroglobulin value equal or higher than 2 ng/ml. Overall, a poor surgical outcome was present in 35.1% (112) patients. Out of 436 patients with differentiated thyroid carcinoma, 86% (375) received radioactive iodine. CONCLUSION: Thyroid cancer histological characteristics and method of diagnosis are like those described in other reports without any evidence of the high frequency of aggressive thyroid cancer histology. However, we observed evidence of overtreatment and poor surgical outcomes that demand additional studies to understand their association with thyroid cancer mortality in Ecuador.

A novel approach to modeling epidemic vulnerability, applied to Aedes aegypti-vectored diseases in Perú.

BACKGROUND: A proactive approach to preventing and responding to emerging infectious diseases is critical to global health security. We present a three-stage approach to modeling the spatial distribution of outbreak vulnerability to Aedes aegypti-vectored diseases in Perú. METHODS: Extending a framework developed for modeling hemorrhagic fever vulnerability in Africa, we modeled outbreak vulnerability in three stages: index case potential (stage 1), outbreak receptivity (stage 2), and epidemic potential (stage 3), stratifying scores on season and El Niño events. Subsequently, we evaluated the validity of these scores using dengue surveillance data and spatial models. RESULTS: We found high validity for stage 1 and 2 scores, but not stage 3 scores. Vulnerability was highest in Selva Baja and Costa, and in summer and during El Niño events, with index case potential (stage 1) being high in both regions but outbreak receptivity (stage 2) being generally high in Selva Baja only. CONCLUSIONS: Stage 1 and 2 scores are well-suited to predicting outbreaks of Ae. aegypti-vectored diseases in this setting, however stage 3 scores appear better suited to diseases with direct human-to-human transmission. To prevent outbreaks, measures to detect index cases should be targeted to both Selva Baja and Costa, while Selva Baja should be prioritized for healthcare system strengthening. Successful extension of this framework from hemorrhagic fevers in Africa to an arbovirus in Latin America indicates its broad utility for outbreak and pandemic preparedness and response activities.

Meteorological factors and childhood diarrhea in Peru, 2005-2015: a time series analysis of historic associations, with implications for climate change.

BACKGROUND: Global temperatures are projected to rise by ≥2 °C by the end of the century, with expected impacts on infectious disease incidence. Establishing the historic relationship between temperature and childhood diarrhea is important to inform future vulnerability under projected climate change scenarios. METHODS: We compiled a national dataset from Peruvian government data sources, including weekly diarrhea surveillance records, annual administered doses of rotavirus vaccination, annual piped water access estimates, and daily temperature estimates. We used generalized estimating equations to quantify the association between ambient temperature and childhood (< 5 years) weekly reported clinic visits for diarrhea from 2005 to 2015 in 194 of 195 Peruvian provinces. We estimated the combined effect of the mean daily high temperature lagged 1, 2, and 3 weeks, in the eras before (2005-2009) and after (2010-2015) widespread rotavirus vaccination in Peru and examined the influence of varying levels of piped water access. RESULTS: Nationally, an increase of 1 °C in the temperature across the three prior weeks was associated with a 3.8% higher rate of childhood clinic visits for diarrhea [incidence rate ratio (IRR): 1.04, 95% confidence interval (CI): 1.03-1.04]. Controlling for temperature, there was a significantly higher incidence rate of childhood diarrhea clinic visits during moderate/strong El Niño events (IRR: 1.03, 95% CI: 1.01-1.04) and during the dry season (IRR: 1.01, 95% CI: 1.00-1.03). Nationally, there was no evidence that the association between temperature and the childhood diarrhea rate changed between the pre- and post-rotavirus vaccine eras, or that higher levels of access to piped water mitigated the effects of temperature on the childhood diarrhea rate. CONCLUSIONS: Higher temperatures and intensifying El Niño events that may result from climate change could increase clinic visits for childhood diarrhea in Peru. Findings underscore the importance of considering climate in assessments of childhood diarrhea in Peru and globally, and can inform regional vulnerability assessments and mitigation planning efforts.

Prevalence, burden of disease, and lost in health state utilities attributable to chronic musculoskeletal disorders and pain in Chile.

BACKGROUND: Musculoskeletal disorders are a leading cause of disability adjusted life years (DALY) in the world. We aim to describe the prevalence and to compare the DALYs and loss of health state utilities (LHSU) attributable to common musculoskeletal disorders in Chile. METHODS: We used data from the Chilean National Health Survey carried out in 2016-2017. Six musculoskeletal disorders were detected through the COPCOPRD questionnaire: chronic musculoskeletal pain, chronic low back pain, chronic shoulder pain, osteoarthritis of hip and knee, and fibromyalgia. We calculated the DALY for each disorder for 18 sex and age strata, and LHSU following an individual and population level approaches. We also calculated the fraction of LHSU attributable to pain. RESULTS: Chronic musculoskeletal pain disorder affects a fifth of the adult population, with a significant difference between sexes. Among specific musculoskeletal disorders highlights chronic low back pain with the highest prevalence. Musculoskeletal disorders are a significant cause of LHSU at the individual level, especially in the case of fibromyalgia. Chronic musculoskeletal pain caused 503,919 [283,940 - 815,132] DALYs in 2017, and roughly two hundred thousand LSHU at population level, which represents 9.7% [8.8-10.6] of the total LSHU occurred in that year. Discrepancy in the burden of musculoskeletal disorders was observed according to DALY or LSHU estimation. The pain and discomfort domain of LHSU accounted for around half of total LHSU in people with musculoskeletal disorders. CONCLUSION: Chronic musculoskeletal pain is a major source of burden and LHSU. Fibromyalgia should deserve more attention in future studies. Using the attributable fraction offers a straightforward and flexible way to explore the burden of musculoskeletal disorders.

The Annual costs of treating genital warts in the Public Healthcare Sector in Peru.

OBJECTIVES: To estimate the cost of six different techniques used to treat Genital Warts and the annual average cost of treating a typical GW patient in Peru. To estimate the annual economic burden diagnosing and treating GW in the Peruvian public healthcare system. METHODS: We developed a prevalence-based, cost-of-illness study from the provider's perspective, the healthcare facilities under the purview of Peruvian Ministry of Health. We used an activity-based costing approach. We conducted primary data collection in three regions in Peru and supplemented it with governmental data. Uncertainty of the costing estimates was assessed via Monte Carlo simulations. We estimated the average cost and associated confidence intervals for six treatment options - three topical and three surgical - and the overall cost per patient. RESULTS: The average treatment cost per patient was 59.9USD (95 %CI 45.5, 77.6). Given a population of 18.4 million adults between 18 and 60 years of age and a GW prevalence of 2.28 %, the annual cost of treating GW was 25.1 million USD (uncertainty interval 16.9, 36.6). CONCLUSIONS: This study provides the first quantification of the economic burden of treating genital warts in Peru and one of the few in Latin America. The costing data did not include other healthcare providers or out-of-pocket expenditures, and hence we present a conservative estimate of the COI of GW in Peru. Our findings bring attention to the financial burden of treating GW, a vaccine-preventable disease.

Health care provider time in public primary care facilities in Lima, Peru: a cross-sectional time motion study.

BACKGROUND: In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care. METHODS: This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection. RESULTS: Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors. CONCLUSIONS: The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Randomized Controlled Trial of Bovine Lactoferrin for Prevention of Sepsis and Neurodevelopment Impairment in Infants Weighing Less Than 2000 Grams.

OBJECTIVES: To determine the effect of bovine lactoferrin on prevention of late-onset sepsis (LOS) and neurodevelopment delay. STUDY DESIGN: Randomized, double-blind, controlled trial in neonates with a birth weight of 500-2000 g in 3 neonatal units in Lima, Peru, comparing bovine lactoferrin 200 mg/kg/day with placebo administered for 8 weeks. The primary outcome was the first episode of culture-proven LOS or sepsis-associated death. Neurodevelopment delay was assessed by the Mullen Scales at 24 months corrected age. RESULTS: Of the 414 infants enrolled, 209 received bovine lactoferrin and 205 received placebo. LOS or sepsis-associated death occurred in 22 infants (10.5%) in the bovine lactoferrin group vs 30 (14.6%) in the placebo group; there was no difference after adjusting for hospital and birth weight; hazard ratio 0.73 (95% CI, 0.42-1.26). For infants with birth weights of <1500 g the hazard ratio was 0.69 (95% CI, 0.39-1.25). The mean age-adjusted normalized Mullen composite score at 24 months was 83.3 ± 13.6 in the bovine lactoferrin group vs 82.6 ± 13.1 in the placebo group. Growth outcomes and rehospitalization rates during the 2-year follow-up were similar in both groups, except for significantly less bronchiolitis in the bovine lactoferrin group (rate ratio, 0.34; 95% CI, 0.14-0.86). CONCLUSIONS: Supplementation with bovine lactoferrin did not decrease the incidence of sepsis in infants with birth weights of <2000 g. Growth and neurodevelopment outcomes at 24 months of age were similar. Neonatal bovine lactoferrin supplementation had no adverse effects. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01525316.

Counseling for improving adherence to antiretroviral treatment: a systematic review.

One-on-one counseling can be an effective strategy to improve patient adherence to HIV treatment. The aim of this systematic review is to examine articles with one-on-one counseling-based interventions, review their components and effectiveness in improving ART adherence. A systematic review, using the following criteria was performed: (i) experimental studies; (ii) published in Spanish, English or Portuguese; (iii) with interventions consisting primarily of counseling; (iv) adherence as the main outcome; (v) published between 2005 and 2016; (vi) targeted 18 to 60 year old, independent of gender or sexual identity. The author reviewed bibliographic databases. Articles were analyzed according to the type of study, type of intervention, period of intervention, theoretical basis for intervention, time used in each counseling session and its outcomes. A total of 1790 records were identified. Nine studies were selected for the review, these applied different types of individual counseling interventions and were guided by different theoretical frameworks. Counseling was applied lasting between 4 to 18 months and these were supervised through three to six sessions over the study period. Individual counseling sessions lasted from 7.5 to 90 minutes (Me. 37.5). Six studies demonstrated significant improvement in treatment. Counseling is effective in improving adherence to ART, but methods vary. Face-to-face and computer counseling showed efficacy in improving the adherence, but not the telephone counseling. More evidence that can determine a basic counseling model without losing the individualized intervention for people with HIV is required.

Staphylococcus aureus bloodstream infections in Latin America: results of a multinational prospective cohort study.

BACKGROUND: Substantial heterogeneity in the epidemiology and management of Staphylococcus aureus bacteraemia (SAB) occurs in Latin America. We conducted a prospective cohort study in 24 hospitals from nine Latin American countries. OBJECTIVES: To assess the clinical impact of SAB in Latin America. PATIENTS AND METHODS: We evaluated differences in the 30 day attributable mortality among patients with SAB due to MRSA compared with MSSA involving 84 days of follow-up. Adjusted relative risks were calculated using a generalized linear model. RESULTS: A total of 1030 patients were included. MRSA accounted for 44.7% of cases with a heterogeneous geographical distribution. MRSA infection was associated with higher 30 day attributable mortality [25% (78 of 312) versus 13.2% (48 of 363), adjusted RR: 1.94, 95% CI: 1.38-2.73, P < 0.001] compared with MSSA in the multivariable analysis based on investigators' assessment, but not in a per-protocol analysis [13% (35 of 270) versus 8.1% (28 of 347), adjusted RR: 1.10, 95% CI: 0.75-1.60, P = 0.616] or in a sensitivity analysis using 30 day all-cause mortality [36% (132 of 367) versus 27.8% (123 of 442), adjusted RR: 1.09, 95% CI: 0.96-1.23, P = 0.179]. MRSA infection was not associated with increased length of hospital stay. Only 49% of MSSA bloodstream infections (BSI) received treatment with ß-lactams, but appropriate definitive treatment was not associated with lower mortality (adjusted RR: 0.93, 95% CI: 0.70-1.23, P = 0.602). CONCLUSIONS: MRSA-BSIs in Latin America are not associated with higher 30 day mortality or longer length of stay compared with MSSA. Management of MSSA-BSIs was not optimal, but appropriate definitive therapy did not appear to influence mortality.

Protocol of an open, three-arm, individually randomized trial assessing the effect of delivering sexual and reproductive health information to young people (aged 13-24) in Kenya and Peru via mobile phones: adolescent/youth reproductive mobile access and delivery initiative for love and life outcomes (ARMADILLO) study stage 2.

BACKGROUND: Young people face special challenges to accessing needed sexual and reproductive health (SRH) information and support. With high penetration and access, mobile phones provide a new channel for reaching young people, but there is little evidence around the impact of digital interventions on improving health outcomes. The Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes (ARMADILLO) study will assess the effect of an intervention providing SRH information to young people via text message on their mobile phones in Kenya and Peru. This protocol details an open, individually-randomized, three-arm trial lasting seven weeks to assess the effect of the ARMADILLO intervention on dispelling myths and misconceptions related to contraception. A secondary objective is to determine whether youth given access to SRH information via text message can accurately retain that information. METHODS: Following a household enumeration, one eligible youth per household will be randomly selected for participation and randomized by computer into one of the three arms. Intervention arm participants will receive access to ARMADILLO content, control participants will receive no information, and 'Arm 3' participant interactions will vary by site: in Kenya, they will be alerted to various SRH domains and encouraged to learn on their own; in Peru, they will receive key content from each domain with the option to learn more if they wish. Participants will complete multiple-choice questionnaires administered by data collectors at baseline (prior to randomization), at intervention-period end (after week seven), and eight weeks after timing out of the intervention period. DISCUSSION: Part of the Sustainable Development Goal commitment towards ensuring healthy lives and promoting well-being for all at all ages includes a commitment to 'ensuring universal access to sexual health and reproductive health-care services, including for family planning, information and education'. If proven to be effective, interventions like ARMADILLO can bridge an important gap towards achieving universal access to SRH information and education for an otherwise difficult-to-reach group. TRIAL REGISTRATION: This trial was retrospectively registered with the ISRCTN Registry and assigned registration number ISRCTN85156148 on 29 May, 2018.

Health effects of 'Juntos', a conditional cash transfer programme in Peru.

In some countries, conditional cash transfer (CCT) programmes show an impact on maternal and child health. Juntos, the CCT programme in Peru, has been evaluated several times operationally, but seldom for maternal and child health outcomes. The objective of this study is to evaluate the impact of Juntos on children under 6 years, pregnant women and mothers of children under 17 years. Outcomes evaluated included (1) anaemia in women and children; (2) acute malnutrition in children; (3) post-partum complications in mothers; and (4) underweight and overweight in mothers. We identified Juntos eligible respondents from the Demographic and Health Surveys of Peru for years 2007 to 2013. Propensity score matching was used to identify comparable treatment and control groups, including eligible respondents enrolled in Juntos vs. those not enrolled in Juntos (individual-level analysis), as well as eligible respondents living in Juntos districts vs. those not residing in Juntos districts (district-level analysis). We then used generalized linear models to estimate prevalence ratios. Individual level analysis showed that Juntos reduced underweight in women (PR:0.39, 95%CI:0.18 - 0.85) and anaemia in children (PR:0.93, 95%CI:0.86 - 1.00). In the district level analysis, the programme was associated with a reduction of overweight in women (PR:0.94, 95%CI:0.90 - 0.98) and acute malnutrition in children (PR:0.49, 95%CI:0.32 - 0.73), but an increase in the prevalence of anaemia in children (PR:1.09, 95%CI:1.01 - 1.17). We found that Juntos had an effect on maternal and child health indicators, but further studies are required to overcome some limitations encountered here.

Partner Notification Among Peruvian Pregnant Women With Syphilis.

INTRODUCTION: As part of an implementation research study on the feasibility of implementing point-of-care tests for syphilis in Peru, we collected information on partner treatment of syphilis-seropositive pregnant women and explored womens' and health providers' knowledge and practices regarding partner notification and treatment (PNT) for maternal syphilis. METHODS: Mixed methods were used to collect information. Quantitative data were collected from consecutive pregnant women with a positive point-of-care test for syphilis. A subset participated in qualitative interviews. Health providers completed a survey on knowledge, attitudes, and behaviors about PNT. RESULTS: Of the 144 seropositive women, 46 (31.9%) had concurrent patient-partner treatment. From the 98 seropositive women whose partner was not at the clinic, 33 partners (33.7%) received at least 1 dose of penicillin. The multivariate model showed that screening at the antenatal care clinic (prevalence ratio [PR], 3.84), first sex after age 16 years (PR, 0.55), and lifetime number of partners (PR, 0.55 for 2-4 partners; PR, 0.77 for >4 partners) were independently associated with treatment for the partner. Women identified the provider as key for the PNT, but less than half of the providers reported having been trained for counseling and recognize the need for defining the procedures and standardization for PNT. Providers and women both reported that men may not come for treatment once notified because of fear, distrust of the system, or barriers associated with the services. CONCLUSION: There is a need for better training of health providers, for clear and standardized processes for partner counseling, registration and follow-up, and an opportunity to introduce new technologies.

Bimodal Modulation of Ipsilateral Spinal-Coeruleo-Spinal Pathway in CRPS: A Novel Model for Explaining Different Clinical Features of the Syndrome.

OBJECTIVE: The objective is to present a hypothesis to explain the sensory, autonomic, and motor disturbances associated with complex regional pain syndrome (CRPS) syndrome. METHODS: The author reviewed the available and relevant literature, which was supplemented with research on experimental animal models, with a focus on how they may translate into humans, particularly in areas about pathophysiologic mechanisms of CRPS. RESULTS: We propose that different CRPS subtypes may result from facilitative or inhibitory influences exerted by the spinal-coeruleo-spinal pathway in three sites at the spinal cord: the dorsal horn (DH), intermediolateral cell column (IML) and ventral horn (VH). A facilitatory influence over DH may have a pronociceptive effect that explains exacerbated pain, sensory disturbances, and spreading sensitization and neuroinflammation. Conversely, a facilitatory influence over preganglionic neurons located in IML cell column may increase sympathetic outflow with peripheral vasoconstriction, which leads to cold skin, ipsilateral limb ischaemia, and sympathetically maintained pain (SMP). For patients presenting with these symptoms, a descending inhibitory influence would be predicted to result in decreased sympathetic outflow and warm skin, as well as impairment of peripheral vasoconstrictor reflexes. Finally, a descending inhibitory influence over VH could explain muscle weakness and decreased active range of motion, while also facilitating motor reflexes, tremor and dystonia. CONCLUSIONS: The proposed model provides a mechanistically based diagnostic scheme for classifying and explaining the sensory, autonomic and motor disturbances associated with CRPS syndrome.

The changing face of HIV in Latin America and the Caribbean.

Latin America and the Caribbean (LAC) is a region with similarities and important disparities. In recent years LAC has witnessed achievements, with HIV prevalence rates relatively stable for LA and decreasing for the Caribbean. However average values hide differences. General population HIV prevalence in LAC is 0.4 % on average. In the Caribbean there are fewer new HIV infections but HIV prevalence among adults exceeds 1 % in several countries. It is estimated that 31 % of adults living with HIV in LA and 52 % of adults in the Caribbean are women. Unprotected sex is the main route of HIV transmission in LAC. Men who have sex with men and transgender women are the populations with the highest prevalence (10.6 % and 17.7 % respectively); however other key populations such as female sex workers (4.9 %), drug users (range 1 %-49.7 % for intravenous drug users), prisoners and indigenous populations are also important. LAC has the highest anti-retroviral treatment coverage of any low- and middle-income region in the world, but women and children are less likely than men to receive treatment. There is an important pending agenda to address the gaps in information, prevention, and care for HIV in LAC.

Sociodemographic and clinical characteristics associated with maternal and congenital syphilis - A prospective study in Peru.

OBJECTIVES: The objective of this study was to explore the factors and outcomes associated with gestational syphilis in Peru. METHODS: Women from the miscarriage, vaginal delivery, and C-section wards from a large maternity hospital in Lima with or without syphilis diagnosis were enrolled and their pregnancy outcomes compared. Maternal syphilis status using maternal blood and child serostatus using cord blood were determined by rapid plasma reagin (RPR) and rapid syphilis tests. The newborns' clinical records were used to determine congenital syphilis. RESULTS: A total of 340 women were enrolled, 197 were positive and 143 were negative for RPR/rapid syphilis tests. Antibody titers in sera from cord and maternal blood were comparable with RPR titers and were highly correlated (rho = 0.82, P <0.001). Young age (P = 0.009) and lower birth weight (P = 0.029) were associated with gestational syphilis. Of the women with gestational syphilis, 76% had received proper treatment. Mothers of all newborns with congenital syphilis also received appropriate treatment. Treatment of their sexual partners was not documented. CONCLUSIONS: Syphilis during pregnancy remains a major cause of the fetal loss and devastating effects of congenital syphilis in newborns.

Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial.

BACKGROUND: Previous community-randomised trials of interventions to control sexually transmitted infections (STIs) have involved rural settings, were rarely multicomponent, and had varying results. We aimed to assess the effect of a multicomponent intervention on curable STIs in urban young adults and female sex workers (FSWs). METHODS: In this community-randomised trial, baseline STI screening was done between August, and November, 2002, in random household samples of young adults (aged 18-29 years) and in FSWs in Peruvian cities with more than 50,000 inhabitants. Geographically separate cities were selected, matched into pairs, and randomly allocated to intervention or control groups with an S-PLUS program. Follow-up surveys of random samples were done after 2 years and 3 years. The intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach to FSWs for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion for FSWs and the general population. Individuals in control cities received standard care. The composite primary endpoint was infection of young adults with Chlamydia trachomatis, Trichomonas vaginalis, or Neisseria gonorrhoeae, or syphilis seroreactivity. Laboratory workers and the data analyst were masked, but fieldworkers, the Peruvian study team, and participants in the outcome surveys were not. All analyses were done by intention to treat. This trial is registered, ISRCTN43722548. FINDINGS: We did baseline surveys of 15,261 young adults in 24 Peruvian cities. Of those, 20 geographically separate cities were matched into pairs, in each of which one city was assigned to intervention and the other to standard of care. In the 2006 follow-up survey, data for the composite primary outcome were available for 12,930 young adults. We report a non-significant reduction in prevalence of STIs in young adults, adjusted for baseline prevalence, in intervention cities compared with control cities (relative risk 0·84, 95% CI 0·69-1·02; p=0·096). In subgroup analyses, significant reductions were noted in intervention cities in young adult women and FSWs. INTERPRETATION: Syndromic management of STIs, mobile-team outreach to FSWs, presumptive treatment for trichomoniasis in FSWs, and condom promotion might reduce the composite prevalence of any of the four curable STIs investigated in this trial. FUNDING: Wellcome Trust and Burroughs Wellcome Fund, National Institutes of Health, Center for AIDS Research, CIPRA, and USAID-Peru.