Abstract in English:After nearly 60 years of universal education and health, coupled with national policies supporting women’s rights and advancement, the results are in: according to recent data, more than half of Cuban scientists and almost 60% of all professionals in Cuba are women. Moreover, women’s representation in government is rising, including at the highest levels such as parliament, where they constitute 53.2% of members. Digging deeper, we find a story richer than national statistics or political representation. It’s the story of the collective achievements of female professionals on the island. For example, the clinical research team responsible for developing CIMAvax-EGF, Cuba’s novel biotech therapy for non-small cell lung cancer, was headed by a woman. Likewise, the lead scientist of the Cuban team that developed the world’s first effective meningitis B vaccine is a woman. And the cofounder of the country’s clinical trials coordinating center and registry is a woman, as is the founder of the National Center for Agricultural Animal Health. Yet, as in any country, there is more to be done to achieve true gender parity and release the full potential of women. To begin our series profiling outstanding Cuban women professionals, MEDICC Review spoke with sociologist Dr Marta Núñez, who has devoted decades to research on gender relations and the role of women in Cuba. She provides an overview and framework for contextualizing the advancement of Cuban women—including the challenges still to overcome.
Abstract in English:ABSTRACT INTRODUCTION Diabetic foot ulcers are a chronic complication in patients with diabetes mellitus. They appear as a result of the combination of diabetic polyneuropathy and angiopathy, and in many cases require amputation of the affected extremity. Clinical trials have demonstrated that repeated local infiltration with Heberprot-P can improve healing of chronic diabetic foot ulcers. Although there is evidence of its effects as a granulation stimulator and on cell migration and proliferation, genetic control mechanisms explaining its anti-inflammatory and oxidative stress reduction properties are not yet thoroughly understood. OBJECTIVE Analyze changes in expression of genes involved in healing after treatment of diabetic foot ulcers with Heberprot-P. METHODS Biopsies were collected from diabetic foot ulcers of 10 responding patients before and after 2 weeks’ treatment with Heberprot-P (75-μg applied intralesionally 3 times per week). Total RNA was obtained and quantitative PCR used to determine expression of 26 genes related to inflammation, oxidative stress, cell proliferation, angiogenesis and extracellular matrix formation. Genetic expression was quantified before and after treatment using REST 2009 v2.0.13. RESULTS After treatment, there was a statistically significant increase in expression of genes related to cell proliferation, angiogenesis and formation of extracellular matrix (PDGFB, CDK4, P21, TP53, ANGPT1, COL1A1, MMP2 and TIMP2). A significant decrease was observed in gene expression related to inflammatory processes and oxidative stress (NFKB1, TNFA and IL-1A). CONCLUSIONS Our findings suggest that Heberprot-P’s healing action on diabetic foot ulcers is mediated through changes in genetic expression that reduce hypoxia, inflammation and oxidative stress, and at the same time increase cell proliferation, collagen synthesis and extracellular matrix remodeling. The kinetics of expression of two genes related to extracellular matrix formation needs further exploration.
Abstract in English:ABSTRACT INTRODUCTION By the end of 2017, there were more than 28,000 individuals living with HIV in Cuba, over 80% receiving antiretroviral therapy, which dramatically reduces viral replication, improves immune status and decreases risk of transmission. These results could be jeopardized by emergence of HIV-1 drug resistance. In 2009, a test for HIV-1 genotypic resistance was introduced in routine clinical practice in Cuba. OBJECTIVE Investigate antiretroviral resistance and its relation to subtype distribution in HIV-1 treatment-naïve and previously treated patients in Cuba. METHODS Resistance and HIV-1 subtype distribution were determined in 342 antiretroviral treatment-naïve patients and 584 previously treated for HIV-1 whose blood specimens were sent to the Pedro Kourí Tropical Medicine Institute during 2009–2014. Transmitted drug resistance was determined using the Calibrated Population Resistance Tool v.6. Drug resistance analysis was conducted using the algorithm Rega v9.1.0. RESULTS Prevalence of transmitted drug resistance was 11.4%, and 41% of mutated viruses exhibited dual-class resistance to nucleoside reverse transcriptase inhibitor and non-nucleoside reverse transcriptase inhibitor. Overall, 84.9% of patients had ≥1 resistance mutation, 80% had ≥1 nucleoside reverse transcriptase inhibitor mutation, 71.4% had ≥1 non-nucleoside reverse transcriptase inhibitor mutation and 31.7% had ≥1 protease inhibitor mutation. K65R and K101E mutations were significantly more frequent in subtype C, L210W in CRF19_cpx, and M47V/I in CRF BGs (20, 23, 24). Full class resistance to nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors and multidrug resistance were detected in 21.2%, 32.4%, 8% and 4.1% of patients, respectively. Average percentage resistance to nucleoside reverse transcriptase inhibitor, protease inhibitor, full class resistance to nucleoside reverse transcriptase inhibitor, protease inhibitor and multidrug resistance increased in patients failing two or more regimens. Nevertheless, after 2011, a declining trend was observed in the frequency of multidrug resistance and full class resistance to nucleoside reverse transcriptase inhibitors and protease inhibitors. CONCLUSIONS Detected levels of transmitted drug resistance highlight the need for a national surveillance study in treatment-naïve patients. Resistance prevalence is high in previously treated patients but appears to be decreasing over time. The frequency of resistance mutations in recombinant forms of HIV in Cuba needs further study.
Abstract in English:ABSTRACT INTRODUCTION Serogroup B meningococcal outer membrane vesicle vaccines have been effective against vaccine-type strains, but their effectiveness against heterologous strains has been controversial. The Cuban VA-MENGOC-BCvaccine is of this type, but also includes meningococcus C capsular polysaccharide. OBJECTIVES Assess the effectiveness of VA-MENGOC-BC in reducing meningococcal disease caused by homologous or heterologous serogroup B strains and its serological effectiveness against meningococcus C. METHODS A review of studies of VA-MENGOC-BC’s application in Cuba, Brazil, Uruguay and Colombia was carried out to examine the vaccine’s effectiveness in reducing meningococcal disease during serogroup B outbreaks. Serological effectiveness against serogroup C determined in these studies (indicated by bactericidal antibody titers before and after vaccination) was also analyzed. RESULTS VA-MENGOC-BC’s effectiveness against homologous serogroup B strains has consistently been greater than 80% in all age groups. Effectiveness in heterologous contexts was also above 80% in individuals aged >4 years. Lower effectiveness in heterologous contexts was found in Brazilian children aged <2 years, although still >50%. Effectiveness increased when assessed based on mortality rates, as well as in cases of clinically severe meningococcal disease. The carrier-state pattern was modified after vaccination with reduction of hypervirulent lineages. Some 60% of infants (aged <1 year) attained protective bactericidal antibody titers against serogroup C. Higher protection rates were achieved in older children. CONCLUSIONS In addition to prevention of meningococcal disease caused by homologous serogroup B strains, VA-MENGOC-BC should be considered for heterologous contexts. It is protective against serogroup C in all age groups.
Abstract in English:ABSTRACT INTRODUCTION Mortality analysis based on a single cause of death is not, in most cases, fully informative. There are several more illuminating procedures using a multiple cause of death approach; these are little known and rarely used in Cuba. The simplest of these methods, while methodologically limited, consists of summing all deaths from a specific cause mentioned on death certificates, regardless of whether the cause is listed as underlying or contributing. OBJECTIVE Using Cuban data, critically assess and implement two of the most recognized approaches to analyzing multiple causes of death. METHODS Multiple causes of death in Cuba were assessed for the years 2005, 2010 and 2015, employing death records from the National Medical Records and Health Statistics Bureau of Cuba’s Ministry of Public Health. With the example of diabetes mellitus as underlying cause, we explored connections between underlying and associated (antecedent and contributing) causes on death certificates using two approaches from the international literature: the simple method and the cause-of-death association indicator. RESULTS The study identified main trends in multiple causes of death identified in 2005, 2010 and 2015, overall and by age group and sex. We observed a trend to increasing mean number of causes of death per death certificate between 2005 and 2015. The number of causes reported showed no substantial differences by age group or sex. Diseases of the arteries, arterioles and capillaries were by far the most frequently associated with diabetes mellitus as underlying cause. CONCLUSIONS The multiple causes of death approach affords more nuanced understanding of patterns of disease, comorbidity and death in the Cuban population. The indicators used fulfill different roles: the simple method brings to light the full range of ways in which a given cause contributes to mortality, and the cause-of-death association indicator enables exploration of links between different causes of death, not possible with the simple method.
Abstract in English:ABSTRACT INTRODUCTION To provide equal access, health care provision should be distributed across geodemographic space based on need. In Argentina, the social security, publicly funded health care and private health care subsectors are responsible for delivering health services. In the public subsector, which is responsible for providing primary and secondary care mainly to the uninsured population, supply of services is not always associated with need. The lack of coordination between levels and subsectors makes it difficult to transform need into demand. OBJECTIVE Design a methodology to systematically estimate need, demand and supply of primary health care services based on secondary data sources in order to assess potential mismatches in any geographical area. METHODS An ecological analysis was conducted based on outpatient visits in primary care in Bahía Blanca, Buenos Aires Province, Argentina. A mathematical approach was proposed to systematize data collection by census tract regarding estimated need (number of outpatient visits needed, by specialty, according to age- and sex-specific care protocols and the area’s demographics), demand (actual outpatient visits by specialty in each primary health care center), and supply (visit capacity or available appointment slots, taking into account number of personnel hours worked, by specialty). RESULTS Demand for outpatient visits exceeded need (299,731) by 24% while available visit capacity (993,903) could have covered more than twice the number demanded (370,881). Analysis of the three variables grouped by area found that supply correlated more closely with demand (ρ = 0.90) than with need (ρ = 0.68), while spatial analysis showed that supply distribution responded to need. Areas with greater need had a health facility relatively close by, although supply was often located in areas of lower need, and some areas struggle with relatively high need and insufficient supply. CONCLUSIONS Results suggest the need for some reconfiguration of primary health care in the study area. The proposed mechanism for estimating relationship among supply, demand and need is a useful tool to support decision-making.
Abstract in English:ABSTRACT INTRODUCTION Despite growing research interest in the epidemic of chronic kidney disease of nontraditional etiology (a distinct form of chronic kidney disease disproportionately affecting agricultural populations across Mesoamerica—Central America and southern Mexico), its etiology remains poorly understood. OBJECTIVE Elucidate factors that impact researchers’ efforts to understand the epidemic of chronic kidney disease of nontraditional etiology. METHODS Semistructured interviews were conducted with 39 international researchers, selected based on their publications and participation in conferences about chronic kidney disease of nontraditional etiology. Interviews were conducted from May through September of 2015 in English or Spanish by video conference, telephone or in person. Interviews were audio recorded, transcribed, and analyzed iteratively using content analysis. RESULTS Of 39 researchers interviewed, 30.8% were women, 84.6% had a medical and/or doctoral degree and 74.3% had ≥6 years’ experience carrying out research on chronic kidney disease of nontraditional etiology. Three major themes were identified related to factors affecting research progress. The first, influence of state and private interests, concerned perceptions that sugar industry and some governments in Mesoamerica dismissed, hindered, intimidated and inaccurately represented research on chronic kidney disease of nontraditional etiology. The second, limited material and human resources, had to do with scarcity of stable, impartial funding and adequate in-country research infrastructure. Researchers were largely funded by nontraditional sources (charitable organizations, private donations, sugar industry in Mesoamerica, personal funds) or not funded at all. The third, logistical challenges across study lifetimes, referred to barriers such as unwieldy approval mechanisms, gang interference and publication hurdles. CONCLUSIONS Producing high quality and clinically relevant studies to address chronic kidney disease of nontraditional etiology in the resource-scarce Mesoamerican research climate has been fraught with challenges. These findings contextualize the progress that has been made in understanding chronic kidney disease of nontraditional etiology to date and highlight the need for public health and biomedical organizations to support researchers’ ongoing efforts to engage all stakeholders in addressing the epidemic, disseminate their research findings and identify feasible strategies for addressing the community-wide suffering caused by chronic kidney disease of nontraditional etiology.