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.

OBJECTIVES Estimate 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.

KEYWORDS Risk factors, risk reduction, community, neighborhood, type 2 diabetes mellitus, heart disease, logistic models, Cuba

Hyperglycemia characteristic of diabetes mellitus triggers pathological processes in fetal development of various structures such as the retina, peripheral nerves, renal glomerulus, and arterial and venous beds. Women with diabetes prior to conception have children with birth defects three to five times more frequently than women without diabetes. There is no specific pattern of birth defects, but the central nervous and cardiovascular systems are the most affected. Hyperglycemia leads to mitochrondrial superoxide radical production, which activates five metabolic pathways that mediate damage leading to diabetic embryopathy. Once oxidative stress is established, there is modification of gene expression controlling embryonic development in critical periods. Vitamin E application in animal models has greatly lowered occurrence of birth defects in embryonic and fetal stages, consistent with an etiologic role for oxidative stress in dysmorphogenesis. Effective metabolic control before and during pregnancy, achieved in Cuba by implementing programs for control of birth defects in children of diabetic pregnant women, has been found effective.

KEYWORDS Diabetes mellitus, hyperglycemia, oxidative stress, gene expression, glucose metabolism disorders, congenital abnormalities, birth defects, Cuba

Cardiovascular disease is the main cause of death for diabetics, and in many cases its presence is silent due to cardiac autonomic neuropathy. Thus, early diagnosis of coronary disease is essential, permitting proper risk stratification and appropriate therapy. This paper examines the usefulness of several noninvasive imaging techniques to study cardiovascular diseases in individuals with diabetes mellitus, with emphasis on nuclear cardiology, and proposes a diagnostic algorithm for detection of silent ischemia.

Keywords Myocardial perfusion scintigraphy, myocardial perfusion imaging, radionuclide imaging, diabetes mellitus, silent myocardial ischemia, Cuba

A possible etiologic role of enteroviruses for type 1 diabetes has been researched for 40 years, but evidence to date is inconclusive. This article summarizes new evidence from Cuban research supporting a role for enteroviruses, both in preclinical stages of autoimmune reactions against pancreatic β cells and at clinical onset, in a population with low type 1 diabetes incidence. Possible pathogenetic mechanisms are also discussed, such as acute cytolytic damage and molecular mimicry. Although direct causal effects of enteroviruses in type 1 diabetes are difficult to demonstrate, arguments supporting their role in type 1 diabetes pathogenesis should not be ignored; and confirmation could contribute to development of more effective preventive strategies.

KEYWORDS Type 1 diabetes, juvenile diabetes, insulin-dependent diabetes, autoimmunity, autoantibodies, enteroviruses, hygiene hypothesis, Cuba

This article describes the background, beginnings, development, evolution and outcomes of kidney transplantation in Cuba. Nephrology as a medical specialty in Cuba began in 1962 and was formalized in 1966. Conditions were created to implement renal replacement therapy (including transplants), bring nephrology care to the entire country and train human resources who would assume this responsibility, making Cuba one of the first countries with a comprehensive program for renal patient care.

After three unsuccessful cadaveric-donor kidney transplantations in 1968–69, the ensuing history of kidney transplantation can be summarized in the following three stages. 1970–1975: In January 1970, cadaveric-donor kidney transplantation began at the Nephrology Institute. That year, 17 kidney transplantations were performed; four of these patients lived with functional kidneys for 15–25 years; 10-year graft survival was 23.5% (Kaplan-Meier survival curve); HLA typing began in 1974. By December 1975, 170 grafts had been done in three hospitals. 1976–1985: Seven transplantation centers performed 893 grafts during this period. HLA-DR typing was introduced in 1976 and the National Histocompatibility Laboratory Network was founded in 1978. The first related living-donor kidney transplantation was done in 1979. 1986–2011: The National Kidney Transplantation Coordinating Center and the National Kidney Transplantation Program were created in 1986; the first combined kidney–pancreas transplantation was performed the same year. In 1990, cyclosporine and the Cuban monoclonal antibody IOR-T3 were introduced for immunosuppression to prevent rejection, as were other Cuban products (hepatitis B vaccine and recombinant human erythropoietin) for transplant patients. By December 2011, the cumulative number of transplants was 4636 (384 from related living donors). With over 40 years of experience, kidney transplantation is now well established in Cuba; it is free and universally accessible, on the basis of need and appropriateness.

KEYWORDS Kidney transplantation, grafting/kidney, end-stage kidney disease, end-stage renal disease, renal insufficiency, living donors, organ donors, organ transplants, history of medicine, nephrology, Cuba

INTRODUCTION Cross-modal plasticity has been extensively studied in deaf adults with neuroimaging studies, yielding valuable results. A recent study in our laboratory with deaf–blind children found evidence of cross-modal plasticity, revealed in over-representation of median nerve somatosensory evoked potentials (SEP N20) in left hemisphere parietal, temporal and occipital regions. This finding led to asking whether SEP N20 changes are peculiar to deaf–blindness or are also present in sighted deaf children.

OBJECTIVE Assess cross-modal plasticity in deaf child cochlear implant candidates using neurophysiological techniques (visual evoked potentials and median nerve somatosensory evoked potentials).

METHODS Participants were 14 prelingually deaf children assessed in the Cuban Cochlear Implant Program. Flash visual-evoked potentials and SEP N20 were recorded at 19 scalp recording sites. Topographic maps were obtained and compared to those of control group children with normal hearing. Analysis took into account duration of hearing loss.

RESULTS Topographic maps of flash visual-evoked potentials did not show changes in deaf child cochlear implant candidates. However, SEP N20 from right median nerve stimulation did show changes from expansion of cortical activation into the left temporal region in deaf children aged ≥7 years, which was interpreted as neurophysiological evidence of cross-modal plasticity, not previously described for this technique and type of somatosensory stimulus. We interpret this finding as due in part to duration of deafness, particularly related to handedness, since expansion was selective for the left hemisphere in the children, who were all right-handed.

CONCLUSIONS Cortical over-representation of SEP N20 in the left temporal region is interpreted as evidence of cross-modal plasticity that occurs if the deaf child does not receive a cochlear implant early in life—before concluding the critical period of neural development—and relies on sign language for communication.

KEYWORDS Neuroplasticity, somatosensory evoked potentials, visual evoked potentials, cochlear implants, deafness, prelingual deafness, hearing loss, sensorineural hearing loss, neurophysiology, Cuba

Diabetic foot ulcer is a principal diabetic complication. It has been shown that diabetic patients have decreased growth factor concentrations in their tissues, particularly epidermal growth factor. Growth factor shortage impairs wound healing, which leads to chronic nonhealing wounds and sometimes eventual amputation. Ischemic diabetic foot ulcer is the most difficult to treat and confers the highest amputation risk.

Injecting epidermal growth factor deep into the wound bottom and contours encourages a more effective pharmacodynamic response in terms of granulation tissue growth and wound closure. Epidermal growth factor injected into the ulcer matrix may also result in association with extracellular matrix proteins, thus enhancing cell proliferation and migration.

Heberprot-P is an innovative Cuban product containing recombinant human epidermal growth factor for peri- and intra-lesional infiltration; evidence reveals it accelerates healing of deep and complex ulcers, both ischemic and neuropathic, and reduces diabetes-related amputations.
Clinical trials of Heberprot-P in patients with diabetic foot ulcers have shown that repeated local infiltration of this product can enhance healing of chronic wounds safely and efficaciously. As a result, Heberprot-P was registered in Cuba in 2006, and in 2007 was included in the National Basic Medications List and approved for marketing. It has been registered in 15 other countries, enabling treatment of more than 100,000 patients.

Heberprot-P is a unique therapy for the most complicated and recalcitrant chronic wounds usually associated with high amputation risk. Local injection in complex diabetic wounds has demonstrated a favorable risk–benefit ratio by speeding healing, reducing recurrences and attenuating amputation risk. Further testing and deployment worldwide of Heberprot-P would provide an opportunity to assess the product’s potential to address an important unmet medical need.

KEYWORDS Diabetic foot ulcer, Heberprot-P, amputation, healing, unmet medical need, rhEGF, Cuba

In 2011 the Cuban health system began a process of sectoral reform to maintain and improve the health of Cuba’s population, in response to new challenges and demands in the health sector and population health status. The main actions involved are reorganization, consolidation and regionalization of services and resources. Although community engagement and personal responsibility are not explicitly mentioned in the strategy document, it is advisable to use this opportunity to revitalize both topics and encourage appropriate and full incorporation into the Cuban health system. Both are consistent with the objectives and actions of system reforms proposed, in that they allow the various social actors to assume shared responsibility in working toward social goals—in this case, health gains.

This approach also recognizes that reaching such goals is a collective endeavor, to be pursued according to ethical principles (beneficence as responsibility and justice as solidarity), with community involvement and personal responsibility emerging as two important factors subject to reorientation in the context of the health system reform under way.

KEYWORDS Community action, community participation, self care, self-management, social responsibility, health care reform, Cuba

Following 48 years of successful operation of the National Tuberculosis Control Program, Cuban health authorities have placed tuberculosis elimination on the agenda. To this end some tuberculosis control processes and their indicators need redesigned and new ones introduced, related to: number and proportion of suspected tuberculosis cases among vulnerable population groups; tuberculosis suspects with sputum microscopy and culture results useful for diagnosis (interpretable); and number of identified contacts of reported tuberculosis cases who were fully investigated. Such new indicators have been validated and successfully implemented in all provinces (2011–12) and are in the approval pipeline for generalized use in the National Tuberculosis Control Program. These indicators complement existing criteria for quality of case detection and support more comprehensive program performance assessment.

KEYWORDS Tuberculosis, detection, monitoring, surveillance, contact tracing, disease outbreaks, program evaluation, quality indicators, Cuba

One of the most common shortcomings in non-communicable disease risk factor surveillance, especially in prevalence studies, is sampling procedures, which can and do compromise accuracy and reliability of derived estimates. Moreover, sampling consumes significant time and resources. Since the early 1990s, risk factor surveys in Cienfuegos province, Cuba have paid particular attention to careful sampling methods. The new survey conducted in 2011 was not only statistically rigorous but introduced an innovative, more efficient method. This article provides a detailed description of the sample design employed to optimize resource use without compromising selection rigor.

KEYWORDS Sampling, descriptive studies, risk factors, non-communicable diseases, hypertension, Cuba

We describe the clinical impact of the RehaCom computerized cognitive training program instituted in the International Neurological Restoration Center for rehabilitation of brain injury patients. Fifty patients admitted from 2008 through 2010 were trained over 60 sessions. Attention and memory functions were assessed with a pre- and post-treatment design, using the Mini-Mental State Examination, Wechsler Memory Scale and Trail Making Test (Parts A and B). Negative effects were assessed, including mental fatigue, headache and eye irritation. The program’s clinical usefulness was confirmed, with 100% of patients showing improved performance in trained functions.

KEYWORDS Acute brain injuries; traumatic brain injury; brain injury, vascular; rehabilitation; intellectual disability; neuropsychology; Cuba

INTRODUCTION Acute myocardial infarction is one of the leading causes of death in the world. This is also true in Cuba, where no national-level epidemiologic studies of related mortality have been published in recent years.

OBJECTIVE Describe acute myocardial infarction mortality in Cuba from 1999 through 2008.

METHODS A descriptive study was conducted of persons aged ≥25 years with a diagnosis of acute myocardial infarction from 1999 through 2008. Data were obtained from the Ministry of Public Health’s National Statistics Division database for variables: age; sex; site (out of hospital, in hospital or in hospital emergency room) and location (jurisdiction) of death. Proportions, age- and sex-specific rates and age-standardized overall rates per 100,000 population were calculated and compared over time, using the two five-year time frames within the study period.

RESULTS A total of 145,808 persons who had suffered acute myocardial infarction were recorded, 75,512 of whom died, for a case-fatality rate of 51.8% (55.1% in 1999–2003 and 49.7% in 2004–2008). In the first five-year period, mortality was 98.9 per 100,000 population, falling to 81.8 per 100,000 in the second; most affected were people aged ≥75 years and men. Of Cuba’s 14 provinces and special municipality, Havana, Havana City and Camagüey provinces, and the Isle of Youth Special Municipality showed the highest mortality; Holguín, Ciego de Ávila and Granma provinces the lowest.
Out-of-hospital deaths accounted for the greatest proportion of deaths in both five-year periods (54.8% and 59.2% in 1999–2003 and 2004–2008, respectively).

CONCLUSIONS Although risk of death from acute myocardial infarction decreased through the study period, it remains a major health problem in Cuba. A national acute myocardial infarction case registry is needed. Also required is further research to help elucidate possible causes of Cuba’s high acute myocardial infarction mortality: cardiovascular risk studies, studies of out-of-hospital mortality and quality of care assessments for these patients.

KEYWORDS Acute myocardial infarction, ischemic heart disease, cardiovascular diseases, chronic disease, mortality, case-fatality, epidemiology, surveillance, registries, Cuba

He sips mate, the bitter brew of his native Uruguay as he converses at PAHO’s offices in Havana. Yet, he already feels at home here, says Dr Di Fabio, who took up his post in July of 2011. This is not surprising, since his connection to Cuban health care and research predates his arrival by two decades. In 1992–93, he worked on the Americas’ vaccine system (SIREVA) for PAHO and became involved in monitoring cooperation in vaccine regulatory issues, quality and production. From that period emerged one of Latin America’s great achievements: Vicente Vérez Bencomo’s development at the University of Havana of the world’s first Haemophilus influenzae type b (Hib) synthetic-antigen vaccine. Dr Di Fabio came to Cuba often to follow up on the vaccine’s regulatory process, production, and quality control for PAHO.

Later, he continued working on access to vaccine technology at PAHO headquarters in Washington, DC. It’s a journey that has taken him not only far from home, but also from his professional beginnings in Vancouver, Canada, as a PhD in organic chemistry. But it’s Dr Di Fabio’s “chemistry” with Cuba that is the subject of our conversation, his openness incongruent with the stiff antique furniture in his upstairs PAHO quarters—which nevertheless offer one of the best tree-top views of the Cuban capital.

AIDS is a major cause of death in the Caribbean, a region with a high prevalence of HIV. However, prevalence in Cuba’s population aged 15 to 49 years, despite a slight increase in recent years, is considered extremely low (0.1%). At the close of 2010, 5692 Cuban patients were receiving antiretroviral therapy. SIDATRAT, an informatics system, was developed at the Pedro Kourí Tropical Medicine Institute in Havana to ensure proper monitoring and followup of drug administration. Functioning on a web platform utilizing an Apache server, PHP and MySQL, it records patients’ general information, CD4 counts, viral load and data from other laboratory tests, as well as endoscopic and imaging studies. It also compiles information on their AIDS classification, opportunistic infections, HIV subtype and resistance studies, followup consultations, drug regimen, adverse reactions to medications, changes in drug combinations, and survival; and tracks total number of individuals under treatment. SIDATRAT follows the client-server philosophy and enables access by authorized users throughout Cuba via the health informatics network. SIDATRAT has been found effective in supporting quality care for persons living with HIV/AIDS and universal access to antiretroviral therapy, compiling most of the information needed for decisionmaking on patient health and therapies. SIDATRAT has been offered to the UNDP office in Havana for sharing with other developing countries that may wish to adapt or implement it.

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.

KEYWORDS Bioethics, leadership, medical education, health professional education, health, values, workplace stress, Cuba

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.

KEYWORDS Medical laboratory science, medical clinical science, medical education, curriculum, biological science disciplines, interdisciplinary communication, transfer of learning, Cuba