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BACKGROUND Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. METHODS The INTERSTROKE study is a case­control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). FINDINGS Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46­1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61­2.11) than ICH (OR 1.19 95% CI 1.00­1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24­4.10) and PAR (18.6%, 15.1­22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63­2.87) and undetermined cause (OR 1.97, 95% CI 1.55­2.50). Both filtered (OR 1.73, 95% CI 1.50­1.99) and non-filtered (OR 2.59, 95% CI 1.79­3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69­2.27), ischemic stroke (OR 1.89, 95% CI 1.59­2.24) and ICH (OR 2.00, 95% CI 1.60­2.50). INTERPRETATION There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. FUNDING The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

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OBJECTIVE: We aim to assess the accuracy and effectiveness of the HemoCue 301, a point-of-care (POC) device for measuring hemoglobin levels, and detecting anemia among individuals living in Tumbes, a rural, underserved area in Northern Peru. METHODS: Baseline analysis of a clinical trial aimed at assessing the effect of multi-fortified bread (NCT05103709). Adult women with capillary blood HemoCue 301 readings below 12 g/dL were recruited in coastal city of Tumbes, Peru. A total of 306 women took part of the study, venous blood samples were taken and analyzed with an automated hematology analyzer. Serum samples were used to measure ferritin, serum iron and C reactive protein. RESULTS: Capillary blood measured by the Hemocue 301 has a bias of 0.36 ± 0.93 g/dL respect to the automated Hb. More than 50% of women with normal ferritin values were classified as anemics according to the HemoCue 301. Automated Hb cut-off of 10.8 g/dL [AUC 0.82 (0.77-0.88)] had a specificity of 0.817 and a sensitivity 0.711 while with the HemoCue 301 cut-off of 11.1 g/dL [AUC 0.71 (0.62-0.79)] had a specificity of 0.697 and a sensitivity 0.688. The performance of the automated Hb cut-off was significantly better than the HemoCue (p<0.001). CONCLUSION: Caution must be taken when using POC devices, especially with values around the threshold. Cut-off values found in our study could be used as surrogate means when no confirmatory tests are available. Clinical outcomes should be prioritized when diagnosing iron deficiency anemia in women of reproductive age to ensure proper diagnosis.

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BACKGROUND: Both pulmonary and mental health are affected following hospitalization for COVID-19 pneumonia. Pulmonary rehabilitation therapy has demonstrated benefits in improving mental health, but no validated combined programs that include mental health have been proposed. OBJECTIVE: This article presents the design of a trial that aimed to assess whether the participation in a combined rehabilitation program that includes home-based respiratory physiotherapy and telephone-based psychological support is associated with a greater improvement of pulmonary and mental health outcomes 7-12 weeks after COVID-19 hospitalization discharge compared with posthospital usual care provided by a public Peruvian hospital. METHODS: WAYRA (the word for air in the Quechua language) was an open-label, unblinded, two-arm randomized controlled trial. We recruited 108 participants aged 18-75 years who were discharged from the hospital after COVID-19 pneumonia that required >6 liters/minute of supplemental oxygen during treatment. Participants were randomly assigned at a 1:1 ratio to receive the combined rehabilitation program or usual posthospital care provided by a public Peruvian hospital. The intervention consisted of 12 at-home respiratory rehabilitation sessions and 6 telephone-based psychological sessions. The primary outcome was the 6-minute walk distance. Secondary outcomes included lung function, mental health status (depression, anxiety, and trauma), and quality of life. Outcomes were assessed at baseline (before randomization) and at 7 and 12 weeks after hospital discharge to assess the difference between arms. RESULTS: This study was funded by the Peruvian National Council of Science Technology and Technology Innovation in July 2020. Ethics approval was obtained on September 2, 2020. Recruitment and data collection occurred between October 2020 and June 2021. Results are expected to be published by the end of 2022. CONCLUSIONS: WAYRA was the first randomized controlled trial evaluating combined pulmonary-mental health rehabilitation for hospitalized COVID-19 survivors in resource-limited settings, potentially providing a foundation for the cost-effective scale-up of similar multidisciplinary rehabilitation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04649736; https://clinicaltrials.gov/ct2/show/NCT04649736. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/36001.

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We aimed to evaluate the feasibility of a tailored physical activity (PA) prescription in overweight and obese people in a tertiary hospital in Lima, Peru. A feasibility pre-post-pilot study was conducted using mixed methods. Participants received a tailored prescription scheme for PA that lasted twelve weeks. It included two prescription sessions, three follow-up phone calls, and three evaluations. Primary feasibility outcomes were recruitment, visits, and phone call adherence. Primary intervention outcomes were self-reported PA levels and the 6 min walk test. Out of 228 people invited to participate, 30 were enrolled and received the first session of prescription, 11 went to the second session, and 21 went to the final evaluation; phone call participation decreased progressively during follow-up. There were no differences in the 6th week and the 12th week compared to the baseline for all the measures, except in the 6 min walk test. The participants considered the intervention was well designed, but they suggested complementing it with dietary instructions. The prescription of PA in overweight and obese people is feasible for promoting PA, but its implementation requires refinements to anticipate possible barriers to changing behavior.

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OBJECTIVE: To describe the content of overweight and obesity counseling performed in a public Peruvian hospital. METHODS: We audio-recorded 40 visits of patients with overweight or obesity from the internal medicine, cardiology, endocrinology, and family medicine services at Cayetano Heredia Hospital. Fragments of the recordings in which counseling was performed were transcribed and codified. We established a checklist to score each counseling session and performed descriptive analyses. RESULTS: Complete counseling (including weight, nutrition, and physical activity) was performed in 32.5% of consultations. The average time spent in counseling was 1.72 minutes. Counseling on weight loss was performed in 65% of consultations, nutrition in 65%, and physical activity in 35%. On average, 8 of 26 checklist items were fulfilled per appointment. Weight loss goals were established in 15% of visits. The most frequent diet recommendations were eating more fruits and vegetables (32.5%) and eating fewer carbohydrates (30.0%). Suggested physical activities were walking (10.0%), running (7.5%), and playing any sport (7.5%). CONCLUSIONS: Complete counseling was only addressed in one-third of the appointments, and most counseling was superficial without considering therapeutic goals. This suggests the need to include lifestyle counseling in consultations, regardless of the medical specialty or patient's background condition.

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Resumen Objetivo: Sintetizar las características epidemiológicas y clínicas de los niños de COVID-19 con EK, KLD y MIS-C. Métodos: Se realizó una búsqueda en 4 bases de datos y preprints hasta el 31 de Mayo del 2021. Se incluyeron reportes/series de caso que evaluaron las caracte rísticas clínicas del EK, KLD o MIS-C en pacientes pediátricos con COVID-19. Resultados: Se incluyeron 16 estudios (seis informes de casos y diez series de casos, 367 pacientes en total, 58 pacientes con EK, 87 con KLD y 290 pacientes con MIS-C); con edades entre los 6 meses y los 10 años, y el 62% eran mujeres. Se observó COVID-19 positivo en 75,2%. Respecto a EK, KLD y MIS-C, las características clínicas repor tadas fueron compatibles con los cuadros diagnósticos estandarizados en el contexto de COVID-19. La duración de la hospitalización fue de 5 a 14 días para EK y de 4,3 a 13 para MIS-C. Once pacientes con MIS-C (2,8%) necesitaron ECMO. Seis pacientes con MIS-C fueron reportados muertos. Ocho estudios reportaron pacientes en la UCI. Conclusiones: EK o KLD puede asociarse a COVID-19 en niños, y pueden complicarse con MIS-C. El tiempo de hospitalización es prolongado si se presenta EK o KLD asociado a COVID-19 en niños.

Abstract Objective: To synthesize the epidemiological and clinical characteristics of COVID-19 children with MIS-C, KLD and EK. Methods: Databases and preprints were searched until May 31, 2021. Reports/case series that evaluated the clinical features of EK, KLD, or MIS-C in pediatric patients with COVID-19 were included. Results: Sixteen studies were included (six case reports and ten case series, 367 patients total, 58 patients with EK, 87 with KLD, and 290 patients with MIS-C); with ages ranging from 6 months to 10 years, and 62% were female. Positive COVID-19 was observed in 75.2%. Regarding EK, KLD and MIS-C, the reported clinical characteristics were compatible with the standardized diagnostic pictures in the context of COVID-19. The duration of hospitalization was 5 to 14 days for EK and 4.3 to 13 for MIS-C. Eleven patients with MIS-C (2.8%) needed ECMO. Eleven patients with MIS-C (2.8%) needed ECMO. Six patients with MIS-C were reported dead. Eight studies reported patients in the ICU. Conclusions: Children with COVID-19 develop EK or KLD, and can be complicated by MIS-C. Prevention, diagnosis, and treatment measures are needed.

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Patient-centred care (PCC) is a pillar of quality health services, where decision-making power is shared between the clinician and the patient. Although, this approach could be adopted with easiness in high income settings or in countries with unified health systems, in settings such as Peru, where universal access and other structural problems remain a challenge, the practice of PCC is not a priority. In Peru, research on PCC has been conducted for almost two decades, but this has not generated a need for development in academia, decision makers, health personnel or patients. Here, we give an overview of the road that PCC research has taken in Peru and the challenges that remain to translate it into clinical practice.

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RESUMEN Introducción: Las tecnologías de información y comunicación pueden ayudarnos a mejorar el control metabólico y la adherencia de las personas con diabetes mellitus tipo 2 (DM2). Objetivo: Evaluar los efectos de una intervención con llamadas telefónicas en pacientes ambulatorios con DM2 mal controlada de un hospital en Perú. Métodos: Ensayo clínico aleatorizado. Incluimos adultos con DM2 con mal control glicémico (HbA1c > 7%), quienes fueron aleatorizados al grupo control (cuidado usual) o al grupo intervención (cuidado usual más una intervención con llamadas telefónicas cada dos semanas por tres meses). El desenlace principal fue la reducción ≥ 1% de hemoglobina glicosilada a los tres meses. Resultados: Se reclutó 94 participantes (47 en cada grupo). La edad promedio fue 59,8 años (DE: 10,2), 69,2 % fueron mujeres. A los tres meses, solo 14/47 participantes del grupo control y 13/47 participantes del grupo intervención tuvieron medición de HbA1c. Entre estos, el porcentaje de los que lograron una disminución ≥ 1% de HbA1c fue de 35,7% (5/14) en el grupo control y 53,8% (7/13) en el grupo intervención (RR: 0,72, IC 95%: 0,35-1,47). No se encontró diferencias en la adherencia al tratamiento entre ambos grupos. Conclusiones: No se encontró diferencias estadísticamente significativas para los desenlaces de interés. Posiblemente esto se deba al bajo porcentaje de participantes a los que se logró completar el seguimiento.

ABSTRACT Introduction: Information and communication technologies can help us improve metabolic control and adherence in people with type 2 diabetes mellitus (DM2). Objective: To evaluate the effects of an intervention with telephone calls in outpatients with poorly controlled DM2 in a hospital in Peru. Methods: Randomized clinical trial. We included adults with DM2 with poor glycemic control, who were randomized to the control group (usual care) or to the intervention group (usual care plus a telephone intervention every two weeks for three months). The primary outcome was a ≥ 1% reduction in glycosylated hemoglobin at three months. Results: 94 participants were recruited (47 in each group). Mean age was 59.8 years (SD: 10.2), 69.2 % were women. At three months, only 14/47 participants in the control group and 13/47 participants in the intervention group had HbA1c measurement. Among these, the percentage of those who achieved a ≥ 1% decrease in HbA1c was 35,7% (5/14) in the control group and 53,8% (7/13) in the intervention group (RR: 0,72, 95% CI: 0,35-1,47). No differences were found in adherence to treatment between groups. Conclusions: No statistically significant differences were found for the outcomes of interest. This is possibly due to the low percentage of participants who were able to complete follow-up. Innovative solutions are needed to improve the control of people with DM2.

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Introducción: Las tecnologías de información y comunicación pueden ayudarnos a mejorar el control metabólico y la adherencia de las personas con diabetes mellitus tipo 2 (DM2). Objetivo: Evaluar los efectos de una intervención con llamadas telefónicas en pacientes ambulatorios con DM2 mal controlada de un hospital en Perú. Material y Métodos: Ensayo clínico aleatorizado. Incluimos adultos con DM2 con mal control glicémico (HbA1c > 7%), quienes fueron aleatorizados al grupo control (cuidado usual) o al grupo intervención (cuidado usual más una intervención con llamadas telefónicas cada dos semanas por tres meses). El desenlace principal fue la reducción ≥ 1% de hemoglobina glicosilada a los tres meses. Resultados: Se reclutó 94 participantes (47 en cada grupo). La edad promedio fue 59,8 años (DE: 10,2), 69,2 % fueron mujeres. A los tres meses, solo 14/47 participantes del grupo control y 13/47 participantes del grupo intervención tuvieron medición de HbA1c. Entre estos, el porcentaje de los que lograron una disminución ≥ 1% de HbA1c fue de 35,7% (5/14) en el grupo control y 53,8% (7/13) en el grupo intervención (RR: 0,72, IC 95%: 0,35-1,47). No se encontró diferencias en la adherencia al tratamiento entre ambos grupos. Conclusiones: No se encontró diferencias estadísticamente significativas para los desenlaces de interés. Posiblemente esto se deba al bajo porcentaje de participantes a los que se logró completar el seguimiento.

Introduction: Information and communication technologies can help us improve metabolic control and adherence in people with type 2 diabetes mellitus (DM2). Objective: To evaluate the effects of an intervention with telephone calls in outpatients with poorly controlled DM2 in a hospital in Peru. Material and Methods: Randomized clinical trial. We included adults with DM2 with poor glycemic control, who were randomized to the control group (usual care) or to the intervention group (usual care plus a telephone intervention every two weeks for three months). The primary outcome was a ≥ 1% reduction in glycosylated hemoglobin at three months. Results: 94 participants were recruited (47 in each group). Mean age was 59.8 years (SD: 10.2), 69.2 % were women. At three months, only 14/47 participants in the control group and 13/47 participants in the intervention group had HbA1c measurement. Among these, the percentage of those who achieved a ≥ 1% decrease in HbA1c was 35,7% (5/14) in the control group and 53,8% (7/13) in the intervention group (RR: 0,72, 95% CI: 0,35-1,47). No differences were found in adherence to treatment between groups. Conclusions: No statistically significant differences were found for the outcomes of interest. This is possibly due to the low percentage of participants who were able to complete follow-up. Innovative solutions are needed to improve the control of people with DM2.

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BACKGROUND: The COVID-19 pandemic is an unprecedented challenge to health systems that has revealed shortcomings and increased unmet demands. Such situations might exacerbate workplace violence (WPV) against physicians, as has been reported in several parts of the world. METHODS: To identify the frequency and characteristics of WPV suffered by physicians attending COVID-19 patients in Peru, a descriptive, cross-sectional study was conducted with an online survey of 200 physicians. RESULTS: Of the survey respondents, 84.5% had suffered some type of WPV; 97.6% of these suffered nonphysical violence. Suffering more than one incident of violence was reported by 75.7% of respondents. The primary aggressor was a patient's family member or caregiver. Violence occurred most frequently in critical areas inside the health service facility, such as COVID-19 triage, tents, and hospital units, although it also occurred during teleconsultations. Multiple shortcomings of the health services were perceived as the main trigger of violence. Being a female physician (odds ratio [OR] = 2.48, 95% confidence interval [CI] = 1.06-5.83) and working in a COVID-19 ICU (OR = 5.84, 95% CI = 1.60-21.28) were the main factors associated with WPV. CONCLUSION: Violence against physicians attending COVID-19 patients in Peru is common. The perceived factors that contribute most to violence are linked to deficiencies in health services.

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