In 2018, NPH continued to provide quality healthcare with a child-centered approach in countries where the basic human right of access to healthcare is quite difficult to accomplish. Our medical programs strive to provide the best care possible for populations of children living in NPH homes and for those in the surrounding communities. Medical Services uses an integral, holistic, and comprehensive approach that takes into consideration environmental, psychological, preventive, and curative factors. Each regional medical coordinator assists in monitoring children with chronic conditions, delivering vaccinations, coordinating therapies and annual well-child checkups, ensuring the appropriate use of cost-effective drugs, procuring specialized medicines, and implementing public health interventions.

The NPH Medical Services’ motto is “what would you do if this patient were your own child?” The answer is obvious. Even if the necessary treatment can only be found abroad, NPH will do it! For the past 10 years NPH has sent nine children to Italy and Spain for difficult surgeries or treatment, among them kidney transplants, congenital heart diseases, leukemia, oncology diseases, and severe orthopedic problems. All of this is possible thanks to the surgeons, hospitals, airlines, and NPH fundraising offices. What we can do working together as a team has no limits.

The NPH healthcare programs reached many milestones in 2018 that are aligned with the U.N. Sustainable Development Goals and with the international standards of well recognized healthcare organizations.

Zero Hunger – Sustainability Goal #2
NPH’s food menus have improved substantially, providing children with the necessary micronutrients and vitamins to grow healthy and happy. Nevertheless, Latin American children overall continue to show a high percentage of chronic malnutrition, an invisible condition that is identified through consistent measurement of growth and development.

Chronic malnutrition in children inhibits growth as a result of deficient nutritional intake. Long-term deficiencies can have grave consequences, affecting lifelong physical and cognitive development. These children will have difficulty understanding lessons in school leading to high dropout rates, which, in turn, can lead to low levels of job skills and a lifetime of low-paying employment.

Global leaders in chronic malnutrition are some of the countries where NPH operates—Guatemala, Honduras, Nicaragua, Mexico, and Peru. Of the 200 million children worldwide who live with chronic malnutrition, 25% or 50 million are in Latin America.

Good Health and Well-being – Sustainability Goal #3
Fortunately there were no major vector-born epidemics (dengue, the Zika virus, chikungunya, or malaria) thanks to the strengthening of preventive measures, like mosquito nets and regular fumigation. Only a few homes reported chicken pox cases, which is quite common in settings where a high number of children live together. NPH maintains an average 85% vaccination rate according to the ages of the population. Our goal is 92%, which has been achieved in previous years with additional funding sources. The World Health Assembly Global Vaccine Action Plan calls on all countries to reach 90% coverage with all vaccines by 2020.

Clean Water and Sanitation – Sustainability Goal #6
Water is life. It is also the source of many diseases, if not properly treated, thus making clean water a priority in all NPH homes. NPH Haiti formed a partnership with a team from the United States and used funds from Europe to improve water service for the flagship property located in the mountains of Kenscoff. This project has brought hot water to the property, a change welcomed by the children and caregivers given the cold and foggy climate of the region.

Chronic Conditions and Children with Disabilities or Special Needs
The prevalence of children with chronic conditions is quite high in NPH countries as a result of inadequate prenatal care, teenage pregnancy, and environmental factors. Almost half of the population in some NPH countries has some sort of chronic condition and 20% have disabilities, which means higher healthcare expenses and more follow up care.

In 2018 Medical Services developed and presented first at the medical services workshop in April and then again at the psychology workshop in October, “Sex Education Guidelines for Children with Disabilities,” which will be implemented in each NPH home in 2019.

Expanding Programs and Community Outreach
Medical Services has developed cost effective and impactful healthcare initiatives for our expanding programs. With the increase in the number of adolescents in the population, we have restructured our programs to adapt to this change. These initiatives include health school programs for children of all ages from pre-K to high school. The program also includes health monitoring for children in community centers run by NPH, for children in transition homes, and for NPH OneFamily.

Mental Health
Mental health in vulnerable communities demands a professional and multidisciplinary approach to evaluate needs and provide integral, specific support for the healthy development of the individual and the benefit of the community.

A multidisciplinary approach is applied case by case for effective evaluation, treatment, follow-up, and staff training and advice. For staff, empowerment and training in trauma-informed practices is a requirement, as most of the NPH population has suffered an adverse childhood experience (ACE). In our efforts to comply with UNICEF guidelines and accepted children’s rights practices, we provide age-appropriate sex education based in human and spiritual values. Among the most common diagnoses are post-traumatic stress disorder (PTSD), attachment, depression, attention deficit hyperactivity disorder (ADHD), and adverse childhood experiences (ACE).

Health Education for Local Staff and Clinicians
Medical Services delivers continual on-site training and hosts an annual medical workshop. We develop healthcare policies, manuals, guidelines, protocols, and procedures based on international standards and best practices, using evidence-based medicine.

Healthy Pequeños
University of Pennsylvania School of Nursing senior Alaina Hall was among the nine winners of a $100,000 prize in funding for Penn seniors to design and undertake post-graduation projects that make a positive, lasting difference in the world. Hall’s nonprofit project – Healthy Pequeños (Healthy Little Ones) – is a nurse-led multi-interventional health-promotion effort that aims to address the global health problem of infectious disease in children. Working in partnership with NPH Mexico, Hall is working to improve health education for children and their caregivers, strengthen infection screening and identification processes, and reduce exposure to infection-causing pathogens by providing filtered water and repairing damage to local sewage structures.

The World Health Organization (WHO) defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

NPHI Medical Services Team

NPHI Medical Services On-site Visits
– One per year to each NPH Home
– Regular monitoring of core programs
– Annual evaluation of country-specific healthcare goals
– Ensure adherence to NPH healthcare policy, quality standards, and global health indicators

On behalf of the NPHI Medical Services team, we express our deepest gratitude to all the professionals and teams, and all of those who have provided us with continued support in 2018.

Pilar Silverman, MD
NPHI Medical Services Director

World Immunization Week April 24-30, 2018

Immunization saves millions of lives and is widely recognized as one of the world’s most successful and cost-effective health interventions.

• In 2017, NPH home clinics administered 2,566 vaccines to children living in the homes.
• The NPH vaccination program in our home clinics covers children and youths in the home with 85-98% of their basic vaccines. By basic vaccines we consider: diphtheria, tetanus, pertussis, Measles, Mumps, Rubella and Hepatitis B.
• Governments supply some of these vaccines, but NPH supplies over half of the vaccinations provided to children using either donations or purchasing them to increase coverage.
• In 2017, St. Damien Pediatric Hospital in Haiti provided 10,760 vaccinations to the public.

Reflecting on 2017, our NPHI Medical Services team feels a great sense of gratitude for all the support and accomplishments we have been able to achieve together within the NPH community. At NPH, we ensure that every child has access to quality health care at any level, to vaccines, to safe water, to good and balanced nutrition, as well as to health education and a safe environment; all of which are included in NPH core programs.

We live in a world full of uncertainty and change; a challenging world the NPH faces every day. NPH has been experiencing and adapting to these environmental changes, transforming its programs to meet the current needs of children and communities. It is exciting to witness and be part of the variety of ways that NPH serves children in nine different countries.

One of the most evident results of these changes is the current population in NPH. In 2017, the demographic trends of the population that NPH serves changed dramatically from previous years. Currently, NPH has more adolescents and young adults, and fewer children under five years old. This population pattern prompted NPH to develop new age-appropriate programs and protocols for our largest age demographic, adolescents and young adults. These programs include, but are not limited to: values-based sexual education, Chicas Poderosas (a female empowerment group which promotes gender equality, healthy living practices, and conscientious decisions about adulthood), guidance on for adolescents to care for their own physical and mental health, violence prevention programs, formation on skills for growth toward independence, and both technical and a university education.

The programs we share on the next page are among the 16 NPHI core programs. We measure our progress by key standards that align with the United Nations, UNICEF and PAHO guidelines.

IMMUNIZATION
Vaccines protect children against some of the most dangerous diseases of childhood, some of which can leave consequences for life. The immunization program at NPH is ongoing; we either receives the vaccines from the country’s public health department, or we purchase them ourselves in order to complete the vaccination series as soon as possible, according to the age the full series of immunizations. Vaccinations not only protect the individual, they impact their entire community.

MENTAL HEALTH
In societies with deep health disparities, mental health programs need to be executed seriously and professionally. At NPH, we promote:

• Interdisciplinary work administers appropriate treatment, follow up, and further education, always in a transparent manner.
• Empowering and supporting our staff’s professional development to care for children with mental health needs.
• Health education and disease prevention for our children, especially in adolescents. NPH reinforces the cycle of awareness, experimentation and repetition, ensuring that our children understand the messages clearly.
• Sexual education based on human and spiritual values.

NUTRITION
On average, approximately 75% of children arrive at NPH with signs of malnutrition such as anemia or low weight. Usually, following only a few months of receiving three balanced, regular meals a day as well as additional nutrition when needed, they reach an appropriate weight and height for their age, and NPH physicians monitor the growth and development of every child on a yearly basis. For those who have any delay in their development – including low weight or height – each home has either individual or group programs available to support them.

MOSQUITO-BORNE PREVENTION
As most NPH programs are in tropical and subtropical areas, protection against mosquito-borne diseases is a must. Malaria, Zika, Chikungunya, yellow fever and Dengue are among those infections easily preventable with mosquito screens, bed nets and other attainable measures.

WATER AND SANITATION
Access to safe water is not only a human right, it prevents diarrhea, pneumonia, parasites, hepatitis and a long list of other preventable diseases. Educating our youth on healthy habits is one essential and cost-effective measure that we use to fight water-borne diseases, with the goal that they carry these skills with them into their adult lives. Our team works hard to ensure that every home has a reliable and lasting water system. Sanitation and waste disposal systems and programs are also essential to preventing infectious diseases. Furthermore, every year, each NPH home joins the worldwide “Handwashing Day”, a UN initiative that promotes this easy, everyday practice that makes a big difference in preventing the spread of infections.

NPH OneFamily PROGRAM
NPH social workers and psychologists check in on the health of each child at every visit. If children have chronic conditions, they are also responsible for ensuring follow-up visits with the local specialists and that their medication is available.

NATURAL DISASTERS
Each year, NPH faces the risk of being impacted by natural disasters – hurricanes, heavy rains, earthquakes – that bring with them enormous damage and can put our children at risk. Our Medical Services team proactively developed a healthcare manual to better respond to natural disasters in the future.

NPH Medical Services has also developed policies and guidelines for the prevention of sport injuries, patients’ security, waste management, disaster preparedness, health guidelines for caregivers, nutrition, injury prevention, documentation, and tracking, all in consultation with best practices in the healthcare industry.

Finally, we would like to thank our partners: the IT support that we received in going paperless, using the Electronic Medical Records, reporting online, medical brigades, and the various experts that supported us in the areas of pediatrics, neurology, ophthalmology and dental, as well as helping us provide hot water to the kids homes in Kenscoff, Haiti. Your support has made 2017 a great year. On behalf of the NPHI Medical Services team, we express our deepest gratitude to these professionals and teams, and all those who have provided us with continued support.

Pilar Silverman, MD, NPHI Medical Services Director

Breast cancer starts when cells in the breast begin to grow out of control. These cells usually form a tumor that can often be seen on an x-ray or felt as a lump. The tumor is malignant (cancer) if the cells can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body.

Breast cancer occurs almost entirely in women, but men can get breast cancer, too.

Cells in nearly any part of the body can become cancer and can spread to other areas. To learn more about cancer and how all cancers start and spread, see Cancer Basics.

Breast cancers can start from different parts of the breast. Most breast cancers begin in the ducts that carry milk to the nipple (ductal cancers). Some start in the glands that make breast milk (lobular cancers). There are also other types of breast cancer that are less common.

A small number of cancers start in other tissues in the breast. These cancers are called sarcomas and lymphomas and are not really thought of as breast cancers.

Breast cancer can spread when the cancer cells get into the blood or lymph system and are carried to other parts of the body.

The lymph system is a network of lymph (or lymphatic) vessels found throughout the body that connects lymph nodes (small bean-shaped collections of immune system cells). The clear fluid inside the lymph vessels, called lymph, contains tissue by-products and waste material, as well as immune system cells. The lymph vessels carry lymph fluid away from the breast. In the case of breast cancer, cancer cells can enter those lymph vessels and start to grow in lymph nodes. Most of the lymph vessels of the breast drain into:

• Lymph nodes under the arm (axillary nodes)
• Lymph nodes around the collar bone (supraclavicular [above the collar bone] and infraclavicular [below the collar bone] lymph nodes)
• Lymph nodes inside the chest near the breast bone (internal mammary lymph nodes)

Symptoms and detection of breast cancer

An important part of breast health is to know how your breasts look and feel normally. Discovering breast cancer as soon as possible will give you more chances for your treatment to be effective; however, knowing which signs to pay attention to is not a substitute for routine mammograms or other screening tests. screening can help find breast cancer in its early stages, before any symptoms appear.

The most common symptom of breast cancer is a new mass or lump. a non-painful, hard mass with irregular borders is more likely to be cancer, although cancerous breast tumors may also be palpation sensitive, soft and rounded. they can even cause pain. For this reason, it is important for a doctor with experience in the diagnosis of breast diseases to examine any new lumps or lumps, or any changes in the breasts.

Other possible symptoms of breast cancer include:

• swelling of the entire breast or part of it (even if you do not feel a definite protuberance)
• skin irritation or dimpling (sometimes resembling the skin of an orange)
• pain in the breast or nipple
• retraction (contraction) of the nipples
• redness, scaling or thickening of the skin of the breast or nipple
• secretion of the nipple other than breast milk
• protuberance or swelling in armpit area and around clavicular (by lymph nodes)

Are there any new investigations?

In several countries around the world, researchers are striving to find better ways to prevent, detect and treat breast cancer, and to improve the quality of life for patients and survivors of breast cancer.some of the many active research áreas aiming to prevent it; include:

• causes of breast cancer
• causes and treatment of metastatic breast cancer
• reduced risk of breast cancer
• how to treat ductal carcinoma in situ (dcis):new laboratory tests for breast cancer
• new imaging studies for breast cancer
• breast cancer treatments
• supportive care

Causes of breast cancer

So far, the exact causes of breast cancer are not well understood, however there are several risk factors you know Dr. Ananya Mandal, such as age:

• Risk factors without being able to modify: gender, breast density, family history, those with a previous history of breast cancer, those with previous benign breast tumors, exposure to estrogens, height.
• Modifiable risk factors: being fat or obese, alcohol intake, exposure to radiation, hormone replacement therapy (HRT), exposure to Diethylstilbesterol (DES), breast cancer and breast implants. (https://www.news-medical.net/health/Breast-Cancer-Causes-(Spanish).aspx, 10-18-2017).
• Studies are continuing to discover factors and habits, as well as hereditary genes, that affect the risk of breast cancer.
•  is also researching in new labs and imaging studies to detect breast cancer in time.

Therapy

• Chemotherapy depends on the type of cancer
• Oncoplastic surgery: Breast-conserving surgery (lumpectomy or partial mastectomy) can often be used for breast cancers in the early stages. however, breasts may remain of different sizes or shapes in some women. for larger tumors, it may not even be possible, and a mastectomy is needed. some physicians solve this problem by combining cancer surgery and plastic surgery techniques, which is known as oncoplastic surgery.
• Triple negative breast cancer: Because triple negative breast cancers can not be treated with hormone therapy or targeted therapy, such as her-2 medications, treatment options are limited to chemotherapy. in recent years, molecules that could be targeted for new breast cancer drugs have been identified. the use of drugs targeting these molecules, such as kinase inhibitors and immunotherapy, is currently being studied to treat triple negative breast cancers, either alone, in combination, or with chemotherapy.
• Targeted Therapy: Targeted therapies are a group of drugs that specifically target the genetic changes in cancer cells that help them grow or spread. new therapies aimed at combating breast cancer, including parp inhibitors, are being studied. these drugs are likely to be useful against cancers caused by brca mutations and have been shown to be somewhat promising in the treatment of some types of breast cancer. olaparib and veliparib are two inhibitors of parp that have been studied in breast cancer positive brca with encouraging results.
• Supportive care: trials are being conducted with different medications to try to improve memory and symptoms of the brain affected by chemotherapy. other studies are evaluating whether certain heart medications, known as beta-blockers, can prevent heart damage sometimes caused by conventional chemotherapy drugs used for breast cancer, doxorubicin, epirubicin.

CANCER DE MAMA

El cáncer de seno (o cáncer de mama) se origina cuando las células en el seno comienzan a crecer en forma descontrolada. Estas células normalmente forman un tumor que a menudo se puede observar en una radiografía o se puede palpar como una protuberancia (masa o bulto). El tumor es maligno (cáncer) si las células pueden crecer penetrando (invadiendo) los tejidos circundantes o propagándose (metástasis) a áreas distantes del cuerpo. El cáncer de seno ocurre casi exclusivamente en las mujeres, pero los hombres también lo pueden padecer.

(https://www.cancer.org/es/cancer/cancer-de-seno/acerca/que-es-el-cancer-de-seno.html)

Existen DOS TIPOS PRINCIPALES DE CÁNCER DE MAMA. el carcinoma ductal infiltrante, que comienza en los conductos que llevan leche desde la mama hasta el pezón, es por mucho el más frecuente (aproximadamente el 80 % de los casos). el segundo lugar lo ocupa el carcinoma lobulillar infiltrante (10 a 12 % de los casos), que comienza en partes de las mamas llamadas lobulillos, que producen la leche materna.​ los restantes tipos de cáncer de mama no superan en conjunto el 10 % de los casos.

Según american cancer society el cáncer de seno se puede propagar cuando las células cancerosas alcanzan la sangre o el sistema linfático y llegan a otras partes del cuerpo.

El sistema linfático es una red de vasos linfáticos (o linfático) encontrado en todo el cuerpo que conecta los ganglios linfáticos (pequeñas agrupaciones en forma de un fríjol de células del sistema inmunitario). el líquido transparente dentro de los vasos linfáticos, llamado linfa, contiene productos derivados de los tejidos y materia de desecho, así como células del sistema inmunitario. los vasos linfáticos transportan líquido linfático fuera de los senos. en el caso de cáncer de seno, las células cancerosas pueden ingresar en los vasos linfáticos y comenzar a crecer en los ganglios linfáticos. la mayoría de los vasos linfáticos del seno drenan hacia:

• los ganglios linfáticos localizados debajo del brazo (ganglios axilares)
• los ganglios linfáticos que rodean la clavícula (ganglios linfáticos supraclaviculares [encima de la clavícula] e infraclaviculares [debajo de la clavícula])
• los ganglios linfáticos que se encuentran en el interior del tórax y cerca del esternón (ganglios linfáticos mamarios internos)

Sintomas y detection del cancer de seno.

Una parte importante de la salud de los senos consiste en saber cómo se ven y se sienten normalmente sus senos. descubrir el cáncer de seno tan pronto como sea posible le dará más probabilidades de que su tratamiento sea eficaz. no obstante, conocer los signos a los que debe prestar atención no reemplaza a los mamogramas de rutina ni a otras pruebas de detección. las pruebas de detección pueden ayudar a encontrar el cáncer de seno en sus etapas iniciales, antes de que aparezca algún síntoma.

El síntoma más común del cáncer de seno es una nueva masa o protuberancia. una masa no dolorosa, dura y con bordes irregulares tiene más probabilidades de ser cáncer, aunque los tumores cancerosos del seno también pueden ser sensibles a la palpación, blandos y de forma redondeada. incluso pueden causar dolor. por este motivo, es importante que un médico con experiencia en el diagnóstico de enfermedades de los senos examine cualquier masa o protuberancia nueva, o cualquier cambio en los senos.

Otros posibles síntomas del cáncer de seno incluyen:

• hinchazón de todo el seno o parte de él (aunque no se sienta una protuberancia definida)
• irritación de la piel o formación de hoyuelos (a veces parecido a la cáscara de una naranja)
• dolor en el seno o en el pezón
• retracción (contracción) de los pezones
• enrojecimiento, descamación o engrosamiento de la piel del seno o del pezón
• secreción del pezón que no sea leche materna
• protuberancia o hinchazon en area de axilas y alrededor de clavicular (por los ganglios linfaticos)

Hay nuevos investigaciones?

En diversos países del mundo, los investigadores se están esforzando para encontrar mejores maneras de prevenir, detectar y tratar el cáncer de seno, y para mejorar la calidad de vida de pacientes y sobrevivientes de esta enfermedad.

algunas de las muchas áreas activas de investigación incluyen:

• las causas del cáncer de seno
• causas y tratamiento del cáncer de seno metastásico
• reducción del riesgo de padecer cáncer de seno
• cómo tratar el carcinoma ductal in situ (dcis)
• nuevas pruebas de laboratorio para el cáncer de seno
• nuevos estudios por imágenes para el cáncer de seno
• tratamientos del cáncer de seno
• cuidado de apoyo

Causas del cáncer de seno

• Las causas exactas del cáncer de pecho no están bien entendidas, sin embargo hay varios factores de riesgo sabe Dr. Ananya Mandal, como la edad
• Factores de riesgo sin poder modificarse: el género, densidad del pecho, antecedentes familiares, esos con una historia anterior del cáncer de pecho, esos con los tumores benignos anteriores del pecho, exposicion a los estrogenos, altura.
• Factores de riesgo modificables: siendo gordo u obeso, admision de alcohol, exposicion a la radiacion, terapia de reemplazo hormonal (HRT), exposicion a Diethylstilbesterol (DES), cancer de pecho y implantes de pecho. (https://www.news-medical.net/health/Breast-Cancer-Causes-(Spanish).aspx, 18-10-2017).
• se siguen realizando estudios para descubrir factores y hábitos, así como genes hereditarios, que afectan el riesgo de padecer cáncer de seno.
• tambien esta investigando en nuevos laboratorios y estudios por imagenes para detectar el cancer de seno con tiempo.

Terapia

• quimioterapiadepende del tipo del cancer
• cirurgia oncoplastica: la cirugía con conservación del seno(tumorectomía o mastectomía parcial) a menudo se puede usar para los cánceres de seno en etapas tempranas. sin embargo, los senos pueden quedar de tamaños o formas diferentes en algunas mujeres. para los tumores más grandes, puede que ni siquiera sea posible, y que se necesite una mastectomía. algunos médicos resuelven este problema mediante la combinación de cirugía del cáncer y técnicas de cirugía plástica, lo que se conoce como cirugía oncoplástica.
• cáncer de seno triple negativo: debido a que los cánceres de seno triple negativos no se pueden tratar con terapia hormonal o terapia dirigida, tal como medicamentos her-2, las opciones de tratamiento están limitadas a la quimioterapia. en los últimos años, se han identificado moléculas que podrían ser blanco de nuevos medicamentos contra el cáncer de seno. actualmente se estudia el uso de medicamentos dirigidos a estas moléculas, como los inhibidores de cinasa y la inmunoterapia, para tratar los cánceres de seno triple negativos, bien sea solos, en combinación, o con quimioterapia.
• medicamentos de terapia dirigida: las terapias dirigidas son un grupo de medicamentos que ejercen su acción específicamente en los cambios genéticos de las células cancerosas que les ayudan a crecer o a propagarse. se están estudiando nuevas terapias dirigidas para combatir el cáncer de seno, incluyendo inhibidores de parp. estos medicamentos muy probablemente sean útiles contra los cánceres causados por mutaciones brca, y han demostrado ser algo prometedores en el tratamiento de algunos tipos de cáncer de seno. el olaparib y el veliparib son dos inhibidores de parp que han sido estudiados en el cáncer de seno brca positivo con resultados alentadores.
• cuidado de apoyo: se están realizando ensayos con diferentes medicamentos para tratar de mejorar la memoria y los síntomas del cerebro afectado por la quimioterapia. otros estudios están evaluando si ciertos medicamentos cardiacos, conocidos como betabloqueadores, pueden prevenir el daño al corazón a veces causado por los medicamentos de quimioterapia convencional que se emplean para el cáncer de seno, doxorrubicina, epirrubicina.

NPHI Medical Services

Mycosis is caused by fungi (fungal or mycotic diseases are basically several diseases caused by microscopic fungi, which tend to multiply on the surface of the skin (superficial mycosis), or in the organs themselves. When this disease appears for the first time, relapses are common and medical treatment tends to be long.

Mycoses are infections caused by different species of fungi that are located in the epithelium or outermost layer of mucous membranes, skin and nails.

Mycosis appears more often in tropical, humid and hot climates. Trichophyton rubum is the most common infectious agent in the world and is the cause of 47% of cases of tinea corporis.

Trichophyton and Microsporum is the most common agent in children.

EPIDEMIOLOGY

Mycosis pedis or athlete’s foot, is the most common superficial cutaneous mycosis worldwide, affecting the majority of the population (79%) at some point in their lives. The risk increases with age, and men are more affected but there is no predilection for any racial group. Among the triggers, we can mention some as: occlusion – nylon socks, sports shoes, hyperhidrosis, hot and humid environments, peripheral arteriovenous insufficiency, chronic diseases – diabetes, chronic use of antibiotics and topical or systemic steroids; as well as sports activities involving occlusion or prolonged humidity, such as skiing and swimming.

RISK FACTORS

• Tropical or semitropical climate.
• Nail trauma.
• Sweating of hands and feet (hyperhidrosis)
• Labor exposure.
• Exposure in swimming pools, gyms and public baths.
• Perform activities without shoes in areas contaminated with dermatophytes. This promotes the appearance of ringworm and omnicomicosis.

SYMPTOMS

It affects especially the spaces between the toes and is very common among athletes, teenagers and sea workers. Redness, bad smell and blisters appear in the folds, which then turn into fissures.

DIAGNOSIS

To establish the diagnosis, the following must be done:

• Direct examination: Material from the bottom of the fissure or the top of the blister / vesicle should be collected using a No. 15 scalpel blade or swab. Carry on a slide, add KHO solution to 20- 30% with Parker ink, let it act for a few minutes or accelerate the process by heat for a few seconds.
• Examine under the light microscope to identify septate hyphae of dermatophytes.
• Cultivation for fungi: It allows the morphological identification of the species of fungus.
• Cultivation and antibiogram: Allows to discard and treat properly associated bacterial infections.

TREATMENT

Therapeutic measures should include:

• Dry properly the interdigital spaces after the shower, bath or sports activities.
• Change shoes and socks at least twice a day.
• Morning daily use of antifungal powders, for example bifonazole, in socks and shoes.
• Baths with potassium permanganate solution in 1: 9,000 dilution, 1-2 times / day or 20-30% aluminum chloride, once or twice daily in case of highly inflammatory lesions with serous or purulent secretion.
• Add topical antibiotic according to the result of the cultivation.
• Use of topical antimycotics: terbinafine, bifonazole, clotrimazole, econazole, with twice daily application of cream or solution for an average of three weeks, it gets mycological response rates higher than 94% in tinea pedis.
• Use of systemic antimycotics: griseofulvin, imidazole, itraconazole or terbinafine in extensive or very symptomatic cases as in the inflammatory variety, relapses, lack of response to topical treatment and patients with risk factors – diabetes, arterial or peripheral venous insufficiency.
• Treatment of other associated mycoses, especially onychomycosis

NPH Peru Clinic Team

Suicide is a serious public health problem and devastating for families and loved ones. Affecting in high numbers children and adolescents. It demands the attention of all, and in particular health workers for prevention, control and early detection. Reducing the loss of life due to suicide has become a critical international mental health goal

Every year, more than 1,800,000 people die by suicide and up to 25 times as many make a suicide attempt. Behind these statistics are the individual stories of those who have, for many different reasons, decided that their own live is not valuble for anyone.

Suicide results from a complex interaction of genetical, biological, pysicological, sociological, cultural and environmental factors.

The critical challenge of prevention is to identify people who are at-risk and vulnerable to understand the circumstances that influence their self-destructive behavior.

The prevention of suicide, while feasible, involves interdisciplinary work and a variety of broad activities including assessment of child well-being, family awareness, education and counselling, treatment of mental disorders as well as environmental control of risk factors.

Guidelines for professionals are important in order to identify risk factors/situations and protective factors.

Protective factors mean that the environment where the person live can make a positive impact to disregard suicidal ideas. Some of the protective factors are: support from family and friends, social integration, religious, cultural and ethic beliefs, access to mental health care and services.

Risk and situation factors means that the person will mostly execute his/her thoughts. Among those risks: low social economic status, social stress, problems with family functioning, trauma such as physical and psychological abuse, personal losses, mental disorders, poor copying skills.

It is an estimate that as many as 90% of individuals who have ended their lives by committing suicide had a mental disorder, 60% were depressed at this time. Depression, one of the mental health disorders, and its symptoms (e.g sadness, lethargy, anxiety, irritability, sleep and eating disorders) should alert counselors for the potential risk of suicide. Elevate risk of suicide has also been associated with schizophrenia, substance abuse, personality disorders, anxiety, and PTSD.

In 90% of child and adolescent deaths by suicide, some form of mental disorder has been identified as a root cause with the most common diagnosis being: mood disorders, anxiety disorder, substance abuse and disruptive behavior disorder.

Previous suicidal attempts heighten the risk of suicide as well as persistent thoughts about harming oneself and resolved plans and preparations to carry out suicide.

Although there is no factual style of communicating the intentions, warning signs for suicidal behaviors includes; lack of concern about personal welfare, changes in social patterns, decline in work productivity, alterations in sleep and eating patterns, attempts to put personal matters in order, atypical interest on how others are feeling, preoccupations on themes about death and violence, sudden improvement of mood after a period of depression.

In children and adolescents, a counselor can play a vital role in preventing suicide. When a child or adolescent becomes suicidal, the youth is communicating difficulty to solve problems, coping with stress, expressing emotions and feelings.

In children and adolescents, a negative peer pressure might be behind self-destructive behaviors. Other suicidal factors include the loss of a romantic relationship, inability to cope with academic challenges and other life stressors.

Regardless of the circumstances, the community where they live have an important role to play in supporting those who are vulnerable.

As members of a community, it will be our responsibility to look out for those who may be struggling, check in with them, listen with no judgement, offer kind words of support and encourage them to tell their story in their own way. We don’t need to have all the answers. The evidence suggests being caring and listening with a non-judgemental ear are far more likely to reduce distress than exacerbate it.

NPHI Medical Services

Sources :

WHO Preventing Suicide – Department of Mental health 2006

International Association for suicide prevention (IASP) 2017

The pediculosis capitis is an ectoparasitic disease of the hair and the human hairy skin, caused by pediculus Humanus ver. Capitis (head lice).

Infestation by this ectoparasite is a hyperendemic disease worldwide. In Mexico, a prevalence of 18 to 33% was reported in some populations of students from urban and rural schools in the states of Yucatan, Morelos and Guerrero.

Several authors agree that pediculosis does not distinguish between cultural and social level, nor age or gender.

The louse is fed by sucking blood, its saliva contains vasodilatative and anticoagulant substances and it deposits its eggs adhered to individual hair denominated nits.

Female lice can lay about 150 eggs during their cycle which is 30 days.

Physically, the patient may suffer constant pruritus and excoriations of the scalp, followed by impetiginization, cervical lymphadenopathy, conjunctivitis, fever and general malaise, although this may be rare.

In NPH Mexico, San Salvador Clinic, Dr. Michell Pérez and his team of nurses are responsible for the timely detection of those parasites by carrying out activities such as instructing caregivers in the detection and prevention of the lice, carrying out activities called “the Monkey” where the children are placed in a row and each one inspects the head in front of the other.

Also health institutions are invited, for example nursing students, to support head washing with permethrin shampoo and extraction of living lice and nits. In cases of resistant lice, we count with an oral treatment based on ivermectin applied in an initial dose that kills all living lice and after the first intake between days 8 and 10, a second dose is provided for the lice that leave the nits.

Rickettsias are cocobirals bacterias, many of them are transmitted by vectors including lice. In general Rickettsiosis is considered as a zoonosis, the human being is a random host, except for the epidemic typhus (transmitted by lice). They are obligate intracellular parasites, that´s why there was a lot of doubt about whether they are considered viruses or bacterias. They are very sensitive and rarely survive outside the host (reservoir or vector). For this reason NPH Mexico considers the importance of this vector and does everything possible to eliminate it.

Clínica Médica NPH Casa San Salvador Mexico

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La pediculosis capitis es una ectoparasitosis del pelo y la piel cabelluda del humano, causada por pediculus Humanus ver. Capitis (piojo de la cabeza).

La infestación por este ectoparásito es una enfermedad hiperendemica en todo el mundo.

En Mexico se reportó una prevalente del 18 al 33% en algunas poblaciones de estudiantes de escuelas urbanas y rurales en los estados de Yucatán, Edo. Morelos y Guerrero.

Diversos autores coinciden en señalar que la pediculosis no distingue entre nivel cultural, social ni tampoco edad ni género.

El piojo se alimenta succionando sangre, su saliva contiene sustancias vasodilatadoras y anticoagulantes, deposita sus huevos adheridos a pelos individuales denominadas liendres.

Los piojos hembra pueden poner alrededor de 150 huevos durante su ciclo el cual es de 30 días.

Clínicamente el paciente portador puede cursar con prurito constante, excoriaciones de piel cabelluda, impetiginizacion secundaria, adenopatías cervicales, conjuntivitis, fiebre y malestar general, y aunque son poco frecuentes pueden estar presentes.

En NPH Mexico clínica San Salvador a cargo del Doctor Michell Pérez y su equipo de enfermeros se encarga de realizar la detección oportuna de dicho paracito realizando actividades como la educación a tíos/encargados de casa para la detección y prevención del mismo, actividades denominadas o llamadas del Mono donde cada niño se ponen en fila donde a su vez cada uno revisa la cabeza de su compañero, asi como invitar a instituciones ligadas a la salud como estudiantes de enfermería para apoyo de lavado de cabezas con shampo a base de permetrin a y extracción de piojo vivo y liendre.

En los casos de piojo resistente damos tratamiento a base de ivermectina aplicada en una dosis inicial que mata a todo piojo vivo y posteriormente a la primera toma entre los dias 8 y 10 ofrecemos una segunda dosis para los pijos que salen de la liendre. Correspondiente a su ciclo de vida.

Las Rickettsias son bacterias cocobacilares, muchas de ellas son transmitidas por vectores entre ellos piojos. En general la Rickettsiosis se considera una zoonosis, siendo el humano un huésped accidental excepto por el tifo epidémico (transmitido por piojos). Son parásitos intracelulares estrictos, por eso existieron dudas mucho tiempo sobre si pertenecían a los virus o a las bacterias. Son muy sensibles y raramente sobreviven fuera del huésped (reservorio o vector).

Por tal motivo NPH Mexico considera la importancia de este vector y realiza todo lo posible para la eliminación del mismo.

Dr. Michell Perez

NPH Mexico/Miacatlan

Como todos sabemos, el agua es parte fundamental en nuestra vida diaria, y está presente en nuestras vidas y donde menos lo pensamos, y sobre todo con significados diferentes para cada uno. Como por ejemplo, para los químicos es un compuesto estable formado por 2 átomos de hidrogeno y 1 de oxígeno, uno de los estados de la materia que puede estar en varios estados como sólido, líquido y gaseoso; para los geólogos constituye que el 71% de la tierra está conformado por agua, y claro, en el ser humano constituye al menos dos terceras partes de esta. En definitiva, el agua es importante para nuestro funcionamiento, es como el aceite del carro que necesitamos para que cada una de nuestras células funcione en su más óptima tarea. La ausencia de agua siempre ha estado asociada con la desaparición de los seres vivos, es por lo que se dice que “el agua es indispensable para la vida del ser humano”. Es el principal termo regular del organismo, permite conseguir un equilibrio de temperaturas en todo el cuerpo. Nuestro organismo, y de cualquier otro ser vivo, necesita agua para funcionar normalmente, puesto que tanto las reacciones bioquímicas como el transporte adecuado de las sustancias tiene lugar en solución acuosa.

Como sabemos el agua es incolora y su color es el resultado de fenómenos de difusión, absorción y sobre todo, reflexión/refracción de la luz que penetra la superficie marina y oceánica.

Se dice que un feto humano a los tres días contiene un 94% de agua y que cuando se convierte en bebé alcanza el 75 % de agua, siendo en la vejez la menor cantidad de agua que es del 65%. La sangre contiene un 83 %, los músculos un 76% y el cerebro un 75%. Los huesos, que quizás a priori podrían parecer carentes de agua, están formados por un 22% de agua. Por todos estos datos, es fácil darse cuenta de la importancia que tiene el agua para el organismo.

El organismo, cada día pierde una media de dos litros de agua al día entre la respiración y la traspiración de la piel y la orina. Es por ello que los médicos aconsejan beber hasta dos litros de agua diarios, o aportarlos en la dieta ya sea con frutas o con vegetales que contengan gran cantidad de agua.

La sed aparece en el organismo cuando se pierde el 2 % del agua, lo que equivale a un litro de agua. Tras perder el 10 %, lo que equivale a 5 o 6 litros, se sufren alucinaciones y la piel se contrae. A partir del 15 %, 8 o 9 litros se puede morir.

El agua es importante para el organismo ya que actúa en la fabricación de las células, ayuda en los jugos digestivos, participa en las señales eléctricas entre músculos, transporta la sangre y elimina los desechos y los filtra a través de los riñones.

En condiciones normales, un ser humano cada día pierde unos dos litros de agua entre el sudor, la respiración, la orina y las defecaciones, y estos dos litros deben ser recuperados cada día, ya sea ingiriendo agua, refrescos,  fruta, alimentos acuosos, etc. Lo lamentable y triste es que al gua está al alcance de nuestra mano, en cada una de las casas, siempre existe un grifo del que poder beber, pero aun así, la mayoría de las personas del primer mundo, sufren de lo que se suele denominar “deshidratación crónica” ya que no beben el líquido suficiente, y luego se quejan de cansancio general. Tan solo bebiendo un poco más de agua cada día podría solucionarse.

El cerebro humano, está compuesto de un 95 % de agua, la sangre de un 82%, y los pulmones de un 90% de agua. Es por ello, que apenas una disminución de un 2% en la composición de nuestro cuerpo puede causar ya los primeros síntomas de deshidratación, como son la perdida momentánea de la memoria, problemas con las matemáticas, dificultad en enfocar la mirada en objetos o letras pequeñas, etc…

Un déficit de agua del 4% acarrea dolores de cabeza, irritabilidad, somnolencia y graves dificultades de concentración. Si alcanzamos un 10% de pérdida de peso corporal debido a la deshidratación, podemos perder la vida.

Un mantenimiento diario del agua que consumimos puede ser un papel clave en la prevención de enfermedades. Por ejemplo, beber 8 vasos de agua al día, en caso de no tomar frutas y otros alimentos acuosos, puede reducir el riesgo de cáncer de colon en un 45 % y el de vejiga en un 50%. El agua puede también ser beneficiosa en la prevención y cura de muchos tipos de enfermedades y dolencias que afectan a muchos sistemas del ser humano.

Dado que el agua es un componente tan importante para nuestra fisiología, debemos tener en cuenta tanto la cantidad como la calidad del agua que tomamos. El agua debe ser siempre potable, limpia, libre de contaminantes. Pero no todo es beber agua, es importante recordar que para mejorar su salud, conviene el ejercicio regular, una alimentación equilibrada y una actitud positiva ante la vida. Nos sorprenderíamos de saber de la propia capacidad natural que tiene el ser humano para curarse a sí mismo, así que ayudémoslo y ahora mismo tomemos un vaso de agua.

Dra Karla Monterrosa, NPH El Salvador

More stories on the importance of water at:https://www.nph.org/ws/page.php?path=homes/honduras/children/CleanWater.php

Club Foot, also called Foot Zambo, is a congenital malformation in which the affected foot, could be one or both, appears to have been rotated internally to the ankle. Often times it appears as if the person is walking on their ankles. It is a birth defect in which the foot is crooked or inverted inwards and downwards, resembling a golf club. Without treatment, affected people experience pain, discomfort and difficulty in mobility.

Before and After

Causes:·

• Studies indicate that tendons have much denser tissues and equally more cells and less lax tissue than normal tissues. Therefore the ligaments and muscles are too tense to allow a correct placement of the bones with a simple manipulation.
• Genetic or familial
• Mechanical cause due to lack of space for the formation of the fetus during pregnancy
• Neuromuscular diseases

Diagnosis:

In some cases, it is usually possible to visualize the malformation in the ultrasound study of the fetus at 20 weeks of gestation. The diagnosis is confirmed after birth, observing the shape of the foot down (equine) and inside (varus), and checking that by manipulation, not able to obtain a normal position.

Treatment:

There are two methods of treatment:·”French Method of Physical Therapy”: Use the fixation to maintain the correct posture. Foot manipulations begin within one to two weeks of birth.·

“Ponseti Method”: Consists of performing soft manipulations to obtain the best possible alignment with the plaster bandage. This pattern is repeated every week with complete correction of the deformity is achieved except the tipped position. At this point a small intervention should be performed, percutaneous Achilles tendon lengthening, with local anesthesia and no hospitalization is needed.

NPH case:

A seven year old boy living in one of NPH homes arrived in 2015 having difficulty walking. The diagnosis was obvious “Congenital Bilateral Club Foot”. The doctor from the NPH clinic consulted with several specialists in the country and abroad. After careful consideration of the case, the medical staff local and international decided to go for the conservative approach known as the Ponseti Method, before going with painful and invasive surgeries. After 10 months of weekly work changing the cast and physical therapy,  the patient was ready for minor surgery, elongation of the Achilles Tendon. After eight days he was dismissed from the hospital and has follow up with physical therapy. The treatment of club foot should start right away after birth. This boy was so lucky to arrive to NPH and get treatment since otherwise he would continue living on the streets and forever being the center for jokes and mocking.

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PIE EQUINO VARO bilateral congénito, También llamado: Pie Zambo, es una malformación congénita, en la cual este aparece en punta (equino), y con la planta girada hacia adentro (varo).

Es un defecto de nacimiento, en el que el pie se encuentra torcido o invertido hacia adentro y hacia abajo, semejando un palo de golf. Sin tratamiento, las personas afectadas frecuentemente aparentan caminar apoyados en sus tobillos

Causas:

• Los estudios indican que los tendones tienen tejidos muchos más densos e igualmente más células y menos tejido laxos, que los tejidos normales. Por tanto los ligamentos y músculos están demasiados tensos para permitir una correcta colocación de los huesos con una simple manipulación.
• Genética o familiar
• Causa mecánica por falta de espacio para la formación del feto durante el embarazo.
• Enfermedades neuromusculares.

Diagnostico:

En algunas ocasiones suele ser posible la visualización de la malformación en el estudio ecográfico del feto en las 20 semanas de gestación.

El diagnostico se confirma tras el nacimiento, observando la forma del pie hacia abajo (equino) y adentro (varo), y comprobando que por manipulación no somos capaces de obtener una posición normal.

Tratamiento:

Existen básicamente dos métodos de tratamiento:

“Método francés de fisioterapia”: Usa la fijación para mantener la postura correcta. Las manipulaciones del pie comienzan en una o dos semanas de nacidos.

“Método Ponseti”: Consiste en la realización de manipulaciones suaves hasta obtener la mejor alineación posible con el vendaje de yeso, esta pauta se repite cada semana, se consigue la corrección completa de la deformidad excepto la posición de puntillas. En este punto se debe realizar una pequeña intervención, alargamiento percutáneo del tendón de Aquiles, se realiza con anestesia local y no necesita hospitalización.

Este es el caso el niño de 7 años de edad quien ingreso en el 2015, con pie Equino Varo, este fue llevado con varios Especialistas, quienes ofrecían operaciones en los pies del niño, pero el tercer Traumatólogo lo refirió a Managua al Hospital de Especialidades de niños.

El niño, fue valorado por el especialista en Traumatología del hospital infantil, quien inicio un tratamiento conservador, según Método Ponseti, en Enero del 2016 y termino después de 10 meses , en Octubre del 2016 , fechas en la que ya le realizaron una cirugía de elongación del tendón de Aquiles. Fue dado de alta a los 8 días ya con sus pies alineados y continuidad por parte de Fisioterapia.

El niño ha tenido una buena evolución, sigue con sus actividades normales.

Foto de su llegada a NPH antes del tratamiento 2015

Dra Silvia Echaverry , Medico NPH Nicaragua and Julia Spettel, NPHI RMC Nicaragua, El Salvador, Peru and Bolivia

May is Mental Health Awareness Month and the first week of the month is dedicated to create children’s mental health awareness.

• Mental Health is an important and integral part of the adolescents’ wellbeing.
• Mental Health is not simply the presence or absence of symptoms. It includes general feeling and functioning, as well as having resilience when facing a setback.
• Adolescence is a time where mental health disorders first appear.
• Two- thirds of adults with psychiatric problems began between the ages of 15-25.
• Most adolescents enjoy a positive mental health development, though more than a third of this group have experienced or currently are experiencing anxiety, depression symptoms or a debilitating mental health disorder.
• Everyone feels worried or anxiety at times; adolescents experience strong emotions as part of their normal development but when symptoms persist for more than two weeks and interfere with their daily lives, it can be a warning sign for the adults caregivers.
• Suicide deaths (usually prompted by a mental health disorder) globally surpass vehicle accidents at the age of 10-14, and is the second leading cause of death among 15-24 year olds.
• Mental health support starts at the home, school and at the health professional office (physician or psychologist).
• Adolescents should have access to Mental Health services breaking the barriers of stigma, ignorance and misunderstanding.

The maturation process in adolescents to adults is through changes and development, facing issues that most of them will overcome.

Key aspects in their development to empower youths:

• Healthy relationships with peers and caring adults
• Helping them to build a positive mental health & physical health habits as they grow and change
• Coping, resilience, good judgment for good/right decisions
• Healthy eating habits, exercise, preventing substance abuse
• Inform and educate on reproductive health and teen pregnancy
• Substance use and abuse 

Ways to support

• Caring adults
• Clinical prevention
• Crisis intervention
• Education

For all adults and peers living with adolescents or teenagers and according to the NIMH (National Institute of mental health – US) a child or teen might need help if they:

• Often feel very angry or very worried
• Have difficulty sleeping or eating
• Are unable to enjoy pleasurable activities they used to enjoy
• Isolate themselves and avoid social interactions
• Feel grief for a long time after a loss or death
• Use alcohol, tobacco, or other drugs
• Exercise, diet, and/or binge eat obsessively
• Hurt other people or destroy property
• Have low or no energy
• Feel like they can’t control their emotions
• Have thoughts of suicide
• Harm themselves (e.g., burning or cutting their skin)
• Think their mind is being controlled or is out of control
• Hear voices

At NPH a comprehensive assessment physical, developmental and psychological is given upon entrance and is monitored and followed up by the clinic staff (doctor and psychologist) if there is a mental health diagnosis. This helps to prevent future complications.

Most NPH children experience some sort of PTSD , because of their background before entering NPH and if they had suffered violence, abuse of any type of abandonment and neglect.

Around 2% need to have consultation with external specialists and have psychiatric treatment.

NPH uses an interdisciplinary team including physician, psychologist, occupational therapist, art therapist and physical therapist to support children.

NPHI Medical Services

Data from

US department of health and Human Services

NIH National Institute of Health

MGMH Movement for Global Mental Health