This paper presents the first published report of a national-level effort to implement the integrated management of childhood illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the multicountry evaluation of IMCI effectiveness, cost and impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru’s 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru; it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management st...

Objectives: (1) To document trends in integrated management of childhood illnesses (IMCI) implementation in the 24 departments of Peru from 1996 to 2000. (2) To documenttrends in indicators of health services coverage and impact(mortality and nutritional status) for the same period. (3) To correlate changes in these two sets of indicators. And (4)to attempt to rule out contextual factors that may affect the observed trends and correlations. Materials and Methods: An ecological analysis was performed in which the units of study were the 24 departments.Results: By 2000, 10,2% of clinical health workers were trained in IMCI,but some districts showed considerably higher rates. There were no significant associations between clinical IMCI training coverageand indicators of outpatient utilization, vaccine coverage, mortality or malnutrition. The lack of association persisted after adjustment fo...

The concept of evidence-based medicine (EBM) has been increasingly incorporated in medicine practice and teaching. In the clinical arena it is defined as the use of the best available scientific evidence coming from clinical research for decision-making purposes, when facing individual patients. This paradigm change in the way medicine is taught and practiced has been due in part to the accelerated progress in scientific research, particularly in the last few decades, albeit the increasing costs involved in care of patients also played an important role in its development and consolidation. EBM involves integration of clinical expertise with the available external evidence, and provides a more critical approach to clinical problems, reducing error probabilities in different phases of the clinical process. It is not easy to reach a definitive conclusion about its impact on teaching and pr...

A critical review is made of this new proposal for medicine practice and teaching. A brief introduction of the medical context is first outlined. The content of Evidence-Based Medicine is then described, emphasizing the best available external clinical evidence, the clinical expertise and the predicaments of patients. Applications of this movement in clinical medicine and public health are pointed out. Finally, its advantages and potential risks and limitations are discussed. Evidence-based medicine is a novel viewpoint proposing a healthy subversion in medicine. It promotes a rational scepticism of physicians when faced with a clinical problem. To make a clinical decision, they should not be satisfied with the advice of their venerable expert colleagues, they should instead turn their attention to the combination of external evidence, their own clinical expertise and the predicaments of...

Objective:To compare the diagnostic usefulness of index tests in the identification of invasive diarrhea. Methods: Combination of qualitative and metanalytic methods. Data identification and study selection: Of 2603 MEDLINE references (1970-1994) and correspondence with tield experts, 81 fulfilled preestablished selection criteria and 25 of them had sufficient data for additional metaanalysis. Extraction of data: During the qualitative review, one author extracted extended information on the diagnostic value of index tests and on methodologic characteristics of primary studies. During the metanalytical phase, all data from the selected articles were extracted by one observer whereas the second reviewer checked them for accuracy. True positive (TPR) and false positive rates (FPR) were calculated with the 2 x 2 contingency table. To compare the diagnostic usefulness of index tests, a summa...

A prospective study was performed in 108 hospitalized children younger than 2 years old from May 1994 to June 1995. Urine specimens obtained through suprapubic aspiration were assessed for nitrite, leukocyte esterase and leukocyturia. Quantitative urine culture was the reference test employed. Prevalence of urinary tract infection was 10% (11 of 108 patients). Sensitivity and negative predictive values were 100% for leukocyte esterase (cut-point criterion 10-25 leukocytes/ul) or for nitrite these same thresholds were used. For leukocyte esterase with positivity criterion of 500 leukocytes/ul, sensitivity and positive predictive values were 82% and 100%, respectively. Nitrite with threshold excluding slight color changes yield sensitivity of 91% and positive predictive value of 43%. Both specificity and negative predictive values remained high for either nitrite or leukocyte esterase with...

Background: Deployment of health workforce in rural areas is critical to reach universal health coverage. Students’ perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. Methods: In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. Results: Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, ear...

Background: Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru. Methods: We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis. Results: Public expenditure increased in all departments, particula...

Background: Stunting prevalence in children less than 5 years has remained stagnated in Peru from 1992 to 2007, with a rapid reduction thereafter. We aimed to assess the role of different predictors on stunting reduction over time and across departments, from 2000 to 2012. Methods: We used various secondary data sources to describe time trends of stunting and of possible predictors that included distal to proximal determinants. We determined a ranking of departments by annual change of stunting and of different predictors. To account for variation over time and across departments, we used an ecological hierarchical approach based on a multilevel mixed-effects regression model, considering stunting as the outcome. Our unit of analysis was one department-year. Results: Stunting followed a decreasing trend in all departments, with differing slopes. The reduction pace was higher from 2007–...

En los últimos años la práctica y la enseñanza médica han incorporado en forma progresiva y creciente el concepto de medicina basada en la evidencia (MBE). La misma se define como la utilización de la mejor evidencia proveniente de la investigación clínica para la toma de decisiones en el manejo del paciente individual. Esta propuesta de cambio en la manera de practicar y enseñar la medicina clínica es, en parte, consecuencia del vertiginoso avance de la investigación científica, particularmente en las últimas décadas, aunque el costo creciente involucrado en la atención de los pacientes ha jugado también un rol importante en su desarrollo y consolidación. La MBE implica la integración de la preparación y experiencia del médico con la mejor evidencia clínica externa accesible, proveniente de la investigación sistemática, proporcionando una visión más crítica en ...

Debido a los bajos niveles de comprensión lectora en los estudiantes, según los resultados de la ECE 2014, 2015 y 2016 y evaluaciones internas de primero al sexto grado, se propone mejorar las estrategias metodológicas de los docentes a través del uso de cuentos locales para desarrollar adecuadamente las capacidades de comprensión lectora en los estudiantes de la Institución Educativa Nº 38994-1/Mx-P Divino Maestro.

INTRODUCTION. Fecal leukocytes are widely used to identify invasive diarrhea and to make then the decision of prescribing or not antibiotics. This test has been hardly assessed in small hospitals of developing countries with efficient laboratory processes. We aimed to assess the diagnostic performance of different thresholds of fecal leukocytes in children under-five with acute diarrhea. MATERIAL AND METHODS. Retrospective study of clinical and laboratory records in the Pediatric Emergency Hospital, Lima, Peru. All cases with a stool culture and fecal leukocytes independently and systematically performed were studied. Sensitivity, specificity, predictive values, likelihood ratios (LR), and receiver operating characteristics (ROC) curves were calculated. RESULTS. Out of 1,804 stool samples assessed, 901 (49,9%) were positive for one or more bacterial entheropathogens. Sensitivity (Sn), sp...

INTRODUCCIÓN. Los leucocitos fecales son utilizados para identificar diarrea invasiva y decidir el uso de antibióticos. Se conoce poco sobre su utilidad en hospitales de países en desarrollo con procesos de laboratorio eficientes. Buscamos evaluar el rendimiento diagnóstico de la prueba en menores de 5 años con diarrea aguda. MATERIAL Y MÉTODOS. Estudio retrospectivo de registros clínicos y de laboratorio en el Hospital de Emergencias Pediátricas, Lima, Perú. Se evaluó los casos a los que se había solicitado sistemática e independientemente leucocitos fecales y coprocultivo. Se calculó sensibilidad, especificidad, valores predictivos, cocientes de probabilidad (CP) y la curva de características operativas del receptor (ROC). RESULTADOS. De 1,804 muestras fecales, 901 (49,9%) fueron positivos para uno o más enteropatógenos bacterianos. La sensibilidad (S), especificidad (E...

OBJETIVO: Evaluar el efecto de la disponibilidad de un método diagnóstico rápido y preciso de rotavirus sobre la frecuencia en el uso de antibióticos en niños menores de 5 años con diarrea aguda de menos de 5 días de duración del Hospital Nacional Arzobispo Loayza; Lima, Perú. MATERIALES Y MÉTODOS: se realizó un estudio observacional, prospectivo, aleatorizado, controlado, entre Julio 2008 y Enero 2009. Se asignó aleatoriamente 101 pacientes al GrupoA (con prueba de leucocitos fecales) y 100 al Grupo B (con prueba de leucocitos fecales y prueba rápida de rotavirus/adenovirus). Se evaluó en cada grupo la decisión clínica de administrar o no antibióticos. RESULTADOS: No existieron diferencias significativas en el tiempo de enfermedad, edad ni peso entre ambos grupos. Los casos de rotavirus tuvieron leucocitos fecales positivos en un46.9%. El grado de positividad de...

Pott’s disease is a health problem in developing countries and its diagnosis in children is a challenge. Here we present the case of a two-year-old boy with Pott’s disease involving T1 to T3 thoracic vertebrae. The clinical presentation was characterized by difficulty walking, fever, cough, and dyspnea. At physical examination, kyphosis and bony prominence were observed in the cervicodorsal area. A positive tuberculin test was obtained, and Mycobacterium tuberculosis was isolated via culture of the gastric aspiration sample. The spine MRI showed a chronic abscess, destruction of two vertebrae, and bone marrow compression. The patient experienced some improvement with anti-TB therapy. Here, we emphasize the importance of giving consideration to the clinical suspicion for the early detection of this condition, as well as a quick TB-treatment start so as to avoid the disability and mort...

This is an inquiry study about the main issues of the biomedical scientific-technologic progress in Peru. It was made in the view of the comprehensive development of the country, as well as regional and worldwide situation. Health models used to approach socioeconomic inequalities are commented.Positive association between the principal science and technology agency, health field and Pan American health Organization is examined. This is investigated with dyadic evaluations domestic decisions.This article focus scientific and bibliographic attitude, as well as human resources and science and technology investment. In the same way, it outlines a strength and weakness analysis.Strengthen the information and communication necessity to excellence degrees and construction of a new biomedical research culture is noted.The importance of introduce a national progressive accreditation system, suit...

Background Anaemia is highly prevalent in children of developing countries. It is associated with impaired physical growth and mental development. Palmar pallor is recommended at primary level for diagnosing it, on the basis of few studies. The objective of the study was to systematically assess the accuracy of clinical signs in the diagnosis of anaemia in children. Methods A systematic review on the accuracy of clinical signs of anaemia in children. We performed an Internet search in various databases and an additional reference tracking. Studies had to be on performance of clinical signs in the diagnosis of anaemia, using haemoglobin as the gold standard. We calculated pooled diagnostic likelihood ratios (LR's) and odds ratios (DOR's) for each clinical sign at different haemoglobin thresholds. Results Eleven articles met the inclusion criteria. Most studies were performed in Africa, in...

Introduction: Neonatal resuscitation demands equipment for respiratory support not always available in rural areas. Innovative devices are required, and rapid prototyping allows to generate them using three-dimensional (3D) designs and printers. Objective: To evaluate the non-clinical performance and the acceptability by health personnel of a neonatal respiratory device produced by rapid prototyping. Methods: Observational study, descriptive, of proof of concept developed in two steps. Step 1: Manufacture of the device with rapid prototyping in three-dimensional (3D) scanners and printers. Step 2: Demonstration of the invention during training programs in neonatal resuscitation for health personnel in three regions of Peru (Tarapoto, Huánuco and Ayacucho). In both steps, we evaluated the performance of the device connected to a gas flow analyser. ...

Background. Asthma and allergic rhinitis are highly prevalent conditions that cause major illness worldwide. This study aimed to assess the association between allergic rhinitis and asthma control in Peruvian school children. Methods. A cross-sectional study was conducted among 256 children with asthma recruited in 5 schools from Lima and Callao cities. The outcome was asthma control assessed by the asthma control test. A score test for trend of odds was used to evaluate the association between allergic rhinitis severity and the prevalence of inadequate asthma control. A generalized linear regression model was used to estimate the adjusted prevalence ratios of inadequate asthma control. Results. Allergic rhinitis was present in 66.4% of the population with asthma. The trend analysis showed a positive association between allergic rhinitis and the probability of inadequate asthma control (...

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