Hospital Roosevelt

Importance There is growing understanding that Social Determinants of Health (SDH) impact on the outcomes of different pediatric conditions. We aimed to determine whether SDH affect the severity of MIS‐C. Design Retrospective cohort study, 2021–2023. Children and adolescents with MIS‐C younger than 18 years of age fulfilling the MIS‐C CDC definition within the REKAMLATINA network were invited to participate. We assessed the i mpact of SDH on the risk of children with MIS‐C to be diagnosed with shock, need of inotropes, respiratory support, transfusion, and death. Results Two hundred and seventy seven patients from 30 centers in 13 countries were included. Of them, 241 children from the four most‐represented countries were included in the final analysis. Food insecurity, higher distance from a health center, not possessing a private vehicle to transport the patient to hospital, and having a home in poor condition, were associated with low LVEF, need of transfusion, shock, and need for respiratory support, when controlling for age, BMI, and ethnicity. The Score of Social Disadvantage was associated with Shock (OR: 1.35, P: 0.011, 95% CI: 1.07–1.71), Respiratory support (OR: 1.39, P: 0.005, 95% CI: 1.1–1.75), Transfusion (OR: 1.63, P0.013, 95% CI 1.1–2.41), but not death (OR: 0.76, P: 0.38, 95% CI: 0.41–1.40). Conclusions Among a large cohort of Latin American children with MIS‐C, SDH negatively affect outcomes. These findings reinforce the need for better investigation of the role of SDH in MIS‐C and other inflammatory conditions and may guide public health interventions.

Introducción: Alrededor del 10% de los pacientes con dengue presentan alteraciones neurológicas durante o después de la infección. La infección por el virus del dengue se puede presentar con tres cuadros neurológicos: 1) síntomas neurológicos agudos no específicos, 2) encefalitis aguda o síntomas neurológicos focales y 3) complicaciones neurológicas post infecciosas. El presente estudio es un reporte de una serie de cinco casos de dengue neurológico confirmados por pruebas de laboratorio. El objetivo es reportar una serie de casos de manifestaciones neurológicas asociadas a la infección por el virus de dengue y sus características clínicas. Metodología: Se trata de la presentación de una serie de cinco casos de dengue neurológico confirmados por pruebas de laboratorio. Resultados: De la serie de casos, dos pacientes cursaron con debilidad de miembros inferiores, dos tuvieron alteración de conciencia y otro paciente presentó debilidad en hemicuerpo derecho asociado a disartria. Todos ellos con el diagnóstico serológico positivo, a través de anticuerpos anti-virus, del dengue. Una paciente desarrolló Síndrome neurológico mediado por inmunidad, otro paciente sufrió disfunción muscular y tres pacientes desarrollaron encefalitis. Conclusión: Los trastornos neurológicos asociadas al DENV deben ser motivo de sospecha en todo paciente que presente síntomas neurológicos agudos no específicos, encefalitis aguda, síntomas neurológicos focales con evidencia de positividad para DENV, o que presente complicaciones neurológicas durante la fase de convalecencia por este virus.

Background Infection prevention and control (IPC) programs are essential to prevent and control the spread of multidrug-resistant organisms in healthcare facilities (HCFs). The current implementation of these programs in Latin America remains largely unknown. Methods We conducted a mixed-methods evaluation of IPC program implementation in HCFs from Guatemala, Panama, Ecuador, and Argentina, March-July 2022. We used the World Health Organization (WHO) IPC Assessment Framework (IPCAF) survey, a previously validated structured questionnaire with an associated scoring system that evaluates the eight core components of IPC (IPC program; IPC guidelines; IPC education and training; healthcare-associated infection [HAI] surveillance; multimodal strategies; monitoring and audit of IPC practices and feedback; workload, staffing, and bed occupancy; and the built environment and materials and equipment for IPC). Each section generates a score 0–100. According to the final score, the HCF IPC program implementation is categorized into four levels: inadequate (0–200), basic (201–400), intermediate (401–600), or advanced (601–800). Additionally, we conducted semi-structured interviews among IPC personnel and microbiologists using the Systems Engineering Initiative for Patient Safety model to evaluate barriers and facilitators for IPC program implementation. We performed directed content analysis of interview transcripts to identify themes that focused on barriers and facilitators of IPC program implementation which are summarized descriptively. Results Thirty-seven HCFs (15 for-profit and 22 non-profit) completed the IPCAF survey. The overall median score was 614 (IQR 569, 693) which corresponded to an “advanced” level of IPC implementation (32% [7/22] non-profit vs. 93% [14/15] for-profit HCFs in this category). The lowest scores were in workload, staffing and bed occupancy followed by IPC training and multimodal strategies. Forty individuals from 16 HCFs were interviewed. They perceived inadequate staffing and technical resources, limited leadership support, and cultural determinants as major barriers to effective IPC guideline implementation, while external accreditation and technical support from public health authorities were perceived as facilitators. Conclusions Efforts to strengthen IPC activities in Latin American HCFs should focus on improving support from hospital leadership and public health authorities to ensure better resource allocation, promoting safety culture, and improving training in quality improvement.

Objectives To identify antibiotic stewardship (AS) opportunities in Latin-American medical-surgical intensive care units (MS-ICUs) and general wards (Gral-wards). Methods We conducted serial cross-sectional point-prevalence surveys in MS-ICUs and Gral-wards in 41 Latin-American hospitals, between March 2022-February 2023. Patients >18 years of age on the units of interest were evaluated for antimicrobial use (AU) monthly (MS-ICUs) or quarterly (Gral-wards). Antimicrobial data were collected using a standardized form by the local AS teams and submitted to the coordinating team for analysis. Results We evaluated AU in 5,780 MS-ICU and 7,726 Gral-ward patients. Hospitals’ median bed-size was 179 (IQR 125, 330), 52% were non-profit. The aggregate AU prevalence was 53.5% in MS-ICUs and 25.5% in Gral-wards. Most (88%) antimicrobials were prescribed to treat infections, 7% for surgical prophylaxis, and 5% for medical prophylaxis. Healthcare-associated infections led to 63% of MS-ICU and 38% of Gral-ward AU. Carbapenems, piperacillin-tazobactam, intravenous (IV) vancomycin, and ampicillin-sulbactam represented 50% of all AU to treat infections. A minority of IV vancomycin targeted therapy was associated with documented methicillin-resistant Staphylococcus aureus infection or underwent therapeutic drug monitoring. In both units, 17% of antibiotics prescribed as targeted therapy represented de-escalation, while 24% and 15% in MS-ICU and Gral-ward, respectively, represented an escalation of therapy. In Gral-wards, 32% of antibiotics were used without a microbiologic culture ordered. Half of surgical prophylaxis antibiotics were prescribed for > first 24 hours. Conclusions Based on this cohort, areas to improve AU in Latin-American hospitals include antibiotic selection, de-escalation, duration of therapy, and dosing strategies.

Purpose To report a case of Chorioretinitis Sclopetaria after a forehead machete trauma. Observations A 28-year-old male patient was referred to the ophthalmology department in Guatemala City due to a laceration on the forehead caused by a machete. The visual acuity of his right eye (OD) was decreased to 5/200. Examination of the fundus revealed vitreous hemorrhage and commotio retinae. Imaging with computed tomography displayed a fracture on the temporal wall and the roof of the right orbit. The optical coherence tomography of the right eye showed abnormalities in the external layers and subfoveal hemorrhage. Utilizing ultrasound in B-scan, it was noted that the vitreous was not completely attached to the back of the eye, with the retina being displaced and increased echogenicity in the posterior segment. A vitrectomy was performed two weeks after the initial assessment. Following the surgery, the patient's visual acuity in the right eye improved to 20/200 after four months. Conclusions Chorioretinitis Sclopetaria Traumatic is rare, but reports have increased over the past two decades. It can happen not only in response to a high-velocity missile striking or passing adjacent to but not penetrating, the globe but also in response to a strong impact in adjacent areas.

Introduction Surgery is a cost-effective public health intervention. Access to safe surgery is a basic human right. However, there are still significant disparities in the access to and safety of surgical and anaesthesia care between low-income and middle-income countries and high-income countries. The Latin American Surgical Outcomes Study in Paediatrics (LASOS-Peds) is an international, observational, 14-day cohort study to investigate the incidence of 30-day in-hospital complications following elective or emergency paediatric surgery in Latin American countries. Methods and analysis LASOS-Peds is a prospective, international, multicentre observational study of paediatric patients undergoing both elective and non-elective surgeries and procedures, inpatient and outpatient, including those performed outside the operating room. The primary outcome is the incidence of in-hospital postoperative complications up to 30 days after surgery. Secondary outcomes include intraoperative complications and the need for intensive care unit admission. Ethics and dissemination This study received approval from the Institutional Review Board of the coordinating centre (Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo) as well as from all the participating centres. The study results are expected to be published in peer-reviewed journals and disseminated at international conferences. Trial registration number NCT05934682 .

The Guatemalan Foundation for Children with Kidney Diseases collaborated with Bridge of Life, a not-for-profit charitable organization, to establish a vascular access program. We reviewed our experience with graded surgical responsibility and structured didactic training, creating arteriovenous fistulas (AVF) for Guatemalan children. Pediatric vascular access missions were completed from 2015 to 2023 and analyzed retrospectively. Follow-up was completed by the Guatemalan pediatric surgeons, nephrologists, and nursing staff. AVF patency and patient survival were evaluated by Kaplan–Meier life-table analysis with univariate and multivariable association between patient demographic variables by Cox proportional hazards models. Among a total of 153 vascular access operations, there were 139 new patient procedures, forming the study group for this review. The mean age was 13.6 years, 42.6% were female, and the mean BMI was 17.3. Radial or ulnar artery-based direct AVFs were established in 100 patients (71.9%) and ten of the 25 transposition procedures. Brachial artery inflow was required in 29 direct AVFs (20.9%). Two patients underwent femoral vein transpositions. Access-related distal ischemia was not encountered. Seven of the AVF patients later required access banding for arm edema; all had previous dialysis catheters (mean = 9, range 4–12). Primary and cumulative patency rates were 84% and 86% at 12 months and 64% and 81% at 24 months, respectively. The median follow-up was 12 months. Overall patient survival was 84% and 67% at 12 and 24 months, respectively. There were no deaths related to AVF access. Safe and functional AVFs were established in a teaching environment within a Guatemalan comprehensive pediatric nephrology center. A higher resolution version of the Graphical abstract is available as Supplementary information

Introduction Small cell neuroendocrine carcinoma is a rare and aggressive pathology with significant diagnostic challenges. Treatment typically involves multimodal therapy, including surgery and chemotherapy, but outcomes vary. The objective of this study is to describe and report a case of small cell neuroendocrine carcinoma. Case presentation A case study illustrates the follow-up of a 36-year-old female patient from diagnostic biopsy to maxillectomy, followed by adjuvant chemotherapy with cisplatin and etoposide. Small cell neuroendocrine carcinoma poses significant challenges due to its rarity and aggressive behavior. Discussion Multimodal therapy remains the mainstay, but the prognosis is unfavorable. Despite advances, managing small cell neuroendocrine carcinoma remains challenging. Conclusions Integrated approaches are crucial, underscoring the need for ongoing research to improve outcomes in this rare malignancy.

The year 2024 marked a pivotal moment in the history of public health in the Americas as the region grappled with an unprecedented surge in dengue cases1,2. Dengue, primarily transmitted by Aedes aegypti and A. albopictus, now also has the risk of transmission by A. vitattus3, detected in Caribbean countries such as the Dominican Republic and Puerto Rico. Dengue has long been a concern in tropical and subtropical regions. However, the magnitude and severity of the outbreaks witnessed so far in 2024 surpassed anything previously recorded, posing immense challenges to healthcare systems, governments, and communities across the continent4,5. Further, it must be regarded as the potential role of travellers in the risk of introducing dengue into areas where mosquito vectors may be present and where there is no indigenous circulation of the virus. Therefore, there is a need to educate on preventive measures for both the population living in endemic areas and travellers from non-endemic areas. Since Latin America is one of the most frequent destinations for travellers from Europe and North America, dengue vaccination should be widely considered as a prevention tool within the scope of national dengue control programs in endemic areas and in a perspective of traveler health6,7.

The diagnostic criteria, treatments at the time of admission, and drugs used in patients with acute coronary syndrome are well defined in countless guidelines. However, there is uncertainty about the measures to recommend during patient discharge planning. This document brings together the most recent evidence and the standardized and optimal treatment for patients at the time of discharge from hospitalization for an acute coronary syndrome, for comprehensive and safe care in the patient's transition between care from the acute event to the outpatient care, with the aim of optimizing the recovery of viable myocardium, guaranteeing the most appropriate secondary prevention, reducing the risk of a new coronary event and mortality, as well as the adequate reintegration of patients into daily life.

Introduction Tibial nerve anatomy has not been studied profoundly in comparison to Tarsal Tunnel Syndrome (TTS). Assuming symptoms are caused by an anatomical variant or mechanical cause regarding the tibial nerve, it is essential to investigate the anatomy of this structure taking in consideration that surgical and conservative treatments have shown poor results. Methods 40 lower-leg specimens were obtained. Dissection started 20 centimeters proximal to the Dellon-McKinnon (DM) line towards the medial aspect of the naviculo-cuneiform joint distally. Anteriorly, dissection began at the tibio-talar medial gutter until the medial aspect of the Achilles tendon posteriorly. The plantar aspect extended from medial to lateral within the parameters previously described, ending at the level of the second metatarsal. Results The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was found absent and 77.2% of cases as undistinguished extension of the crural fascia. The lateral plantar nerver (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM line, 31.2% distally and 34.3% at the same level. The medial calcaneal nerve (MCN) emerged proximal to the DM line in 100% of specimens. The medial plantar nerve (MPN) has its origin proximal to the DM line in 95% of cases. Conclusion The flexor retinaculum is an extension of the crural fascia and not an independent structure. The LPN and ADM have the same origin in most cases and this presents as an important finding that must be studied in detail for clinical correlations between the motor and sensatory affections of the ADM and LPN respectively. Finally, the branches of the MCN and MPN are the most constant in their distribution and proximal origin in relation to the Dellon-McKinnon line.

Introducción: SARS-CoV-2 ha causado millones de muertes a nivel global desde su primer caso reportado en China. En Guatemala existen pocos estudios que describan los factores pronósticos. Nuestro objetivo fue determinar los factores asociados de mortalidad a 30 días en pacientes con neumonía (Nm) por SARS-CoV-2 y construir un modelo predictor. Material y Métodos: Estudio retrospectivo en 144 sujetos en el Hospital Roosevelt de marzo a diciembre 2020 con criterios de Nm por SARS-CoV-2. Se revisó el expediente médico para datos clínicos y de laboratorio desde ingreso hasta alta hospitalaria o muerte. Resultados: Se evaluaron 105 hombres y 39 mujeres con media de edad 53 años. El 47% tenía comorbilidades como diabetes mellitus 2 e hipertensión arterial sistémica. Promedio de días de hospitalización: 13. Cuadros leves a moderados de Síndrome de Distrés Respiratorio Agudo (SDRA): 92%. Se indicó ventilación mecánica invasiva (VMI) a 46 pacientes. La mortalidad general fue 35%. Factores asociados a mortalidad a 30 días: edad ≥50 años, inicio de síntomas ≥7 días, SDRA severo, radio NL >4,4, recibir VMI, alteración en LDH y procalcitonina. Nuestro modelo mostró que los mejores predictores de mortalidad eran alteración en procalcitonina (OR: 4,45), recibir VMI (OR: 112) y días de estancia hospitalaria (OR: 1,12) con precisión de 91,5% y área bajo la curva de 94,4%. Conclusiones: Los factores pronósticos de mortalidad en pacientes guatemaltecos con Nm por SARS-CoV-2 son múltiples e incluyen rasgos demográficos, clínicos y serológicos; identificarlos y contar con un modelo pronóstico ayudará a brindar atención médica de precisión.

Academic global surgery consists of collaborative partnerships that address surgical inequities through research, training, education, advocacy, and diplomacy. It has been characterized by increased scholastic production through global surgery publications, dedicated global surgery sessions within scientific conferences, global surgery-specific research grants, database development to support global surgery research, global surgery research fellowships, and global surgery-based academic promotion paradigms. The increased emphasis on global surgery research has been accompanied by multiple ethical challenges. This article reviews critical ethical dilemmas presented by global surgery research efforts and proposes interventions on the partnership, infrastructural, and policy levels to enhance fidelity within research partnerships.

Background The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers’ (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region. Methods HCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March–April 2023. Findings Overall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% “other”). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term “antibiotic stewardship”. Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians’ opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions. Conclusions Although HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

Background Hemorrhage is the leading cause of preventable death after trauma. In high‐income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low‐cost training model for tourniquet application using a combination of virtual and physical components. Methods The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre‐training novices with experts. Training validation compared pre and post training novices for improvement. Results Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre‐training novices and experts. When comparing pre‐ and post‐training novices, we found a significantly lower bleeding control time between the groups. Conclusion This study suggests that this training approach can enhance access to life‐saving skills for prehospital personnel. The inclusion of self‐assessment components enables self‐regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first‐responder end users, and expanding the training program to include other skills.

Background Concomitant substance use is frequent among patients with alcohol use disorder (AUD), but its impact on alcohol-associated hepatitis (AH) is unknown. Aims To assess the prevalence and impact of substance use in patients hospitalized for AH in a multinational cohort in Latin America. Methods Multicenter prospective cohort study including patients with AH between 2015-2022. We recorded sociodemographic and clinical information, including data on alcohol and drug use. We assessed the impact of substance consumption using competing-risk models. Results We included 405 patients from 24 centers in 8 countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru). The mean age was 49.6±12.2 years, 345 (85.4%) were men, 210 (57.5%) had a previous diagnosis of cirrhosis, and the median MELD at diagnosis was 25 [20–31] points. Around 74% of patients fulfilled ACLF criteria (ACLF-1: 11.1%, ACLF-2: 11.6%, ACLF-3: 49.6%). A total of 82 (20.3%) reported active substance use, while 22 (5.4%) were former substance users. The most common drugs used at admission were marijuana (11.1%), cocaine (10.4%), methamphetamine (4.4%), and heroin (0.5%). Out of the total, 35.7% died, and only 2.5% underwent liver transplantation during follow-up. Active substance use was higher in younger patients (users 44.4±16.1 years vs. non-users 51.0±10.6 years; pampersand:003C0.001) and in men compared to women (22.0% vs 10.2%, p=0.036). In a competing-risk model adjusted by age, sex, history of cirrhosis, MELD, and ACLF grade, active substance use was independently associated with mortality (subdistribution Hazard Ratio [sHR] 1.53, 95%CI:1.01–2.32; p=0.043). Also, active cocaine (sHR 1.69, 95%CI:1.07–2.70; p=0.025) and marijuana use (sHR 1.83, 95%CI:1.11–3.04; p=0.018) were independently associated with mortality in adjusted competing-risk analyses. Conclusions Active drug use is common in AH patients. Marijuana and cocaine were the most frequent substances and were independently associated with increased mortality. Substance use should be screened in patients with AUD, and integrated management with addiction specialists and psychiatrists could impact survival in AH. Funding Agencies None