Abstract in English:INTRODUCTION: Health systems and services research by nursing personnel could inform decisionmaking and nursing care, providing evidence concerning quality of and patient satisfaction. Such studies are rather uncommon in Cuban research institutes, where clinical research predominates. OBJECTIVE: Assess the results of a strategy implemented between 2008 and 2011 to develop nursing capacity for health systems and services research in 14 national research institutes based in Havana. METHODS: The study comprised four stages: description of approaches to health systems and services research by nurses worldwide and in Cuba; analysis of current capacities for such research in Cuba; intervention design and implementation; and evaluation. Various techniques were used including: literature review, bibliometric analysis, questionnaire survey, consultation with experts, focus groups, and workshops for participant orientation and design and followup of research projects. Qualitative information reduction and quantitative information summary methods were used. Initially, 32 nursing managers participated; a further 105 nurses from the institutes were involved in research teams formed during intervention implementation. RESULTS: Of all published nursing research articles retrieved, 8.9% (185 of 2081) concerned health systems and services research, of which 26.5% (49 of 185) dealt with quality assessment. At baseline, 75% of Cuban nurses surveyed had poor knowledge of health systems and services research. Orientation, design and followup workshops for all institute teams developed individual and institutional capacity for health systems and services research. Post-intervention, 84.7% (27) of nurses reached good knowledge and 14.3% (5) fair; institutional research teams were formed and maintained in 9 institutes, and 13 projects designed and implemented (11 institutional, 2 addressing ministerial-level priorities) to research nursing issues at selected centers. CONCLUSIONS: A systematic strategy to build nursing capacity for health systems and services research can be effective in involving nurses in such research and in developing institutional support for it, fostering compliance with Cuban and international professional development priorities for nursing, as well as contributing to quality of patient services.
Abstract in English:INTRODUCTION: One reason given by the South African government for establishing a physician training agreement with Cuba is that the ethical, humanistic and solidarity principles promoted in Cuban medical education are difficult to acquire in other settings. However, Cuba's general medical training program does not provide all skills needed by a general practitioner in South Africa: other competencies are required, such as management of general and gynecological or obstetrical surgical emergencies, administration of anesthesia and nursing procedures. As long as the desired humanistic values were assured, South African authorities have preferred to complement these competencies. Thus, since 2003, the Medical University of Villa Clara has applied a curricular strategy of 12 complementary courses to develop the requested additional skills, but results have not met expectations. OBJECTIVE: Determine why the complementary curricular strategy has not been entirely successful and identify possible courses of action for improvement. METHODS: A document review was conducted of the curricular strategy applied and of minutes of meetings between Cuban and South African counterparts to identify correspondence between requested professional skills and actions to develop them. In addition, South African students were surveyed and Cuban professors were interviewed in depth. Senior university administrators and key informants were also interviewed. Variables assessed were course quality and satisfaction of students and professors. RESULTS: Some actions originally included in the curricular strategy were not implemented and there were structural weaknesses in complementary courses, primarily in objectives, teaching strategy and evaluation. Students reported insufficient practical activities and lack of relationship between content and the health situation in South Africa. Professors were dissatisfied with student levels of motivation and ability to manage their own learning. Other influencing factors were insufficient academic management and professors' lack of knowledge about the context where these future professionals would eventually practice. CONCLUSIONS: Curricular strategy deficiencies detected are primarily in academic management; overcoming them could facilitate action in specific directions identified to improve the requested skill levels.
Abstract in English:INTRODUCTION: Continuous venovenous hemodiafiltration, generally used in patients with acute renal failure, enables elimination of humoral mediators of systemic inflammatory response and sepsis from blood. This effect should improve treatment results in patients with multiple organ dysfunction, but evidence of improved survival is insufficient. OBJECTIVES: Describe the effect of continuous venovenous hemodiaflitration on patients with multiple organ dysfunction syndrome in terms of systemic and brain hemodynamics, oxygenation, metabolism and status on ICU separation. METHODS: An observational case series was done of 18 patients (11 men and 7 women) aged 24-78 years with multiple organ dysfunction syndrome treated with continuous venovenous hemodiafiltration in the Medical-Surgical Research Center's ICU in Havana. General, systemic and brain hemodynamic, oxygenation and metabolic variables were assessed immediately before and 12 hours after starting the procedure; vital status on separation from intensive care was recorded. For analysis, patients were grouped by whether cause of multiple organ dysfunction syndrome was septic or nonseptic. Variable means before and after treatment were compared using the Wilcoxon matched pairs test. Standardized mortality ratios were calculated for both groups, with survival efficacy defined by a ratio of <0.9. RESULTS: After 12 hours continuous venovenous hemodiafitration, the septic group showed clinical improvement, with statistically significant improvement in all variables except mean arterial pressure and brain hemodynamics. Survival to discharge from ICU was 64%, with a standardized mortality ratio of 0.66. In the nonseptic group, survival was 0% and ratio was 2.13; temperature was the only variable found to improve significantly. CONCLUSIONS: Continuous venovenous hemodiafltration improved clinical parameters and survival in patients with multiple organ dysfunction of septic origin. Further studies are needed with larger numbers of patients to corroborate these results.
Abstract in English:INTRODUCTION: The therapeutic potential of adult stem cells in coronary and peripheral arterial diseases has been proposed in recent years. However, factors possibly predictive of unfavorable angiogenic results have not been clearly identified as yet. OBJECTIVES: Identify candidate predictors of poor angiogenesis, as indicated by need for amputation, after autologous hematopoietic stem cell transplantation for chronic lower limb ischemia. METHODS: A retrospective analytical case-series study was carried out to detect factors possibly associated with hematopoietic stem cell autograft failure due to low angiogenic potential. The study universe was composed of 47 patients (19 women, 28 men) with critical lower limb ischemia in Fontaine stages IIb, III and IV, who received autologous stem cell transplantation at the Dr Gustavo Aldereguía Lima University General Hospital in Cienfuegos, Cuba, from January 2007 through December 2010. Variables studied were sex, age, medical history (high blood pressure, ischemic cardiomyopathy, diabetes mellitus and chronic renal insufficiency), Fontaine ischemia stage, intermittent claudication, pain score on a 1-10 scale, ankle-brachial pressure index in the affected extremity, presence of ulcers, and smoking. Laboratory variables included: blood concentrations of hemoglobin, glucose, creatinine, liver enzymes, cholesterol, triglycerides and LDH; as well as leukocyte and platelet counts, stem cell viability, prothrombin time and erythrocyte sedimentation rate. The main response variable was amputation, an indicator of poor angiogenesis. Using logistic regression, a prognostic score of 1 to 4 was developed for each risk factor and scores added to create a risk prediction scale. Predicted risk for amputation and observed amputation rates were compared for patients in three risk groups: low, 0-4; medium, 5-8; and high, 9-12. RESULTS: Factors identified as possibly predictive of poor angiogenesis were: final leukocyte count <20 x 10(9)/L after mobilization with granulocyte colony stimulating factor; age >60 years; pain scale score of 10; glycemia of >6 mmol/L; and triglycerides of >1.8 mmol/L. Patients who scored low on predicted amputation risk scale were spared amputation in 90.9% (10/11) of cases, versus 16.7% (2/12) in patients scoring high. CONCLUSIONS: Five possible prognostic factors for low angiogenic potential in stem cell autotransplantation were identified and a preliminary scale established to predict in which patients autotransplantation would be more likely to be successful.
Abstract in English:An intervention to address vision loss was carried out in 2008 in Táchira, Venezuela, by health teams of the joint Cuban-Venezuelan initiative known as Misión Milagro. It included active case identification of patients with ophthalmologic conditions and, where warranted, surgery, followup, rehabilitation and medical discharge. From a universe of 345 patients aged >18 years with ophthalmologic conditions found, 210 were selected for cataract or pterygium surgery. Of cataract patients, 55.2% recovered optimal vision within three months after surgery, as did 90.9% of those with pterygium; frequency of complications was 15.4% in cataract patients and 41.7% in pterygium patients. The intervention was considered successful, although many patients' low-income status required premature postoperative return to their jobs and other labors, a factor considered detrimental to optimal recovery.
Abstract in English:In the 20th century, the basic biomedical sciences (particularly anatomy, histology, embryology, physiology and biochemistry) were taught predominantly in the first semesters of Cuban medical education, with differing curricular connections between these and the clinical sciences. Establishment of the University Polyclinic Program in 2004 laid the foundation for integration of basic biomedical sciences into a transdisciplinary unit designated morphophysiology. This paper argues for improvements in this curricular unit and in its coordination with family medicine in the first semesters of medical training, complemented by integration of basic biomedical sciences into family medicine clinical courses throughout the remainder of the six-year curriculum.
Abstract in English:Leadership is the perception or acceptance by members of a group of their superior's ability to inspire, influence and motivate them to meet their goals and contribute to the achievement of shared objectives. This article analyzes the characteristics of bioethics and the profile of the bioethicist in relation to the comprehensive development required of health leaders. We address this relationship in the areas of research and clinical practice; intersectoral activity; health sciences education; bioethicist's profile; and influence on organizational structures, functioning and decisionmaking, with particular reference to development and current situation of these aspects in Cuba.