Evolución satisfactoria de un paciente adulto con malaria grave y complicada por Plasmodium falciparum / Satisfactory course of an adult patient with severe complicated Plasmodium falciparum malaria

Introducción: La malaria continúa siendo un importante problema de salud a nivel mundial, su diagnóstico temprano y tratamiento inmediato son fundamentales para prevenir las complicaciones y la muerte. Objetivo: Reportar el caso de un paciente cubano procedente de República de Guinea, que presentó malaria complicada por Plasmodium falciparum, el cual fue hospitalizado en el Instituto de Medicina Tropical Pedro Kourí (IPK). Caso clínico: Paciente masculino, cubano, de piel negra, 63 años de edad, profesión marinero mercante. Sin antecedentes patológicos personales. Llegó al IPK en camilla, con cierto deterioro de la conciencia, debilidad generalizada, dificultad respiratoria y compromiso del ritmo diurético. Ingresó en la Unidad de Cuidados Intensivos donde recibió tratamiento con los antipalúdicos artesunato y primaquina. La parasitemia fue descendiendo en el decursar de los días. El paciente sobrevivió y egresó satisfactoriamente a los 16 días posteriores a su ingreso. Fue debidamente notificado a las autoridades del Ministerio de Salud Pública de Cuba, lo que constituye un procedimiento obligatorio del Sistema Nacional de Vigilancia de Enfermedades Transmisibles en Cuba. Conclusión: La rapidez en el diagnóstico, así como el tratamiento integral, eficaz y oportuno, fue de importancia vital y condujo a un buen desenlace de la enfermedad.

Introduction: Malaria continues to be a major health problem worldwide, its early diagnosis and prompt treatment are critical to prevent complications and death. Objective: To report the case of a Cuban patient from the Republic of Guinea, who presented with complicated Plasmodium falciparum malaria, who was hospitalized at the Institute of Tropical Medicine Pedro Kourí (IPK). Clinical case: Male patient, Cuban, black-skinned, 63 years old, occupation: merchant seaman. No personal pathological history. He arrived at the IPK on a stretcher, with some deterioration of consciousness, generalized weakness, respiratory distress and diuretic rhythm compromise. He was admitted to the Intensive Care Unit where he received treatment with the antimalarial drugs artesunate and primaquine. Parasitemia decreased over the days. The patient survived and was discharged satisfactorily 16 days after admission. This case was duly notified to the authorities of the Ministry of Public Health of Cuba, which is a mandatory procedure of the National Surveillance System of Communicable Diseases in Cuba. Conclusion: Prompt diagnosis, as well as a comprehensive, effective, and timely treatment was vital and led to a good disease outcome.

Communication protocols evaluation for a wireless rainfall monitoring network in an urban area.

Rainfall monitoring networks are key elements for the development of alerts and prediction models for communities at risk of flooding during high intensity rainfall events. Currently, most of these networks send the precipitation measurement to a data center in real-time using wireless communication protocols, avoiding travel to the measurement site. An Early Warning System (EWS) for pluvial flash floods developed in Barranquilla (Colombia), used the GPRS protocol to send rain gauge data in real-time to a web server for further processing; however, this protocol has a high consumption of energy and also high maintenance costs. This article carried out an evaluation in terms of link budget, link profile, energy consumption and devices costs of three low-power wireless communication protocols, Zigbee, LoRaWAN and Sigfox, to determine which one is the most suitable for the EWS of the city of Barranquilla. To perform the evaluation, a wireless sensor network was designed and characterized for Zigbee and LoRaWAN with Radio Mobile tool taking into account the measurement points implemented with GPRS network. The evaluation included the power consumption of Zigbee, LoRaWAN and Sigfox. From the results of simulations, LoRaWAN and Zigbee network has similar radio signal received and the LoRaWAN network obtains the least losses per path. As for power consumption, the LoRaWAN devices has the lowest energy consumption, as well as, the LoRaWAN network sensor nodes are cheaper. Finally, the protocol with the best general performance was LoRAWAN, since complies with the communication, consumption and cost requirements.

COVID-19: presentación clínica en pacientes hospitalizados en el Instituto de Medicina Tropical "Pedro Kourí" / COVID-19: clinical presentation in patients admitted to Pedro Kourí Tropical Medicine Institute

. Introducción: Con los primeros casos de COVID-19 en Cuba era necesario el reconocimiento temprano de los pacientes con riesgo de evolucionar hacia formas graves de la enfermedad. Objetivo: Describir el comportamiento clínico de la COVID-19 en pacientes hospitalizados en el Instituto de Medicina Tropical "Pedro Kourí" e identificar factores asociados a la gravedad. Métodos: Se presentaron los primeros 73 casos de COVID-19 hospitalizados en el Instituto de Medicina Tropical Pedro Kourí desde el 11 de marzo al 5 mayo de 2020. Los pacientes se clasificaron en dos grupos: graves y con enfermedad ligera. Se compararon variables clínicas, demográficas, de laboratorio e imagenológicas en el momento del ingreso, y su posible asociación con la gravedad de la enfermedad. Resultados: Hubo siete pacientes graves (9,6 por ciento), cinco fallecieron. La edad > 60 años, tener más de una comorbilidad, hipertensión arterial y asma bronquial, fueron más frecuentes en pacientes graves. La fiebre más de seis días (p= 0,00), disnea (p= 0,00), presencia de estertores húmedos (p= 0,00), frecuencia respiratoria > 24/min (p= 0,00) y valores de linfocitos < 0,8 x109/L (p= 0,00), de ferritina > 500µg/L (p =0,00), proteína C reactiva ( 10μg/L (p= 0,01) y LDH ( 500 U/L (p= 0,01) se relacionaron con la gravedad. El 18,2 por ciento de las radiografías de tórax mostró alteraciones, con predominio de focos de condensación inflamatoria bilateral. Las complicaciones más frecuentes fueron: distrés respiratorio, choque, sepsis bacteriana y afecciones cardíacas. Conclusiones: Existen características clínicas y de laboratorio, identificables al ingreso, que están relacionadas con la gravedad de la enfermedad; lo que puede ser útil para la estratificación del riesgo y el manejo adecuado de los pacientes(AU)

Introduction: Upon appearance of the first COVID-19 cases in Cuba, early identification of patients at risk of developing severe forms of the disease became a necessity. Objective: Describe the clinical behavior of COVID-19 in patients admitted to Pedro Kourí Tropical Medicine Institute and identify factors associated to severity. Methods: A presentation was made of the first 73 COVID-19 cases admitted to Pedro Kourí Tropical Medicine Institute from 11 March to 5 May 2020. The patients were divided into two groups: severe and mild disease. A comparison was made of clinical, demographic, laboratory and imaging variables at admission, and their possible association to disease severity. Results: Seven patients (9.6%) were critically ill; five died. Age > 60 years, more than one comorbidity, arterial hypertension and bronchial asthma were more common among critical patients. Fever for more than six days (p= 0.00), dyspnea (p= 0.00), presence of humid stertors (p= 0.00), respiratory rate > 24/min (p= 0.00) and lymphocytes < 0.8 x109/l (p= 0.00), ferritin > 500 µg/L (p =0.00), C-reactive protein 10 μg/l (p= 0.01) and LDH 500 U/l (p= 0.01) were related to disease severity. 18.2 percent of the chest radiographs showed alterations, with a predominance of bilateral foci of inflammatory condensation. The most common complications were respiratory distress, shock, bacterial sepsis and heart disorders. Conclusions: Some clinical and laboratory characteristics identifiable at admission may be associated to disease severity, which makes them useful for risk stratification and the appropriate management of patients(AU)

Evaluación de resultados del tratamiento aplicado a adultos mayores con entidades del SOMA en Sala de Rehabilitación Integral / Evaluation of the results of the treatment applied to older adults with OMAS entities in the Comprehensive Rehabilitation Room

RESUMEN Introducción: el paciente anciano está expuesto a múltiples problemáticas con el envejecimiento que van a condicionar en gran manera su independencia y que de forma obligatoria hay que conocer y tratar de solucionar. Objetivo: evaluar el resultado del tratamiento aplicado a adultos mayores con entidades del sistema osteomioarticular en sala de rehabilitación integral. Materiales y Métodos: se realizó un estudio observacional, descriptivo, de tipo longitudinal de los todos los pacientes de 60 y más años, que acudieron al Centro de rehabilitación integral, quedando la muestra constituida por 920 pacientes tratados en el período comprendido entre enero y diciembre de 2007 con enfermedades del Soma. Resultados: predominó el sexo femenino (59 %) en el grupo de edades de 60 a 69 años (48%). Las afecciones ortopédicas fueron las más frecuentes con el 64 % y dentro de estas, la periartritis escapulo humeral. La electroterapia fue el tratamiento más utilizado (38,4%) de los casos. Dentro de los síntomas que presentaron estos pacientes el que más frecuente se encontró fue el de alteraciones en las funciones tanto al inicio y como posterior al tratamiento aplicado. El 93% de los pacientes resultaron rehabilitados, siendo el 86 % los evaluados de excelente al final de tratamiento aplicado. Conclusiones: los resultados en la atención al adulto mayor fueron excelentes en la gran mayoría de los casos con la aplicación del tratamiento rehabilitador (AU).

SUMMARY Introduction: the elder patient is exposed to multiple problems with ageing that will greatly condition their independence and that we will necessarily have to know and try to solve, using all the available resources within our reach. Objective: to assess the result of the treatment applied to older adults with entities of the osteomyoarticular system in the comprehensive rehabilitation room. Materials and methods: an observational, descriptive, longitudinal study of all the patients aged 60 years and over who attended the Comprehensive Rehabilitation Center was carried out, intentionally the sample stayed formed by 920 patients treated in the period between January and December 2007 with diseases of the OMAS. Results: female sex predominated (59%) in the age group of 60 to 69 years (48%). Orthopedic conditions were the most frequent with 64% and within these, scapular-humeral periarthritis. Electrotherapy was the most used treatment (38.4% of the cases). Among the symptoms that these patients presented, the most frequently found was alterations in functions both at the beginning and after the treatment applied. 93 % of the patients were rehabilitated, resulting outstanding 86 % of the assessed patients at the end pf the treatment. Conclusions: the results of elder people care was outstanding in most of the cases with the rehabilitative treatment application (AU).

Infecciones bacterianas y patógenos relacionados en pacientes cubanos con virus de inmunodeficiencia humana, Instituto de Medicina Tropical Pedro Kourí, 2014-2017 / Bacterial infections and related pathogens in Cuban patients with human immunodeficiency virus,Pedro Kourí Institute of Tropical Medicine, 2014-2017

Introducción: Las enfermedades bacterianas representan una de las causas más importantes de morbilidad y mortalidad en los pacientes infectados con el virus de la inmunodeficiencia humana (VIH). Ha este suceso se adicionan hoy las infecciones asociadas a los servicios sanitarios, escenario agravado por la aparición de bacterias con multirresistencia, las que impactan negativamente sobre la salud humana. Objetivo: Caracterizar las infecciones bacterianas en pacientes cubanos con el VIH, ingresados en el centro hospitalario del Instituto de Medicina Tropical Pedro Kourí, entre enero de 2014 y diciembre del 2017. Métodos: Se realizó un estudio de corte transversal con componente analítico cuyo universo estuvo constituido por 538 pacientes seropositivos en VIH-1 con diagnóstico de infección bacteriana documentada por aislamiento microbiológico. Resultados: Las infecciones bacterianas a nivel de vías respiratorias en pacientes con VIH y CD4 ≤ 200 cel/mm3 resultaron los eventos más frecuentes. Se demostró la mayor positividad en muestras de hemocultivo y esputos bacteriológicos 40,1 por ciento y 36,1 por ciento respectivamente. El 69,7por ciento de los aislamientos evidenciaron infección asociada a la asistencia sanitaria revelando asociación estadísticamente significativa con factores de riesgo seleccionados (estadías hospitalarias prolongadas y uso de dispositivos), además con la presencia de infección por bacterias gramnegativas y estafilococos coagulasa positivo. Conclusiones: Las infecciones bacterianas son frecuentes en pacientes VIH con inmunodepresión severa y su causa principal son las neumonías. Existe alta incidencia de infección asociada a la asistencia sanitaria, las que muestran asociación estadísticamente significativa con las estadías hospitalarias prolongadas y el uso de dispositivos, también revelan asociación con aislamientos de bacterias gramnegativas y estafilococos coagulasa positivo(AU)

Introduction: Bacterial diseases are one of the most important causes of morbidity and mortality in patients infected with human immunodeficiency virus (HIV). To this event are added nowadays infections associated with health services, a scenario aggravated by the emergence of bacteria with multi-resistance, which negatively impact human health. Objective: Characterize bacterial infections in Cuban HIV patients, admitted to the hospital center of Pedro Kourí Institute of Tropical Medicine between January 2014 and December 2017. Methods: A cross-sectional study with analytical component was conducted consisting of 538 HIV-1 positive patients diagnosed with bacterial infection detected by microbiological isolation. Results: Bacterial infections at the airway level in patients with HIV and CD4≤ 200cel/mm3 were the most common events. The highest positivity was demonstrated in samples of blood culture and bacteriological sputus with 40.1 percent and 36.1 percent, respectively. 69.7 percent of isolations showed healthcare-associated infection revealing statistically significant association with selected risk factors (prolonged hospital stays and devices use), as well as infection with gram-negative bacteria and coagulase-positive staph. Conclusions: Bacterial infections are common in HIV patients with severe immunosuppression and pneumonia is its main cause. There is a high incidence of healthcare-associated infection, which shows statistically significant association with prolonged hospital stays and devices use, also reveal association with isolations of gram-negative bacteria and coagulase-positive staph(AU)

Recuento histórico de la virtud curativa de las aguas minero-medicinales de San Miguel de los Baños / Historical review of the curative virtue of mineral-medicinal waters of San Miguel de los Baños

RESUMEN San Miguel de los Baños surgió y se desarrolló gracias a sus aguas mineromedicinales. Con el objetivo de determinar el origen, estudio y caracterización de estas se realiza revisión bibliográfica, mediante la consulta de bibliografías y documentos históricos recopilados; la información se buscó sin restricción de fecha de publicación, por descriptores, en bases de datos de la Biblioteca Virtual de Salud y por Google, en pos de hallar publicaciones, artículos y archivos que contuvieran en las palabras clave, determinándose que en los momentos fundacionales y durante el funcionamiento del balneario se realizaron estudios de caracterización, uso y terapéutica de las aguas provenientes de los manantiales: "El Tigre" y "La Salud"; desde 1962 no se brinda atención médica, desde 1984 a la fecha solo constan estudios geo- mineros, físico-químicos y bacteriológicos. La población local hace uso de estas aguas sin indicación, dosis y registro. No se han publicado estudios basados en la evidencia necesarios para la prescripción actual (AU).

Summary San Miguel de los Baños was founded and developed thanks to its mineral- medicinal waters. A bibliographic review was carried out with the objective of determining the origin, study and characterization of these waters consulting bibliography and historical documents, searching information without publishing date restriction, using descriptors in databases of the Virtual Health Library and Google for publications, articles and files having the used key words. The authors arrived to the conclusion that in the times of foundation and during the years of the spa functioning, there were carried out studies on characterization, use and therapeutic of the waters running from the springs "El Tigre" and "La Salud"; medical care is not provided since 1962; only geo-mining, physic-chemical and bacteriological studies were carried out from 1984 up to the date. Local population uses the waters without prescription, doses or recording. No evidence-based studies were published for their current prescription (AU).

Sepsis grave en la unidad de terapia intensiva del Instituto de Medicina Tropical Pedro Kourí / Severe sepsis in the intensive care unit of Pedro Kourí Tropical Medicine Institute

Introducción: La última década muestra aumento de la prevalencia de sepsis grave por microorganismos multidrogorresistentes, lo que representa una alerta para los gobiernos y sistemas de salud en el manejo de la multirresistencia. Objetivo: Identificar los microorganismos causantes de sepsis grave y sensibilidad a los antimicrobianos, así como relacionar los niveles de proteína C reactiva con la sepsis grave. Métodos: Estudio descriptivo de corte transversal que incluyó a 30 pacientes con diagnóstico de sepsis grave ingresados en la Unidad de Cuidados Intensivos del hospital del Instituto de Medicina Tropical Pedro Kourí durante el 2016. Resultados: Las neumonías fueron el foco primario dominante (43,3 por ciento), y las infecciones por gérmenes gramnegativos las más frecuentes. Los aislamientos microbiológicos (pseudomonas y acinetobacter baumannii) mostraron multidrogorresistencia que incluye a carbapenémicos y colistina, lo que sugiere utilización de forma indiscriminada y no justificada de antibióticos en pacientes inmunodeprimidos VIH. Se demostró asociación entre la infección por gérmenes gramnegativos y títulos elevados de proteína C reactiva con el desarrollo de sepsis grave y evolución desfavorable. El aumento de las supervivencias de los pacientes VIH con las terapias antirretrovilales, demostraron la predisposición de estos enfermos a infecciones por gérmenes multidrogorresistentes. Conclusiones: Los pacientes VIH tienen predisposición a infecciones por microorganismos multidrogorresistentes, la proteína C reactiva es útil como marcador de sepsis grave en estos enfermos. Estudios de este tipo demuestran a los sistemas de salud la necesidad trazar estrategias a corto plazo para el manejo de pacientes con VIH y sepsis grave por microorganismos multidrogorresistentes(AU)

Introduction: The last decade shows an increase in the prevalence of severe sepsis by multidrug resistant microorganisms which represent an alert for governments and health systems in relation with multiresistance management. Objective: To identify the microorganisms that cause severe sepsis and sensitivity to the antimicrobials, as well as to relate the levels of C-reactive protein with the severe sepsis. Methods: A descriptive, cross-sectional study was carried out involving 30 patients diagnosed with severe sepsis and admitted in 2016 to the Intensive Care Unit of the Hospital in Pedro Kourí Tropical Medicine Institute. Results: The prevalence of severe sepsis was 24.8 percent mainly in male patients (71.1 percent) and with ages from 41 to 50 years old (40.0 percent). Pneumonias were the predominant primary source (43.3 percent), and infections caused by negative Gram germs were the most frequent. Microbiological isolates (pseudomonas and acinetobacterbaumannii) showed multidrug resistance including carbapenems and colistin, which suggests an indiscriminate and non-justified use of antibiotics in HIV inmunodepressed patients. It was demonstrated a relation between infection by negative Gram germs and elevated levels of C-reactive protein with the development of severe sepsis and unfavorable evolution. The increasing survival rate in patients with HIV showed a predisposition of them to infections caused by multidrug resistant germs. Conclusions: HIV positive patients have a predisposition to infections caused by multidrug resistant microorganisms. C-reactive protein is useful as a marker of severe sepsis in this kind of patients. Studies of this type show to health systems the need to develop strategies in short term for managing HIV patients and the severe sepsis caused by multidrug resistant microorganisms(AU)

ACE, APOA5, and MTP Gene Polymorphisms Analysis in Relation to Triglyceride and Insulin Levels in Pediatric Patients.

BACKGROUND AND AIMS: Obesity is a complex, chronic, and multifactorial disease that has become a major, and worldwide, public health problem contributing to an increased number of pathologies, including type 2 diabetes, cardiovascular disease, hyperlipidemia, and metabolic syndrome, thus suggesting a commolon origin. A diet high in sugar and fats coupled with a sedentary lifestyle has a major role in the development of obesity. However, the genetic background has also been associated with body fat accumulation. The aim of this study was to assess the effect ofACE-rs4646994, APOA5-rs662799, and MTP-rs1800591 gene polymorphisms on clinical and biochemical parameters and to evaluate the association with body phenotypes in children and adolescent population of Saltillo, Coahuila, Mexico. METHODS: Anthropometric, clinical, biochemical parameters and BMI were obtained from 405 children and adolescents. The BMI was used to determine the body phenotype. The rs4646994 gene polymorphism was determined by PCR, whereas rs662799 and rs1800591 were determined by PCR-RFLP. The obtained results were analyzed to determine their association of these single nucleotide polymorphisms with body phenotype and biochemical parameters. RESULTS: TT genotype for APOA5-rs662799 was associated with increased levels of HDL-C in the analyzed population (p <0.05). The ACErs4646994gene polymorphism is associated with high Insulin levels, HOMAIR index, and triglyceride levels, mainly when presenting a I/I genotype (p <0.05). CONCLUSION: The polymorphic allele of the ACE gene is capable of modulating triglyceride levels, insulin levels and HOMA-IR index in the evaluated population; it must be highlighted that this has not been reported in other studied populations elsewhere.

HIV-1 Antiretroviral Resistance in Cuba, 2009-2014.

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. KEYWORDS Antiretroviral therapy, highly active antiretroviral therapy, HIV, anti-HIV agents, drug resistance, multiple drug resistance, Cuba.

Evaluación de la Calidad en Salud en la Medicina Familiar y en la Atención Primaria en Iberoamérica / Health Quality Assessment in Family Medicine and Primary Care in Ibero America / Avaliação da Qualidade em Saúde na Medicina de Familia e na Atenção Primária na Ibero-América

El propósito de este estudio es contribuir al desarrollo del concepto y de los procesos relacionados a la evaluación de la Calidad en la Atención Primaria de Salud, bajo la perspectiva de Médicos de Familia y Comunidad (MFyC). Fue basado en la lectura de textos, discusión en grupo de trabajo y en una investigación con la aplicación de una encuesta semi estructurada a MFyC y otros profesionales provenientes de 19 países. Fueran obtenidas informaciones acerca de los servicios de AP y de las percepciones de sus procesos evaluativos, incluyendo los relacionados a la educación permanente, a la motivación y la sobrecarga de trabajo. Los resultados sugieren que evaluar de forma sistemática y adecuada la calidad de la AP en Iberoamérica aún es un proceso muy incipiente. Además, excepto por algunos pocos países, ni siquiera existe una APS universal con MFyCs en los equipos de salud. Por otro lado, si consideramos los principios y las practicas de la MFyC, parece haber una limitación de los instrumentos utilizados para evaluar la calidad en AP. Se concluye que para alcanzar una evaluación de calidad que pueda ser propulsora de una mejora continua de los servicios en la AP es necesario incluir indicadores relacionados a los conceptos y herramientas de la MFyC. Un concepto de Calidad en AP es propuesto y se indica las dimensiones a ser incluidas en los procesos evaluativos, considerando las competencias de la MFyC

The purpose of this study is to contribute to the development of the concept and the assessment of Quality in Primary Care, under the perspective of Family and Community Medicine (FCM). The study was based on texts reading, discussion in a working-group, and a survey with the application of a semi-structured questionnaire to FCM and other professionals from 19 countries. Information about PC services, as well as the perception of its evaluation processes, including those related to permanent education, motivation and work overload was obtained. The results suggest that the quality assessment of PC in Iberoamerica is still a very incipient process. In addition, with the exception of a few countries, there is not even a universal PC with FCM in the health teams. Considering the principles and practices of the FCM, it seems that there is a limitation of the instruments commonly used to evaluate the quality in PC. It is concluded that to achieve a better quality assessment in order to conduct continuous improvements in the PC services, it is necessary to include indicators related to the concepts and tools of FCM. Considering the competences of the FCM, a quality concept in PC is proposed and dimensions to be included in the evaluation processes are indicated.

O objetivo deste estudo é contribuir para o aperfeiçoamento do conceito e dos processos relacionados à avaliação da qualidade na Atenção Primária à Saúde (APS), sob a perspectiva de Médicos de Família e Comunidade (FCM). O estudo foi realizado com base na leitura de textos, discussão em grupo de trabalho e uma pesquisa com a aplicação de um questionário semi-estruturado a MFC e outros profissionais provenientes de 19 países. Foram obtidas informações sobre os serviços de APS e das percepções sobre seus processos de avaliação, incluindo os relacionados à educação permanente, motivação e sobrecarga de trabalho. Os resultados sugerem que avaliar adequadamente e sistematicamente a qualidade da APS na Ibero-América ainda é processo muito incipiente. Além disso, com exceção de alguns países, não existe sequer uma APS universal com MFCs nas equipes de saúde. Por outro lado, se considerarmos os princípios e práticas de MFC parece ser uma limitação dos instrumentos utilizados para avaliar a qualidade em APS, Conclui-se que para alcançar uma avaliação de qualidade que possa ser condutora de uma melhoria contínua dos serviços de APS é necessário incluir indicadores relacionados aos conceitos e ferramentas da MFC. Um conceito de Qualidade na APS é proposto e são indicadas dimensões para ser incluídas nos processos de avaliação, considerando-se as competências da MFC.

Fatal Cryptococcus gattii genotype AFLP5 infection in an immunocompetent Cuban patient.

We describe the first clinical case of cryptococcosis due C. gattii in a Cuban immunocompetent patient who had a traveling history two years before to Central America. Molecular characterization of the isolate showed it to be genotype AFLP5 of which MLST sequences clustered with clinical and environmental strains from Colombia. The patient died one year after the diagnosis despite a prolonged treatment with (liposomal) amphotericin B, fluconazole, voriconazole and gamma interferon.

Enterococos: actualización / Enterococcus infection: Update

El enterococo emerge como una infección nosocomial en los últimos 10 años. Múltiples factores han favorecido este fenómeno, manifestándose como fundamentales la resistencia antimicrobiana y las malas prácticas clínicas. El presente artículo tiene como objetivo realizar una revisión documental del tema, para lo que tiene en cuenta elementos clínico-epidemiológicos y manejo de la infección.

Enterococcus infection emerges in the hospital environment as a nosocomial entity in the last 10 years. Multiple factors have favoured this phenomenon, mainly the antimicrobial resistance and bad clinical practices. The purpose of the present article is to carry out a documentary a taken into account. Review of the subject, for the clinical-epidemiological elements and of management of the infection.

Diseño de un instrumento para evaluar el nivel de conocimientos, sobre leptospirosis humana, en médicos de la atención primaria de salud / Design of a tool to assess the knowledge level on human leptospirosis in primary health care physicians

INTRODUCCION: el éxito en el tratamiento a un paciente con leptospirosis está vinculado con el diagnóstico temprano y oportuno de los casos. A pesar de que en Cuba esta enfermedad tiene un comportamiento endemo epidémico, deficiencias en el tratamiento clínico de algunos casos han influido en la mortalidad. MÉTODOS: se propone un instrumento diseñado y validado por consulta de expertos y evaluado a través de un estudio piloto desarrollado en las 7 áreas de salud de Boyeros, con el objetivo de evaluar el nivel de conocimientos sobre leptospirosis en médicos asistenciales de la atención primaria. RESULTADOS: el instrumento está compuesto por 3 acápites (datos generales, problemas de atención a pacientes, formas de actualización sobre el tema y evaluación de los conocimientos). A su vez, el acápite destinado a la exploración de conocimientos se subdivide en 3 secciones para explorar de forma independiente, elementos de tratamiento clínico, diagnóstico microbiológico y aspectos epidemiológicos de la enfermedad. Los items de cada acápite fueron conformados teniendo en cuenta las normas cubanas para la prevención y control de la leptospirosis, así como los lineamientos para el diagnóstico, vigilancia y control de la leptospirosis humana editado por la Organización Mundial de la Salud y la Sociedad Internacional de Leptospirosis. CONCLUSIONES: el uso de un instrumento estandarizado de este tipo permitirá evaluar el nivel de conocimiento de médicos asistenciales sobre esta zoonosis a nivel comunitario, y contribuir así a trazar estrategias locales y regionales que impacten contra la letalidad causada por esta enfermedad

INTRODUCTION: the treatment success in a patient presenting leptospirosis is linked to the early and timely diagnosis of cases. Despite that in Cuba this disease has an endemic-epidemic behavior, deficiencies in clinical treatment of some cases has influenced on the mortality. METHODS: a tool designed and validated by expert consultation and assessed thorough a pilot study conducted in the 7 health areas of Boyeros municipality to assess the knowledge level of primary care assistant physicians on the leptospirosis. RESULTS: the tool includes three items (general data, patient care problems, updating ways on this subject and knowledges assessment). At the same time, the paragraph aimed to knowledges exploration is subdivided into 3 sections to explore in a independent way the clinical treatment elements, microbiologic diagnosis and epidemiologic features of disease. The items of each paragraph were adapted considering the Cuban guidelines to prevention and control of leptospirosis, as well as the lineaments for diagnosis, surveillance and control of the human leptospirosis published by WHO and the International Society of Leptospirosis. CONCLUSIONS: the use of a standardized tool of this type will allow to assess the knowledge level of assistant physicians on this community level zoonosis and thus to contribute to design local and regional hard-hitting strategies on lethality caused by this entity

Diagnóstico de Mycoplasma hominis, Ureaplasma parvum y Ureaplasma urealyticum en pacientes con vaginosis bacteriana / Diagnosis of Mycoplasma hominis, Ureaplasma parvum y Ureaplasma urealyticum in patients with bacterial vaginosis

Se realizó un estudio observacional descriptivo, para determinar la frecuencia de aislamientos de Mycoplasma hominis, Ureaplasma parvum y Ureaplasma urealyticum en pacientes con vaginosis bacteriana, donde se incluyeron 296 pacientes con secreción vaginal, atendidas en consultas médicas en 2 hospitales. El diagnóstico se llevó a cabo según los criterios Amsel, y a las mujeres positivas a esta enfermedad se les tomó muestra de exudado endocervical para el diagnóstico por métodos convencionales para M. hominis y Ureaplasma spp. Por la reacción en cadena de la polimerasa se identificaron U. parvum y U. urealyticum. Se diagnosticó vaginosis bacteriana en 30,1 por ciento de las pacientes, y en 77,5 por ciento se detectó la presencia de los micoplasmas urogenitales estudiados. M. hominis fue la especie más frecuente encontrada (71 por ciento), mientras que U. parvum y U. urealyticum se identificaron en 23,2 y 5,8 por ciento, respectivamente. En las mujeres con vaginosis bacteriana se debe realizar el diagnóstico de micoplasmas y ureaplasmas, lo que permitiría instaurar un adecuado control terapéutico, y ayudaría a evitar futuras enfermedades en el tracto genital.

An observational descriptive study to determine the frequency of Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum isolates in patients with bacterial vaginosis was carried out in 296 patients who had vaginal secretion and were seen at two hospitals. The diagnosis was based on Amsel´s criteria. Endocervical swabs were taken from women positive to this disease for M. hominis and Ureaplasma spp. diagnosis by traditional methods. Polymerase chain reaction identified U. parvum and U. urealyticum. Bacterial vaginosis was diagnosed in 30.1 percent of females, and in 77.5 percent of them the studied urogenital mycoplasmas were present. M. hominis was the most common species (71 percent) whereas U. parvum and Urealyticum were detected in 23.2 percent and 5.8 percent of cases respectively. The diagnosis of Mycoplasmas and ureaplasmas should be performed in females with bacterial vaginosis, which will allow applying adequate therapeutic control and avoiding future pathologies in the genital tract.

[Diagnosis of Mycoplasma hominis, Ureaplasma parvum y Ureaplasma urealyticum in patients with bacterial vaginosis]. / Diagnóstico de Mycoplasma hominis, Ureaplasma parvum y Ureaplasma urealyticum en pacientes con vaginosis bacteriana.

An observational descriptive study to determine the frequency of Mycoplasma hominis, Ureaplasma parvum and Ureaplasma urealyticum isolates in patients with bacterial vaginosis was carried out in 296 patients who had vaginal secretion and were seen at two hospitals. The diagnosis was based on Amsel's criteria. Endocervical swabs were taken from women positive to this disease for M. hominis and Ureaplasma spp. diagnosis by traditional methods. Polymerase chain reaction identified U. parvum and U. urealyticum. Bacterial vaginosis was diagnosed in 30.1% of females, and in 77.5% of them the studied urogenital mycoplasmas were present. M. hominis was the most common species (71%) whereas U. parvum and Urealyticum were detected in 23.2 % and 5.8% of cases respectively. The diagnosis of Mycoplasmas and ureaplasmas should be performed in females with bacterial vaginosis, which will allow applying adequate therapeutic control and avoiding future pathologies in the genital tract.

Comportamiento de linfoma relacionado con VIH/SIDA en el Instituto Pedro Kourí: 2004-2005 / Behaviour of HIV/AIDS-related lymphoma in Pedro Kourí Institute. 2004-2005

Se realizó un estudio descriptivo prospectivo en 20 pacientes infectados por el virus de la inmunodeficiencia humana (VIH) ingresados en el Instituto Pedro Kourí con diagnóstico de linfoma. Se evaluaron todos los pacientes al inicio del diagnóstico mediante una exhaustiva historia clínica y estudios complementarios como: hemograma completo, velocidad de sedimentación globular, conteo de linfocitos T CD4+, deshidrogenasa láctica, carga viral para VIH, citología y biopsia. De los pacientes, 85 por ciento presentaba conteo de CD4+ por debajo de 350 células/mm3 en el momento del diagnóstico, sin embargo, solo 55 por ciento ofrecía cargas virales por encima de 50 000 copiasp/mL. Histológicamente el subtipo que predominó fue el de células grandes difusas y la localización más frecuente extraganglionar en 70 por ciento de los casos. Llamó la atención la asociación existente entre niveles elevados de deshidrogenasa láctica y localización extranodal del tumor. Se encontró relación estadísticamente significativa (p< 0,05) entre el estado de inmunodepresión dado por valores de CD4+ inferiores a 350 células/mm3 y estadios avanzados (estadios III y IV) de la enfermedad tumoral.

[Behaviour of HIV/AIDS-related lymphoma in Pedro Kouri Institute. 2004-2005]. / Comportamiento de linfoma relacionado con VIH/SIDA en el Instituto "Pedro Kourí". 2004-2005.

A prospective and descriptive study of 20 patients infected with HIV and admitted to "Pedro Kouri" Institute of Tropical Disease after a diagnosis of lymphoma was conducted. They were all evaluated at the onset of diagnosis by a thorough medical record exam and supportive studies such as complete blood count, globular sedimentation speed, CD4+ count, lactic acid dehydrogenase, HIV viral load, cytology and biopsy. Of this number, 85% presented with CD4+ count under 350 cell/mm3 at the time of diagnosis; however, only 55% showed viral loads exceeding 50,000 copies/mL. The predominant histological subtype was large diffuse cells and the most frequent location was the extrapulmonary site in 70% of cases. It called our attention that high levels of lactic acid dehydrogenase and extrapulmonary location of tumors were related. Statistically significant association was found (p < 0.05) between immunosuppresion condition of the patients given by CD4+ count below 350 cell/mm3 and advanced staging of the tumoral disease (stages III and IV).

La formación del psicólogo y su papel en la atención primaria a la salud / Education of psychologists and its role in primary health care

En este trabajo se analiza el concepto integral de salud y se plantea la necesidad de ensayar esquemas complementarios de atención a la salud para contribuir a disminuir la brecha de polarización epidemiológica, proponiendo la atención primaria a la salud como una estrategia primordial. Asimismo, se destaca la importancia de que, a través del sistema de salud, se practique una atención basada en el cuidado de las poblaciones. Se proponen alternativas a fin de estabilizar el estado de salud de la población, entre las que destacan la formación de recursos humanos con un enfoque preventivo, además de curativo. Se destaca el papel del psicólogo como miembro importante y desaprovechado del equipo de salud, y, por último, se presenta el programa de la Maestría en Salud Mental en Poblaciones y Residencia de Psicología en Atención Integral a la Salud, como una opción para contribuir a las propuestas anteriores

This paper takes as its basis the concept of comprehensive health care. The need to try out complementary approaches to health care is emphasized in order to ameliorate the effects of the epidemiological transition. The approach of Primary Health Care as a basic strategy is also presented. The importance of applying health system population approach to health care is also analyzed. A number of health care alternatives are presented in order to stabilize the health of a community. Within these alternatives the training of human resources with a focus on prevention as well as the curative approach are presented. The role that the psychologist plays within the comprehensive health care is also described. Also the authors describe an innovative training program directed to Psychologists at this stage, that integrates a Master on Public Health with emphasis in mental health with a residence program in Comprehensive Health Care as an option to contribute to replicate the alternatives of care presented in the paper. Finally, the programs and their advances are presented.