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Her passion for the “new world of informatics” led engineer Niurka Carlos to study computer sciences and digital systems, and her passion for health led her to join the embryo of Cuba’s Immunoassay Center in 1982 right after graduation from university in 1987, becoming one of the Center’s founders when it was launched that same year. First specializing in software, Ms Carlos was promoted to department chief, the Center’s management team and later to deputy director. She has headed the Center since 2014, leading implementation of research, production and marketing of diagnostic tools for the national health system and export. Today, the Center is expanding its horizons into chronic diseases that have become the main causes of illness and death in Cuba and are afflicting low- and middle-income countries at alarming rates as part of the world’s epidemiological transition. MEDICC Review spoke with Ms Carlos about the history, results, challenges and new frontiers of the Center in its 30th anniversary year.

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ABSTRACT Biotechnology has changed the pharmacopeia. It is expected that in the next five years, 50% of biological products will originate from biotechnology. Yet, treatments based on effective, costly biopharmaceuticals for prolonged use hamper the goals of ensuring universal therapeutic coverage and access to the best treatments. This conflict surfaced 30 years ago with synthetic drugs, and the solution was to create generics once the developers’ patents expired. Biosimilars are not generics, strictly speaking, as it is impossible to guarantee that they are molecularly identical to the original product; nor are they completely new products, as they rely on a great deal of prior work done by other scientists. National strategies are needed to ensure the broadest possible coverage in the best interests of the population. The key to a strategy to ensure access to the best treatment available lies in the concept of “totality of evidence,” which includes all information about a given molecular structure and its mechanism of action; safety and efficacy information from the first clinical trials; and monitoring data from products’ use in medical practice. A strategy of broad biological and molecular categorization plus intense pharmacovigilance would reduce development costs, the main barrier to widespread access.

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ABSTRACT INTRODUCTION Early assessment of prognosis following major abdominal surgery is associated with decreased risk of complications and death. While scoring systems are useful in this regard, there is no index that enables comprehensive individual patient assessment and is also applicable in ICUs with limited resources. OBJECTIVES Demonstrate that a model based on intra-abdominal pressure is effective in predicting death after major abdominal surgery. METHODS A prospective observational study was done of 300 post–abdominal-surgery patients admitted to the ICU of a university hospital affiliated with the General Calixto Garcia Medical Faculty, in January 2008 through January 2010. Patients were randomly assigned (2:1) to two groups: test and validation. The independent variable was vital status at discharge (alive or deceased); independent variables were age, sex, malignancy, APACHE II score and intra-abdominal pressure. In the test group, three mathematical models were fit to predict death (APACHE II, intra-abdominal pressure, and APACHE II plus intraabdominal pressure), which were later validated in the second group. Each model’s capacity to discriminate between living and deceased was evaluated according to sensitivity and specificity of receiver operating characteristic curves. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test and comparison of receiver operating characteristic curves by chi-square test of homogeneity. Each patient was followed until hospital discharge or death. RESULTS The three mortality prediction models displayed excellent calibration and discrimination, very similar predictive power, and no differences among their respective areas under the curve (chi square 2.802, p = 0.094). Variables with the most influence on probability of death were age, APACHE II score and intra-abdominal pressure. CONCLUSIONS The three models show good capacity and similar effectiveness to predict death after major abdominal surgery. The model based on intra-abdominal pressure is the most feasible in limited-resource settings.

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ABSTRACT INTRODUCTION Mosquito-transmitted dengue remains an endemic threat to population health in various tropical and subtropical regions. Recommended dengue prevention practices focus on vector control and reducing human–mosquito interactions, by practices such as removing standing water, wearing protective clothing and using repellent, as well as seeking medical care when symptomatic. Health workers in the community educate and empower citizens about recommended prevention practices, and thus are indispensable in implementing national dengue initiatives at the local level. However, their health messages may not resonate with all community members, resulting in low adherence to recommended prevention practices. Understanding the factors associated with low adherence to dengue prevention and control measures is essential for strengthening national dengue initiatives. OBJECTIVE Identify health workers’ perceived challenges for dengue prevention and control strategies and describe their recommendations for strengthening dengue control in the Dominican Republic. METHODS From January through March 2005, a qualitative study was conducted in five provinces of the Dominican Republic. Based on literature review and consultations with clinical specialists, a semistructured interview guide of nine questions was designed. A purposive sample of 19 health workers (10 men, 9 women) was interviewed, including public health practitioners, entomologists, educators, clinicians and an administrator. Question topics included occupational experiences in dengue prevention and control; views on vector control in communities; perceived challenges for citizens’ adherence to recommended practices; and suggested measures for strengthening adherence to vector control at local and national levels. Thematic analysis was used to identify salient themes. RESULTS Health workers described the following perceived challenges: 1) limited individual economic resources; 2) individual lack of awareness, education or action; 3) limited cohesion among community members; and 4) limitations in sustainability of government interventions. They made 14 recommendations related to the 4 perceived challenges. CONCLUSIONS These findings evince the complex interplay of economic, environmental, health, political and social factors that can directly or indirectly influence individual and community adherence to recommended dengue prevention measures. By understanding how these intrinsic and extrinsic factors hinder adherence, health authorities can adapt national policies to strengthen community participatory action in vector control, empower leadership potential by health workers and community members, and provide an appropriate systemic approach to preventing disease transmission.

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ABSTRACT INTRODUCTION In many countries cancer is or threatens to become the leading cause of death, although incidence and mortality rates differ between high-income and low- and middle-income countries. Developments in evolutionary biology have revealed that carcinogenesis is even more complex than previously thought. Several theories attempt to integrate the various existing points of view about what is known to date. OBJECTIVE Analyze and explain the main current theories of carcinogenesis and explore their possible application to understanding the demographic and epidemiologic transitions’ effects on cancer population dynamics in low- and middle-income countries. EVIDENCE ACQUISITION A systematic literature review was carried out in MEDLINE (via PubMed), SCOPUS (via Science Direct) and SciELO. Consistency and quality of evidence in articles reviewed were taken into account; we excluded studies with consistency levels of IV and V, and those with limited or insufficient quality of evidence. DEVELOPMENT Human evolution has led to a type of life history characterized by numerous tradeoffs with oncogenic implications. Cultural coevolution and socioeconomic development have affected cancer population dynamics. Several theories explain carcinogenesis from an ecological and evolutionary perspective, among them somatic mutation, adaptive oncogenesis, life history theories, and the Noble and Hochberg model. The human environmental effect on cancer risk is manifested in the influence of demographic and epidemiologic transitions in low- and middle-income countries, where cancer represents a high disease burden due to the effects of recently introduced environmental factors in native environments, accentuation of adaptive decoupling, and diversification of genetic polymorphisms for cancer susceptibility. CONCLUSIONS The Noble and Hochberg model best explains the population dynamics of cancer in low- and middle-income countries, especially regarding the effects of recently introduced environmental factors on native environments, adaptive decoupling and genetic diversity (manifest in differences in clinical and biological tumor expression by level of economic development), in response to demographic and epidemiologic transitions.