Scielo RSS <![CDATA[MEDICC Review]]> vol. 19 num. 2-3 lang. en <![CDATA[SciELO Logo]]> <![CDATA[It Was the Best of Times, It Was the Worst of Times…]]> <![CDATA[About the Contributors]]> <![CDATA[Autism Spectrum Disorder in Cuba: Comprehensive & Coordinated Response]]> <![CDATA[Anemia and Iron Deficiency Related to Inflammation, <em>Helicobacter pylori</em> Infection and Adiposity in Reproductive-age Cuban Women]]> ABSTRACT INTRODUCTION Iron deficiency is the main cause of anemia, but infections, inflammation and other factors also play a role. Anemia in women of childbearing age is a risk for pregnancy, childbirth and childhood development during the first two years of life. In Cuba, per WHO definition, anemia is a moderate public health problem in the third trimester of pregnancy and in preschoolers, with a prevalence of 21.6%, in both cases. OBJECTIVE Estimate prevalence of anemia and iron deficiency in women of childbearing age and assess its relation to inflammation, overweight, central adiposity, H. pylori infection and ingestion of iron-rich foods and enhancers of iron absorption. METHODS A cross-sectional, analytical study was performed in 391 women aged 18–40 years in four municipalities of Havana, Cuba, from February through June 2014. Variables (indicators in parentheses) were anemia (hemoglobin), iron deficiency (ferritin), nutritional status (body mass index and waist circumference), inflammation (C-reactive protein, acid alpha 1-glycoprotein and interleukin 6), H. pylori infection and ingestion of iron-rich foods. SPSS 20.0 and Epi Info were used for statistical analysis. RESULTS Anemia prevalence was 24.6% (96/391); iron deficiency, 68% (266/391); H. pylori infection, 47.1% (184/391); inflammation detected by C-reactive protein, 8.4 % (33/391) and by alpha-1-gly-coprotein, 19.9% (78/391). Limited results are included for interleukin 6, which was determined in fewer cases (96). Excess body weight was found in 38.7% (150/388) and increased central adiposity in 26.7% (101/378). Iron deficiency was the main cause of anemia (OR 2.68). Central adiposity, excess body weight, and iron deficiency were positively associated with inflammation (OR of 1.77, 1.23 and 1.72, respectively), whereas H. pylori infection was negatively associated with iron deficiency and anemia (OR 0.75 and 0.94, respectively). Low consumption of meat (OR 1.17) and vegetables (OR 1.36) showed discrete limited positive associations with iron deficiency, as well as low consumption of eggs (OR 1.69) and vegetables (OR 1.56) with anemia. CONCLUSIONS Anemia is a moderate public health problem in the studied group, but with iron deficiency present in two thirds of the population and associated with anemia. Risk factors for anemia and iron deficiency, such as menorrhagia and bacterial or viral infections, should be assessed in women of childbearing age, to support interventions needed to reduce risks in pregnancy and childbirth. <![CDATA[Neonatal Surgery Case Fatality and Associated Factors in a Cuban Pediatric Hospital, 2005–2015]]> ABSTRACT INTRODUCTION Newborns in need of surgery are a challenge to manage and require highly specialized centers with multidisciplinary surgical teams. Since the 1980s, neonatal surgical survival has increased by up to 70% in some countries, mainly due to advances in neonatal intensive care, anesthesia and surgical technique. OBJECTIVE Describe surgical case fatality and survival in a neonatal reference hospital in Cuba, estimate risk of death, and identify potential risk predictors among neonatal characteristics. METHODS A retrospective cohort study was conducted based on hospital administrative data and clinical records for a series of surgical cases in the neonatal intensive care unit of Havana’s William Soler University Children’s Hospital from January 2005 to December 2015. All neonates who underwent surgery during the study period were included. The dependent variable was discharge status (alive, deceased); independent variables were: sex, age (in days) at time of surgery, gestational age, birth weight, indication for surgery, surgical order (first, repeat), and presence of sepsis or other postoperative complications. The study used contingency tables to analyze associations between neonatal characteristics and discharge status. A classifi cation tree was used to obtain simple estimates of surgical risk. RESULTS Survival was 91.3% (675/739) among 739 neonates who underwent surgery. The majority were male (58.7%, 434/739), full term (84.2%, 622/739), and of normal birth weight (80.6%, 596/739). Most surgeries were performed in the first 10 days of life. Digestive system anomalies constituted the most common surgical indication (57.6%, 426/739); among these anorectal malformations (26.8%, 114/426) and esophageal atresia (17.4%, 74/426) predominated. Survival rates were lower for digestive perforation (57.7%, 15/26), gastroschisis (57.1%, 4/7) and intestinal atresia (73%, 27/37). Neonates in the youngest and oldest age groups at time of surgery faced highest risk of death, especially those in the older group. Term infants with normal birth weight operated on for the first time had survival rates &gt;95%. CONCLUSIONS Survival was high and low birth weight conferred the worst prognosis. Infants with normal birth weight operated on for the first time had the greatest probability of survival. <![CDATA[Cuban Exogenous Pulmonary Surfactant in Treatment of Pediatric Acute Respiratory Distress Syndrome]]> ABSTRACT INTRODUCTION Acute respiratory distress syndrome is a complex heterogeneous disorder with low incidence but high case fatality in children. Treatment with pulmonary surfactants is a possible option. Surfacen, a Cuban exogenous pulmonary surfactant, has been proven safe and effective in premature newborns with hyaline membrane disease, but evidence regarding its efficacy in older children is still inconclusive. OBJECTIVE Determine Surfacen’s efficacy in improving oxygenation and increasing survival in children with acute respiratory distress syndrome. METHODS A multicenter (five pediatric intensive care units in four provinces), open-label, controlled, randomized phase III clinical trial with two treatment groups was conducted from November 2009 through August 2013, with 19 girls and 23 boys aged 1 month to 18 years. The experimental group (20 patients) received conventional treatment (oxygenation and mechanical ventilation) plus intratracheal instillation of Surfacen (100 mg/4 mL) every eight hours for three days. The control group (22 patients) received only conventional treatment. The primary dependent outcome was patient vital status (alive or deceased) 28 days after study enrollment. Other variables and outcomes analyzed were age, sex, ARDS presentation, Kirby index (arterial oxygen tension over inspired oxygen fraction), oxygenation index, static lung compliance, transcutaneous oxygen saturation, radiographic course, mechanical ventilation time and length of stay in neonatal intensive care. Statistical tests used were the chi-square test and Fisher exact test. RESULTS On day 28, there was 80% survival in the experimental group versus 38.1% in the control group. There were significant differences between the experimental and the control group in Kirby index, oxygenation index, static lung compliance and radiographic course, all favoring the experimental group. For every 2.38 patients treated in total, there was one additional survivor in the experimental group. CONCLUSIONS When combined with conventional therapy in the regimen employed, Surfacen improves oxygenation and increases survival in children with ARDS. <![CDATA[Association of Antineuronal Antibody Levels with Cognitive Impairment in Older Cuban Adults]]> ABSTRACT INTRODUCTION Alzheimer disease is the main cause of dementia associated with aging in Cuba and the world. Development of methods for early diagnosis is vital to increasing intervention effectiveness and improving patient quality of life. Recent studies have shown associations between alterations in serum levels of antineuronal antibodies and Alzheimer disease pathology. However, the specific relationship between such antineuronal antibodies and Alzheimer pathogenesis remains unclear because of the great variety of antibodies identified and their heterogeneity among patients and nondemented controls. OBJECTIVE Assess the association between serum levels of antibodies against neuronal antigens (total brain protein, aldolase and amyloid beta protein) and cognitive performance in older Cuban adults. METHODS A cross-sectional pilot study was conducted of adults aged ≥65 years living in Havana’s Playa Municipality and Artemisa Province (southwest of Havana). A sociodemographic and risk factor questionnaire was administered, neuropsychological assessment conducted, and physical and neurological examinations performed. A relative or caregiver was also interviewed. Laboratory tests included: complete blood count, glycemia, lipid panel, and apolipoprotein E genotype. Of 143 individuals studied, 33 were cognitively normal, 52 had mild cognitive impairment, and 58, probable Alzheimer disease. Serum antibody levels were determined by ELISA and compared using covariance analysis with a significance level of 0.05. ELISA specificity, sensitivity and predictive value were assessed by analyzing their respective diagnostic performance curves. RESULTS Patients with probable Alzheimer disease performed least well on the mini mental state examination (cognitively normal 28.8, SD 1.2; mild cognitive impairment 27.4, SD 2.2; probable Alzheimer disease 12.9, SD 6.5; ANOVA p &lt;0.001). The percentage of Apo E4 carriers was seven times greater in the group with probable Alzheimer disease than in the cognitively normal group. Among the antibodies studied, only those against amyloid beta peptide had levels significantly higher in the Alzheimer disease group than in the cognitively normal group (p = 0.007) and the group with mild cognitive impairment (p = 0.002). CONCLUSIONS Results support the presence of an autoimmune component in Alzheimer disease and suggest that serum anti–amyloid-beta could be used for its diagnosis. <![CDATA[Origin and Evolutionary History of HIV-1 Subtype B in Cuba]]> ABSTRACT INTRODUCTION Cuba’s HIV epidemic is characterized by high genetic diversity, with circulation of several subtypes and recombinant forms. Earlier studies described a predominance of subtype B in the HIV-positive population, but these studies did not take into account patients’ epidemiologic history. OBJECTIVE Clarify the origin and phylodynamics of HIV-1 subtype B in the Cuban epidemic. METHODS We analysed phylogenetic relationships among 120 sequences (from different geographic origins) of the pol gene in HIV-1 subtype B isolates from Cuban patients diagnosed from 1987 through 2012. Time of HIV-1 subtype B introduction and viral evolutionary rate were determined using a Bayesian coalescent method. RESULTS Based on phylogenetic relationships, subtype B was introduced into Cuba multiple times. Subtype B spread in Cuba through dissemination of strains that probably came from the USA, Canada and Europe. The time of the most recent common ancestor of Cuban subtype B was close to 1977 (95% CI 1974–1982), and the evolutionary rate was 2.7 × 10-3 nucleotide substitutions per site per year. CONCLUSIONS Our results suggest multiple introductions of HIV-1B into Cuba in the late 1970s, predominantly strains from North America and Europe. The results reflect the importance of maintaining, reviewing and updating molecular epidemiology of HIV-1 in Cuba, due to its rapid evolution and possible implications for the National STI/HIV/AIDS Program of Cuba’s Ministry of Public Health. <![CDATA[Measuring Health-related Quality of Life in Cuban Patients with Head and Neck Cancer]]> ABSTRACT INTRODUCTION Quality of life measurement is an important aspect of comprehensive clinical assessment. It does not have a set definition, but changes according to sociocultural context. Head and neck cancer patients experience substantially decreased health-related quality of life. The Cuban public health system needs to develop its own instrument to measure these patients’ quality of life. OBJECTIVES Construct and validate an instrument to measure quality of life in Cuban patients with nasopharyngeal, laryngeal, oral or mesopharyngeal cancer. METHOD The sample comprised adult patients treated for nasopharyngeal, laryngeal, oral or mesopharyngeal cancer in Cuba’s National Oncology and Radiobiology Institute in 2013 and 2014. To construct and validate the instrument, we selected a sample of 520 patients. Initial interviews were held until no substantially new information emerged; 40 patients were selected to participate in focus groups to identify important problems leading to decreased health-related quality of life. Face validity of the preliminary questionnaire was assessed with 40 patients. Internal consistency and validity were assessed with 400 patients. Score stability was assessed with another 40 patients using a test-retest design. There were 24 experts who participated in the process, 15 in the construction phase and 9 in the content validity evaluation of the preliminary version. Assessment of reliability and validity was based on internationally recognized approaches, including Cronbach alpha and empirical verification of convergent, discriminant, clinical and predictive validity. Response burden was also assessed (completion time and item nonresponse). RESULTS A 65-item questionnaire, CV-I0R-CyC-01, was developed and validated, with three domains (physical functioning, psychosocial functioning and family relationships, disease symptoms and treatment side effects) and two ungrouped questions on perceived general health and perceived health-related quality of life. The instrument displayed satisfactory reliability (homogeneity and stability) and validity (face, content, convergent, discriminant, clinical and predictive). Test–retest correlation was strong. Large differences and a downward trend in health-related quality of life across clinical stages and moderate or high standardized response mean values reflect good clinical and predictive validity. Response burden was acceptable (completion time 6.2 minutes, item nonresponse rate 1.3%–3.8%). CONCLUSIONS CV-I0R-CyC-01’s psychometric properties justify its use in clinical trial protocols with patients with nasopharyngeal, laryngeal, oral or mesopharyngeal cancer. <![CDATA[Socioeconomic Status and Perceived Health-related Quality of Life in Chile]]> ABSTRACT INTRODUCTION Changes in the conceptualization of health and illness have led to development of theory and methods to study health-related quality of life. One instrument used frequently to measure this concept is the SF-12 survey, included in the Second National Health Survey carried out in Chile between 2009 and 2010. OBJECTIVE Estimate the association between socioeconomic status stratifiers and health-related quality of life in the adult population residing in Chile. METHODS We conducted a cross-sectional study of a subsample of the National Health Survey, in the population aged ≥25 years. Health-related quality of life was operationalized from two SF-12 composite scales: physical health-related quality of life and mental health-related quality of life. Both were categorized as good or poor relative to their median scores. Socioeconomic status stratifiers were education, employment status and monthly per capita household income. Multiple logistic regression models were generated for physical health-related quality of life and mental health-related quality of life, according to socioeconomic status stratifiers adjusted for several covariates. RESULTS The sample comprised 4473 respondents, 51.6% women, median age 47.8 years. The probability of poor quality of life was higher in persons with only primary school education, those not in the workforce and those whose monthly income was below 100,815 Chilean pesos (US$140); the effect was stronger for physical health-related quality of life (OR 2.8, 95% CI 1.8–4.2; OR 1.7, 95% CI 1.2–2.3 and OR 2.2, 95% CI 1.3–3.8, respectively) than for mental health-related quality of life (OR 1.4, 95% CI 1.1–1.8; OR 1.6, 95% CI 1.2–2.2 and OR 1.9, 95% CI 1.1—3.0, respectively). CONCLUSIONS The probability of poor health-related quality of life is higher in the worst socioeconomic status strata, and the effect is most pronounced in the most vulnerable groups. The direct effect of social stratifiers on living conditions and access to services—both strong influences on subjective health—would explain this finding and highlight the need to adopt equity-oriented strategies aimed at addressing the impact of socioeconomic status on health-related quality of life. <![CDATA[Health Insurance Scheme Performance and Effects on Health and Health Inequalities in Chile]]> ABSTRACT INTRODUCTION Health systems are one determinant of health; their role is to facilitate timely and equitable access to quality services. The way in which a health system is organized can profoundly affect achievement of its objectives. The main feature of the Chilean health system is the coexistence of a public health insurance program (based on a social insurance model) with several market-based private health insurance companies. This hybrid structure provides an interesting framework for analyzing and evaluating the system’s effects on health inequalities. OBJECTIVE Assess Chilean public and private health insurance schemes’ performance and its effects on health inequalities. METHODS Public health insurance was compared with private insurance using indicators from 2013 (or the closest year) in the following domains: inputs, outputs (provider visits, discharges), outcomes (coverage) and impact (on health, quality of life, finances and patient satisfaction) as well as demographic and social determinant indicators. A conceptual framework for measuring health system performance was used. Data were obtained from administrative records and population-based surveys. RESULTS The publicly insured population had greater health care needs, was older (aging index 83.4 vs. 36.5) and poorer (17.2% vs. 1.5% below the poverty line) than the population covered by private insurers. The public insurer received average monthly funding of US$50.94 per beneficiary and spent US$51.43, while private insurers on average collected US$94.79 monthly per beneficiary, and spent US$69.63 on health services (excluding medical leave benefits). Private health insurance beneficiaries were more likely than their publicly insured counterparts to access specialized medical services (18.3% vs. 9.3%) and dentists (11.2% vs. 5.9%), have laboratory tests (18.1% vs. 4.8%), and undergo surgery (7.8% vs. 5.9%). Risk factor and disease prevalence was lower among private insurance beneficiaries for 16 of 18 tracer conditions, although age-adjusted differences were not significant. Finally, incidence of catastrophic spending was slightly lower among private insurance beneficiaries (3.7% vs. 4.2%), and a greater proportion of them were satisfied or very satisfied with the health system (37% vs. 17%). CONCLUSIONS The relative youth and better financial status of beneficiaries of private insurers is compatible with selection for lower risk. While private plans offer greater financial protection and receive higher user satisfaction ratings than the public plan, differences in financing between the two types of insurance affect availability and utilization of services. This constitutes a structural problem for the Chilean health system. There is an urgent need to move toward an integrated health system, in which incentives are aligned with social insurance objectives. <![CDATA[Building Community Capacity in Leadership for Primary Health Care in Colombia]]> ABSTRACT Primary health care looks beyond clinical services to health promotion and primary prevention at the population level. In 2011, Colombia adopted a normative approach to primary health care, to advance efforts to set health priorities and transcend a curative, hospital-based system. An intervention was carried out in eight communities in Bogotá and Cundinamarca, Colombia to build community capacity to influence health. Activities included training community leaders to design and implement health improvement initiatives aimed at the most important health problems identified by their organizations. Twenty-eight leaders completed the training. They designed and implemented eight health improvement plans to address the most important health problems in their respective communities: protecting public spaces for children’s physical activities, improving family practices in child nutrition, organizing a health insurance beneficiaries’ health promotion network, organizing a service delivery network for homeless persons, connecting people with cognitive disabilities to treatment services, combatting violence against women, working against child abuse, and integrating health education into school curricula. Lessons were learned about capacity-building in primary care, approaches to strengthening intra- and interinstitutional conditions, and managing processes for community ownership. The intervention enabled development of initiatives for solving various problems by different types of organizations, highlighted participants’ understanding of their role as health agents, and promoted community participation and intersectoral action. <![CDATA[Statistical Modeling in Health Research: Purpose Drives Approach]]> ABSTRACT Statistical modeling is commonly used in both predictive and explanatory studies in health research. Its use in Cuba continues to grow, although it is sometimes employed inappropriately, which can lead to errors that imperil validity. This article attempts to shed light on faulty practices in statistical modeling by examining and discussing the main differences between explanatory and predictive models, with reference to the following: study objectives, theoretical considerations in model-building, aspects requiring assessment, variable and algorithm selection, analysis of confounders, treatment of multicollinearity, and reporting results. <![CDATA[Postpartum Obesity in Cuba: Risk Outweighs Response]]> ABSTRACT Statistical modeling is commonly used in both predictive and explanatory studies in health research. Its use in Cuba continues to grow, although it is sometimes employed inappropriately, which can lead to errors that imperil validity. This article attempts to shed light on faulty practices in statistical modeling by examining and discussing the main differences between explanatory and predictive models, with reference to the following: study objectives, theoretical considerations in model-building, aspects requiring assessment, variable and algorithm selection, analysis of confounders, treatment of multicollinearity, and reporting results. <![CDATA[Personal Responsibility in Cuba’s Universal Health Model]]> ABSTRACT Statistical modeling is commonly used in both predictive and explanatory studies in health research. Its use in Cuba continues to grow, although it is sometimes employed inappropriately, which can lead to errors that imperil validity. This article attempts to shed light on faulty practices in statistical modeling by examining and discussing the main differences between explanatory and predictive models, with reference to the following: study objectives, theoretical considerations in model-building, aspects requiring assessment, variable and algorithm selection, analysis of confounders, treatment of multicollinearity, and reporting results.