• Contextual and individual influences on diabetes and heart disease in Havana primary care catchment areas Original Research

    Díaz-Perera, Georgia; Bacallao, Jorge; Alemañy, Eduardo

    Abstract in English:

    INTRODUCTION: A population health profile is a cumulative product of socioenvironmental and political factors that create the contexts in which health problems arise, as well as opportunities and barriers to addressing them. Research on context has focused on demonstrating its effects, direct or indirect, on health indicators, but has made few incursions into assessing its role as a mediator of other factors. While individual risk factors for chronic diseases are well known, the same cannot be said for the complex of contextual factors operating at various levels and over the lifespan. OBJECTIVE: stimate relative influences by contextual versus individual factors as determinants of diabetes type 2 and heart disease. METHODS: A cross-sectional study was carried out in populations served by 12 family doctor-and-nurse practices in Havana, in 840 families selected by simple random sampling, 70 per practice. Principal components analysis was used, as well as contextual logistic regression models with a nested model strategy, whose fit was meant to estimate the relative contributions of contextual compared to individual risk factors for diabetes and heart disease. Context was described and analyzed at two levels: that of the family or household and that of the catchment area served by a family doctor-and-nurse practice (geographically defined as a neighborhood). RESULTS: For diabetes, the contextual effect of neighborhood was modified when household effect was removed; that is, the effect of neighborhood was indirect and mediated by household. Individual coefficients were practically invariant; the principal effect of household changed noticeably on removal of individual effects, while age maintained its effect without variation. For heart disease, the effect of neighborhood was slightly modified when household effect was controlled for. Individual coefficients showed little change. There was an important direct effect of household on risk of heart disease. Age and high blood pressure coefficients hardly varied. CONCLUSIONS: We confirmed interactions between individual and contextual (neighborhood and household) factors, whose effects on individual health are not entirely mediated by individual factors. Research needs to pay more attention to context beyond its direct effect on individual risk factors.
  • Diabetes risk in a Cuban primary care setting in persons with no known glucose abnormalities Original Research

    Naranjo, Adrian A.; Rodríguez, Ángel Y.; Llera, Rosa E.; Aroche, Ronald

    Abstract in English:

    INTRODUCTION: With 333 million cases worldwide predicted for 2015, type 2 diabetes mellitus presents an important global health challenge. Its rising tide calls for health policies emphasizing prevention at the primary care level, including public education as well as early risk identification and intervention. OBJECTIVES: Estimate risk of developing type 2 diabetes in persons with no known glucose abnormalities, registered in a primary care setting in Pinar del Río city, Cuba, using FINDRISK. METHODS: A descriptive, cross-sectional study applied FINDRISK to 620 persons aged >18 years randomly selected from a universe of 1058 patients with no known glucose abnormalities, registered in family-doctor-and-nurse office No. 23 in the Turcios Lima Teaching Polyclinic health area, Pinar del Río city. RESULTS: The study population was predominantly aged <45 years (53.5%) and 80.2% was overweight or obese. At least moderate risk of diabetes was found in 74.4% of the sample, and 10.5% was at very high risk, meaning an estimated 120 patients in the sample could be expected to develop type 2 diabetes within the next 10 years. CONCLUSIONS: Type 2 diabetes prevalence can be expected to increase substantially in this population over the next decade. We recommend design and timely implementation of intensive lifestyle change programs to eliminate or slow development of type 2 diabetes in at-risk individuals. We propose following cohorts identified by FINDRISK to assess its prognostic value in the Cuban population.
  • Prognostic value of gated SPECT after reperfusion for acute myocardial infarction Original Research

    Cabrera-Rodríguez, Lázaro O.; Peix, Amalia T.; Padrón, Kenia M.; Chacón, Deilys; Carrillo, Regla; Fernández, Yoel; Mena, Erick

    Abstract in English:

    INTRODUCTION: Myocardial reperfusion during the course of an acute myocardial infarction improves patients' short- and long-term prognosis; coronary blood flow is successfully re-established while preserving a large amount of at-risk muscle. Clinical evolution, however, varies. Presence of residual ischemia or viable myocardial tissue affects a patient's prognosis. Assessment by noninvasive methods allows better prognostic stratification. Cardiac-gated SPECT provides appropriate parameters to support treatment selection and monitoring of these patients. OBJECTIVES: Assess the prognostic value-ability to predict occurrence of major cardiac events-of perfusion and cardiac function obtained by myocardial perfusion scintigraphy in myocardial infarction patients treated by any myocardial reperfusion method, whether pharmacological or surgical. METHODS: Forty patients were included, mean age 58.8±9 years, diagnosed with myocardial infarction. Participants were divided into two groups: primary percutaneous transluminal coronary angioplasty (15) or thrombolysis (25). All received myocardial perfusion scintigraphy with cardiac-gated SPECT to assess perfusion and left ventricular function, and were followed for six months with telephone interviews and review of clinical records. RESULTS: In the 11 patients who had major cardiac events within six months of followup, a nonsignificant increase in perfusion defect extent was seen post reperfusion. Six (54.5%) of those with major cardiac events had anterior perfusion defects. In functional parameters, a significant increase in end-diastolic and end-systolic volumes and decrease in left ventricular ejection fraction were observed post stress (p = 0.006) and at rest (p = 0.001). Post-stress end-diastolic volume of >70 mL had a higher prognostic value for major cardiac events [sensitivity 100%; specificity 89%, area under ROC curve 0.835 (CI 0.702-0.969), p = 0.001]. CONCLUSIONS: Cardiac-gated SPECT is useful to identify variables (including left ventricular systolic dysfunction and dilation of left cavities, particularly left end-systolic volume of >70 mL) predictive of major cardiac events in reperfused patients, independent of treatment modality.
  • Nosocomial ventilator-associated pneumonia in Cuban intensive care units: bacterial species and antibiotic resistance Original Research

    Medell, Manuel; Hart, Marcia; Duquesne, Amílcar; Espinosa, Fidel; Valdés, Rodolfo

    Abstract in English:

    INTRODUCTION: Nosocomial pneumonia associated with use of mechanical ventilators is one of the greatest challenges confronted by intensivists worldwide. The literature associates several bacteria with this type of infection; most common in intensive care units are Acinetobacter baumannii, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus and some of the Enterobacteriaceae family. OBJECTIVES: To identify the causal agents of nosocomial ventilatorassociated pneumonia in patients receiving mechanical ventilation in the intensive care units of Havana's Hermanos Ameijeiras Clinical-Surgical Teaching Hospital in 2011, and to characterize their antibiotic resistance. METHODS: A cross-sectional descriptive study was conducted using hospital administrative data of quantitative cultures from positive tracheal aspirates for January through December, 2011. Records were analyzed from 77 intensive care unit patients who developed nosocomial ventilator-associated pneumonia. Variables examined were age and sex, and pathogens identified from culture of tracheal aspirate and related antibiotic susceptibility. RESULTS: Species most frequently isolated were: Acinetobacter baumannii in 53 patients (68.8%), Pseudomonas aeruginosa in 34 patients (44.2%), other species of Pseudomonas in 15 patients (19.5%), and Serratia marcescens, Klebsiella pneumoniae, and Escherichia coli in 12 patients each (15.6%). Some patients presented more than one pathogen in concurrent or successive infections. Antimicrobial susceptibility testing found high percentages of resistance to antibiotics in all these pathogens. Least resistance was found to colistin. CONCLUSIONS: The prevalence of antibiotic resistance in bacteria causing nosocomial ventilator-associated pneumonia is of concern. Colistin is the drug of choice among the antibiotics reviewed, but sensitivity to other antibiotics should be assessed to search for more appropriate broad-spectrum antibiotics for treating nosocomial ventilator-associated pneumonia. Our results also suggest the need to strengthen infection control efforts, particularly in intensive care units, and to reassess compliance with quality control procedures. Multidisciplinary research involving microbiologists, epidemiologists, internists and intensivists is needed to fully understand the etiological and resistance patterns observed.
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