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ABSTRACT INTRODUCTION For two decades, various countries have experienced an epidemic of chronic kidney disease unexplainable by traditional causes. Typically a chronic tubulointerstitial nephritis, it predominantly affects young male agricultural workers and has been reported in several countries in Central America, as well as in Sri Lanka, India and Egypt. Recent studies in El Salvador have also reported the disease in male nonagricultural workers and in women, both those working in agriculture and not. Epidemiological information on whether this condition affects pediatric populations is virtually nonexistent. Globally, estimates of chronic kidney disease prevalence in pediatric populations range from 21 to 108 per million population. OBJECTIVE Determine the prevalence of urinary markers of renal damage and of chronic kidney disease in persons aged <18 years in rural Salvadoran communities. METHODS Pediatric NefroSalva was a descriptive epidemiologic study in three agricultural regions with known high prevalence of chronic kidney disease of uncertain etiology: Bajo Lempa, Guayapa Abajo and Las Brisas. Demographic and health data were collected and physical measurements were taken for 2115 persons aged <18 years, 1058 boys and 1057 girls. Urine samples were tested for markers of renal damage and blood samples analyzed to measure creatinine for estimating glomerular filtration rate (Schwartz formula). Median glomerular filtration rate was compared with reference values for age groups 2-12 and 13-17 years; mean glomerular filtration rate trends were assessed for age groups 2-5, 6-12 and 13-17 years. Positive test results were confirmed after three months. RESULTS Prevalence of urinary markers of renal damage was 4%, 4.3% in girls and 3.8% in boys. Microalbuminura (albumin:creatinine ratio 30-300 mg/g) was detected in both sexes and all age groups in all three regions, with prevalences of 2.6%-3.8% in boys and 3.3%-3.8% in girls. Macroalbuminuria (albumin:creatinine ratio >300 mg/g) was detected only in girls in Las Brisas, 2.3%. Glomerular hyperfiltration (compared to international norms) was found in all age-sex groups in all three regions. Prevalence of chronic kidney disease was 3.9%—4.1% in girls and 3.6% in boys. The prevalence of chronic renal failure was 0.1%. CONCLUSIONS High prevalence of chronic kidney disease in children and adolescents calls attention to the need for primary prevention from very early ages. This finding in children in areas where chronic kidney disease of uncertain etiology is common in adults is consistent with a contribution of environmental toxins to the epidemic observed in these areas.

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ABSTRACT INTRODUCTION Tuberculosis is the second leading cause of infectious-disease death worldwide, after AIDS. Most tuberculosis patients in Cuba have pulmonary TB and recovery rates are high. When TB chemotherapy fails, the most common adverse outcome is death. OBJECTIVE Determine survival patterns in a cohort of pulmonary TB patients in Cuba. METHODS A retrospective cohort study was conducted of pulmonary TB patients who were notified and treated in Cuba in 2009 and 2010. Time elapsed between diagnosis and death was examined. Patient survival was analyzed with the Kaplan–Meier method and comparisons were made with the log-rank estimator; an adjusted Cox model was used to analyze risk of death. RESULTS The study included 1339 patients, of whom 71.7% were aged 25–64 years and 77.4% were men. Infectious pulmonary tuberculosis was the most common form (75.6%). Only a small number of patients (5.7%) presented TB/HIV coinfection. Ninety-four deaths were reported, 55% during the first 60 days of treatment. Lower survival rates were observed among men (HR 1.87, 95% CI 1.02–3.45), patients coinfected with HIV/AIDS (HR 6.25, 95% CI 3.46–11.31), and patients aged ≥48 years (HR 3.93, 95% CI 2.41–6.40). CONCLUSION The preponderance of deaths early in TB treatment course may be related to diagnostic and/or treatment delays. Older age at diagnosis, male sex and TB/HIV coinfection increase risk of death.

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ABSTRACT INTRODUCTION High prevalence of metabolic syndrome and its associated risk factors in adults represents both a Cuban and a worldwide public health problem. OBJECTIVE Determine prevalence of metabolic syndrome’s component risk factors in a representative sample of adults in Holguín Province, Cuba. METHODS A cross-sectional study was conducted using multistage probability sampling of four Holguín Province municipalities: Holguín, Gibara, Urbano Noris and Banes. We selected a sample of 2085 patients aged ≥20 years during 2004–2013 and measured clinical, anthropometric and biochemical variables. Risk factor prevalence rates were calculated using EPIDAT 3.1. RESULTS Crude metabolic syndrome prevalence rate was 27.2% (CI 25.3%–29.1%). Crude prevalence rates (with 95% CI) of risk factors were as follows: hypertriglyceridemia 36.1% (34.0%–38.2%); hypercholesterolemia 25.5% (23.6%–27.4%); low HDL cholesterol 26.3% (24.4%–28.2%); high LDL cholesterol 10.1% (8.8%–11.4%); prediabetes 2.2% (1.6%–2.8%); diabetes 14.6% (13.1 %–16.1%); prehypertension 3.5% (2.7%–4.3%); hypertension 34.5% (32.5%–36.5%); overweight 23.4% (21.6%–25.2%); obesity 32.0% (30.0%–34.0%) and central obesity 47.3% (45.2%–49.4%). They were significantly higher in women and older adults. CONCLUSION High prevalence of risk factors associated with metabolic syndrome confirms the magnitude of this health problem, particularly in women and older adults.

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ABSTRACT INTRODUCTION Cuba’s science policy is grounded in a scientific and technological innovation system applicable to all institutions. In hospitals, the system should influence medical care and administrative and teaching processes, as well as promotion of scientific activity as such. OBJECTIVE Describe results of the Scientific and Technological Innovation System at the Dr Gustavo Aldereguia Lima University Hospital, the main provincial hospital in Cienfuegos, Cuba. METHOD This was a key informant survey and document review concerning the hospital’s scientific activity during 2000–2014. A questionnaire was administered to 22 key informants to select key indicators and area. Data on the hospital’s scientific activity related to these indicators were retrieved from hospital, provincial public health and scientific publishing databases. A second group of 35 key informants confirmed linkages between scientific outputs and the innovation system’s main activities. RESULTS The following were reported over the study period: sustained development of scientific human resources (40% grade II specialists, 30% master’s degree holders and 11.4% accredited academic researchers among the hospital’s professional staff), high scientific output (annual average of 445 studies completed, 118 publications and 203 projects under way) and high visibility (national and international recognition) of the hospital’s achievements in science and innovation. Key informants considered that results related to development of scientific potential were influenced by the following activities of the Scientific and Technological Innovation System: promotion of grade II specialty training, researcher accreditation and awarding of master’s degrees and PhDs in the sciences, development of an extensive continuing education program (for researchers and their mentors), public recognition of professionals with good scientific results, promotion of research and other scientific activities, and the requirement that professional and technical staff participate in national events sponsored by scientific societies. CONCLUSIONS Implementation of a Scientific and Technological Innovation System can contribute to a hospital’s scientific capacity and productivity.

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INTRODUCTION Urinary incontinence is a disorder of considerable significance in older adults. It causes distress and morbidity, yet its true prevalence in the community is likely underestimated, because stigma and other factors may cause underreporting. WHO has developed a 10-minute screening tool to help primary healthcare providers recognize and manage the most common geriatric conditions: falls, memory loss, depression and urinary incontinence. OBJECTIVE Determine prevalence of urinary incontinence in adults aged ≥60 years in Westmoreland Parish, Jamaica; examine some of the associated risk factors; estimate how much urinary incontinence goes unreported and explore related barriers. METHODS A cross-sectional study in April 2014 of 454 older adults was conducted in 12 community clusters in Westmoreland. Data collection was done using an interviewer-administered questionnaire. Data were analyzed using SPSS version 17. Chi-square and Fisher exact tests were used to assess significance of associations between dependent and independent variables. RESULTS The majority (241/454, 53.1%) of respondents were men aged 60–95 years (median age 69 years; interquartile range: 64–77). Prevalence of urinary incontinence was 10.6% (48/453). Statistically significant associations were found between urinary incontinence and hypertension, diabetes mellitus, prostate problems and arthritis, but not with kidney problems, stroke or parity. Among respondents with urinary incontinence, 30.2% had not reported the condition to their doctor (13/43 who answered this question). Reasons cited for nonreporting included belief that urinary incontinence is normal with aging (9 respondents), not being bothered by urinary incontinence (7), inability to pay for treatment (6), feeling ashamed to report the condition (4), not knowing the appropriate doctor to see (2) and lack of awareness of available treatment options (1). Among respondents who had unreported urinary incontinence, 10 indicated a preference for physician-initiated (as opposed to self-initiated) discussion of urinary incontinence. CONCLUSION The substantial prevalence of urinary incontinence and high rate of nonreporting (almost one in three) underscore the need for systematic screening of older adults by doctors, especially at the primary care level, for early detection and appropriate urinary incontinence management.

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ABSTRACT Arterial hypertension is the most prevalent non-communicable disease worldwide, and has long been recognized as a major risk factor for cardiovascular and cerebrovascular diseases. High blood pressure has deleterious consequences on the main target organs (heart, kidney, brain), and several studies have shown that brain damage is more frequent than heart and kidney involvement. Silent lesions can subsequently lead to cognitive decline, dementia or stroke. Nevertheless, screening for subclinical brain deterioration is rarely performed because it requires imaging techniques whose scarcity and high cost rule out routine use by primary care physicians. The challenge is thus early detection of asymptomatic brain lesions with cost-effective techniques to test thousands of patients in the community. In this review we present an update on the status of biomarkers explored as alternatives for early detection of brain damage in arterial hypertension, potentially useful to identify patients needing referrals for brain MRI: ambulatory blood pressure monitoring, quantitative retinal microvascular assessment, quantitative electroencephalography, carotid ultrasonography, neurocognitive studies and blood-based biomarkers. We place special emphasis on blood-based biomarkers, for which our group reported the first preliminary evidence of an association between serum neuron-specific enolase and severity of white matter lesions in patients with essential hypertension. This review consequently explores the potential for blood-based biomarkers to provide a faster, cheaper and more accessible early-detection solution, particularly beneficial in resource-limited settings such as Cuba’s.

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ABSTRACT Intersectoral action in health refers to actions led by the health sector based on coordinated national and local policies, strategically oriented to address priority health issues where actions by other sectors can have a decisive impact on health outcomes. A Cuban example of this approach is the joint efforts by the Ministry of Public Health and the biotechnology industry in development and application of technologies for cervical cancer screening, early detection and treatment. The resulting products have been used by the National Health System since 2010, as part of efforts to reduce cervical cancer mortality. This is an example of intersectoral action intended to identify and contribute to solving problems affecting people’s well-being and quality of life.

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ABSTRACT This paper discusses integration and implementation of population health and social determinants approaches to the health-disease-care process in the context of ongoing changes to Cuba’s health system. Ideas for strengthening the social conceptualization of public health and prioritizing population health actions over those of individual medical care are discussed, with a view to encouraging rethinking of these as social practice. The paper aims to advance new and renewed strategic proposals for change, based on a broad view of public health and a focus on social medicine that favors a population health perspective and inclusion of a wide range of health determinants. It advances the need to develop or extend debate on the theory and social practice of epidemiology and public health while implementing needed changes in health services and medical care. The paper recommends embarking on technical discussions among all actors and protagonists, not just in the health care system but in the entire health sector, to better integrate and practice a population health approach with social determinants of health.

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ABSTRACT Cuba’s accelerated trend to lower fertility and consequent contraction of population reproductive capacity have now become concerns for various social and political actors, including, of course, Cuban demographers, who have been sounding the alarm for more than three decades. The most striking characteristic of Cuba’s fertility transition is undoubtedly its abrupt onset, rapidity, and the fact that it took place in the absence of accompanying economic development. Hence the current debate focusing on the roles of the various determinants that led to the transition, and especially of economic factors at different stages, particularly in conditions of heightened population vulnerability during economic crises. This article provides elements to help fill gaps in knowledge of the fertility-development relationship today.