HIV/AIDS infection in critical care: epidemiological profile and risk factors for mortality in a Colombian cohort.

INTRODUCTION: Outcomes of human immunodeficiency virus (HIV) infected patients admitted to intensive care units (ICU) have improved with antiretroviral therapy (ART). However, whether the outcomes have improved in low- and middle-income countries, paralleling those of high-income countries is unknown. The objective of this study was to describe a cohort of HIV-infected patients admitted to ICU in a middle-income country and identify the risk factors associated with mortality. METHODOLOGY: A cohort study of HIV-infected patients admitted to five ICUs in Medellín, Colombia, between 2009 and 2014 was done. The association of demographic, clinical and laboratory variables with mortality was analyzed using a Poisson regression model with random effects. RESULTS: During this time period, 472 admissions of 453 HIV-infected patients were included. Indications for ICU admission were: respiratory failure (57%), sepsis/septic shock (30%) and central nervous system (CNS) compromise (27%). Opportunistic infections (OI) explained 80% of ICU admissions. Mortality rate was 49%. Factors associated with mortality included hematological malignancies, CNS compromise, respiratory failure, and APACHE II score ≥ 20. CONCLUSIONS: Despite advances in HIV care in the ART era, half of HIV-infected patients admitted to the ICU died. This elevated mortality was associated to underlying disease severity (respiratory failure and APACHE II score ≥ 20), and host conditions (hematological malignancies, admission for CNS compromise). Despite the high prevalence of OIs in this cohort, mortality was not directly associated to OIs.

Linfadenitis cervical por Salmonella no Typhi en una paciente diabética / Cervical lymphadenitis caused by no typhoid Salmonella in a diabetic patient

Resumen La infección por Salmonella no Typhi es una de las enfermedades transmitidas por alimentos más común y ampliamente extendida en el mundo. Aunque la mayoría de los casos se limitan al tracto gastrointestinal, el compromiso extraintestinal no es infrecuente. Sin embargo, la adenitis como manifestación aislada, es una forma inusual de presentación de la enfermedad. Comunicamos el caso clínico de una mujer de 67 años de edad con diagnóstico de diabetes mellitus y una linfadenitis cervical por Salmonella no Typhi tratada con ciprofloxacina y y que requirió resección quirúrgica.

No Typhoid Salmonella infection is one of the most common and widely spread foodborne diseases worldwide. Although most cases are limited to the gastrointestinal tract, extraintestinal involvement is not uncommon. However, adenitis as an isolated manifestation, is an unusual form of the disease. We report a case of Salmonella no Typhoid cervical lymphadenitis in a 67-year-old female with a recent diagnosis of diabetes mellitus, who was treated with surgery and ciprofloxacin.

[Cervical lymphadenitis caused by no typhoid Salmonella in a diabetic patient]. / Linfadenitis cervical por Salmonella no Typhi en una paciente diabética.

No Typhoid Salmonella infection is one of the most common and widely spread foodborne diseases worldwide. Although most cases are limited to the gastrointestinal tract, extraintestinal involvement is not uncommon. However, adenitis as an isolated manifestation, is an unusual form of the disease. We report a case of Salmonella no Typhoid cervical lymphadenitis in a 67-year-old female with a recent diagnosis of diabetes mellitus, who was treated with surgery and ciprofloxacin.

Malignant Transformation of Hymenolepis nana in a Human Host.

Neoplasms occur naturally in invertebrates but are not known to develop in tapeworms. We observed nests of monomorphic, undifferentiated cells in samples from lymph-node and lung biopsies in a man infected with the human immunodeficiency virus (HIV). The morphologic features and invasive behavior of the cells were characteristic of cancer, but their small size suggested a nonhuman origin. A polymerase-chain-reaction (PCR) assay targeting eukaryotes identified Hymenolepis nana DNA. Although the cells were unrecognizable as tapeworm tissue, immunohistochemical staining and probe hybridization labeled the cells in situ. Comparative deep sequencing identified H. nana structural genomic variants that are compatible with mutations described in cancer. Invasion of human tissue by abnormal, proliferating, genetically altered tapeworm cells is a novel disease mechanism that links infection and cancer.

Long-term/bioinert labeling of rat mesenchymal stem cells with PVA-Gd conjugates and MRI monitoring of the labeled cell survival after intramuscular transplantation.

Noninvasive in vivo imaging of transplanted stem cells is an effective method to clarify the mechanisms involved in stem cell transplantation therapy. We labeled rat mesenchymal stem cells (MSCs) with water-soluble magnetic resonance imaging (MRI) contrast agent poly(vinyl alcohol)-gadolinium (PVA-Gd) in order to ascertain the fate of transplanted MSCs in vivo. PVA-Gd was retained and localized in the cytosolic compartment of MSCs for a longer period of time. The effect of PVA-Gd labeling on MSC proliferation was much less than that of the commercially available contrast agent ProHance, and the labeled MSCs were found to have osteoblastic differentiation ability. To study the MSC lifetime in vivo, MSCs were seeded and trapped in the cytocompatible three-dimensional porous scaffolds of Spongel and transplanted. The MRI signal attributed to MSCs was eliminated from the transplanted site in 14 days. Because free PVA-Gd was rapidly eliminated from the site, this signal reduction indicated MSC death in the transplantation site. The low efficiency of MSC transplantation for ischemic tissue may be due to their short lifetime, making it important to develop highly effective stem cell transplantation systems that address cell number, injection position, and cell formulation (suspension, sheet, and aggregates). Our cell survival tracking system would be a very powerful tool to this end and would be applicable in clinical cell therapies.

Magnetic resonance imaging detection of an uncommon granuloma formation after endothelial progenitor cells transplantation.

Magnetic resonance imaging (MRI) has been recognized as a non-invasive technique for visualizing the ultrastructure of a tissue at high resolution. The work reported here showed the utility of MRI for visualizing the fate of EPCs, and demonstrate how it can be used to further our understanding of angiogenesis mechanisms.The recently developed contrast agent dextran mono-N-succinimidyl 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate-gadolinium³âº (Dex-DOTA-Gd³âº) was used to label endothelial progenitor cells (EPCs). The faith of the transplanted labeled cells in the rat models of ischemic hind limbs was studied by images obtained by MRI.The pattern of migration of Dex-DOTA-Gd³âº-labeled EPCs could be observed and tracked by MRI for a long time and analyzed the change in the migration of the labeled cells. The ability of Dex-DOTA-Gd³âº to provide a clear pattern of cell migration to the limb was confirmed and most importantly, a different behavioral pattern was identified in the migration of labeled cells when an anomaly appeared in the MRI acquisition images 5 days post transplantation.

The use of magnetic resonance cell tracking to monitor endothelial progenitor cells in a rat hindlimb ischemic model.

A water-soluble magnetic resonance imaging (MRI) contrast agent, Dextran mono-N-succinimidyl 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate-gadolinium(3+) (Dex-DOTA-Gd(3+)), was shown to enable monitoring of the anatomical migration and the survival period of transplanted stem cells for up to 1 month. Gadolinium molecules in the cells were rapidly eliminated from the site and excreted upon cell death. Endothelial progenitor cells (EPCs) transplanted into the inguinal femoral muscle of rats migrated distally through the knee in rats after hindlimb ischemia but did not migrate in non-ischemic rats. Interestingly, the survival period of transplanted EPCs was notably prolonged in the ischemic limb, indicating that EPCs are required by the ischemic tissues and that the fate of transplanted EPCs was affected by the disease. Compared to the commonly used particle type of MRI contrast agents, the system described in this study is expected to be invaluable to help clarifying the process of stem cell transplantation therapy.

Percepción de competencias en epidemiología en México y Colombia durante la epidemia de influenza A (H1N1) entre estudiantes de salud pública / Perception of epidemiological competencies by public health students in Mexico and Colombia during the influenza A (H1N1) epidemic

OBJETIVO: Conocer la percepción que los estudiantes de salud pública en México y en Colombia tuvieron sobre el manejo de la epidemia de influenza A (H1N1), como una forma para indagar qué contenidos curriculares pueden ser mejorados en la formación en epidemiología. MÉTODOS: Encuesta durante la epidemia, entre junio y agosto de 2009, a estudiantes de posgrado. Se evaluaron las 30 competencias epidemiológicas del Council of State and Territorial Epidemiologists para "epidemiólogos intermedios". Se describieron los resultados estratificando por covariables, y se identificaron las competencias con menor desarrollo mediante análisis factorial exploratorio. RESULTADOS: Participaron 154 estudiantes, de los cuales 55,8 por ciento estaban en México. Se observaron diferencias importantes en el perfil de los estudiantes de ambos países, lo cual explica parcialmente la percepción de respuesta a la epidemia. En el análisis factorial el primer factor, que explica 21,5 por ciento de la varianza, presentó menores puntajes y se asoció con competencias relacionadas con el vínculo entre el personal sanitario y la comunidad, donde resultan relevantes conocimientos de ciencias sociales y habilidades de comunicación. CONCLUSIONES: Los estudiantes percibieron que la respuesta frente a la epidemia podría haber sido mejor. Se sugiere incorporar en la educación de los recursos humanos en salud pública temáticas sobre cultura y sus efectos sobre conductas y pensamientos, el reconocimiento de los prejuicios de los expertos, la comunicación efectiva con las comunidades, y la habilidad para adaptarse ante nuevas situaciones. El "experimento natural" de la epidemia facilitó la identificación de áreas de oportunidad para mejorar la enseñanza de la epidemiología ante contingencias sanitarias.

OBJECTIVE: Learn about the perception of public health students in Mexico and Colombia regarding the management of the influenza A (H1N1) epidemic to determine which curriculum contents in epidemiological education can be improved. METHODS: Survey administered to graduate students during the epidemic, from June to August 2009. The 30 epidemiological competencies for "intermediate epidemiologists" of the Council of State and Territorial Epidemiologists were evaluated. The results were described through stratification by covariables, and the less developed competencies were identified through exploratory factor analysis. RESULTS: A total of 154 students participated, 55.8 percent of whom were in Mexico. Significant differences in the student profile from each country were observed, which partially explains the perception of response to the epidemic. The first factor, which explains 21.5 percent of the variance, had lower scores in the factor analysis. This factor was associated with competencies related to the links between health personnel and the community, in which knowledge of the social sciences and communication skills are relevant. CONCLUSIONS: The students perceived that the response to the epidemic could have been better. It is suggested that public health human resources education include subjects related to the impact of culture on behavior and thinking, recognition of the prejudices of experts, effective community-level communication, and the ability to adapt to new situations. The "natural experiment" of the epidemic facilitated the identification of areas of opportunity to improve the teaching of epidemiology to health personnel.

Long-term in vivo magnetic resonance imaging tracking of endothelial progenitor cells transplanted in rat ischemic limbs and their angiogenic potential.

Stem cell therapy has been used to repair ischemic tissues in the limbs, in myocardial infarctions, and in the brain. To understand the mechanisms of healing, a contrast agent capable of inducing sufficient magnetic resonance (MR) contrast would be useful in providing fundamental information about the cell migration and incorporation into the ischemic tissue. A magnetic resonance imaging contrast agent composed of dextran and gadolinium chelate was synthesized. Hydroxyl groups of dextran were activated with 1,1'-carbonylbis-1H-imidazole and reacted with propanediamine to obtain aminated dextran. This modified polymer was then reacted with mono-N-succinimidyl 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate, then with fluorescein isothiocyanate, and finally reacted with gadolinium chloride solution (Dex-DOTA-Gd3(+)). Endothelial progenitor cells (EPCs) were selected as a stem cell model for magnetic resonance imaging tracking. Cells were isolated from the bone marrow harvested from the femurs and tibias of rats. Dex-DOTA-Gd3(+) was then introduced into the EPCs by electroporation. The intracellular stability and cytotoxicity of Dex-DOTA-Gd3(+) were evaluated in vitro. Dex-DOTA-Gd3(+)-labeled EPCs were transplanted into a rat model of ischemic limb, and MR images were acquired. Dex-DOTA-Gd3(+) was found to efficiently label EPCs over a long duration without significant cytotoxicity. This provides an MR signal sufficient for tracking the EPCs intramuscularly injected into the limb.

Adrenal function status in patients with paracoccidioidomycosis after prolonged post-therapy follow-up.

This study assessed adrenal function in patients with paracoccididioidomycosis who had been treated to determine a possible connection between high antibody titers and adrenal dysfunction attributable to persistence of the fungus in adrenal gland. Adrenal gland function was studied in 28 previously treated patients, 2 (7.1%) of whom were shown to have adrenal insufficiency and 7 (259%) who showed a below normal response to stimuli by adrenocorticotropic hormone. Paracoccidioides brasiliensis was detected in the adrenal gland from one of the patients with adrenal insufficiency. Although the study failed to demonstrate a significant difference between high antibody titers and low cortisol levels, the proportion of adrenal insufficiency detected and the subnormal response to adrenocorticotropic hormone confirmed that adrenal damage is an important sequela of paracoccidioidomycosis. Studies with a larger number of patients should be conducted to confirm the hypothesis of persistence of P. brasiliensis in adrenal gland after therapy.

Evaluación del proceso de priorización en salud en Colombia: perspectiva de grupos de investigación ubicados en Bogotá / Evaluating how health is prioritised in Colombia from the point of view of Bogotá-based research groups

Objetivo Evaluar el proceso de priorización de investigaciones en salud llevado a cabo en el país a partir de las metodologías internacionales y desde la perspectiva de los grupos de investigación en salud, categoría A, ubicados en Bogotá. Métodos: A partir de un enfoque cualitativo, se realizaron 14 entrevistas semies­tructuradas a líderes de los grupos seleccionados a través de una muestra propositiva. Con el programa de análisis de información cualitativa Atlas Ti se generaron categorías para comparación. Resultados Cada grupo posee diferentes experiencias en investigación en el campo de la salud. Algunos manifestaron sus propias concepciones sobre la salud y sobre la priorización a partir de sus marcos epistemológicos. Diferentes líderes de los grupos expresaron que hay una fuerte orientación biomédica en los procesos de priorización y de las metodologías utilizadas para tal fin. Un número importante de ellos ha reconocido la importancia de la participación de otros actores sociales en la definición de las prioridades para la investigación en salud, además de los mismos investigadores, dentro de un escenario de dialogo y de concertación. Por último, los líderes entrevistados plantearon algunos cuestionamientos frente a la definición de prioridades y sugirieron la importancia de fomentar un proceso más participativo e incluyente comenzando por los mismos investigadores en salud. Discusión Los hallazgos muestran la enorme heterogeneidad de posiciones frente a la temática de la priorización de investigaciones en salud y las dificultades para alcanzar consensos entre los mismos investigadores.

Objective Assessing how priorities are established in Colombia in line with international methodologies and from the perspective of Bogotá-based Category A health research groups. Methods This study used a qualitative approach; 14 leaders from groups selected via a propositive sample were given semi-structured interviews to obtain a compre­hensive interpretation of priority-setting in Colombia. ATLAS Ti software was used for organising information and producing categories from transcripts. Results Each group had a different research background and came from health research areas such as basic science, clinical science and the wide field of public health. Some talked about their own definitions of health and establishing priorities as related to their own epistemological frameworks. Other leaders stressed that a bio­medical approach still predominated in health research, priority-setting and the inter­national methodologies used for such end. Many recognised the importance of differ­ent social actors (i.e. apart from researchers) becoming involved in defining health research priorities within a scenario emphasising dialogue and coming to agreement. The leaders criticised the national health science and technology system raising questions regarding defining priorities; they stated that dialogue and involvement must be promoted. Discussion These findings revealed enormous heterogeneity regarding prioritising health research as every researcher has a different point of view due to their experi­ence and backgrounds and the difficulties in researchers' reaching consensus.

Escritura, comunicación científica y acceso abierto: un proyecto internacional y multidisciplinario-NECOBELAC / Scientific writing, scientific communication and open access: an international, multidisciplinary project NECOBELAC

Una red de colaboración entre seis países de Europa, América latina y El Caribe ha iniciado un proyecto para mejorar la comunicación y la diseminación científica en salud pública. El proyecto apunta a fomentar la comunicación científica en aspectos de valor actual y futuro como son la escritura científica y el acceso abierto a la información en salud. El proyecto NECOBELAC (www.necobelac.eu) es auspiciado por la Comunidad Europea (7th Framework Programme) y tiene una duración de tres años. Como un reto, el proyecto reconoce las diferencias socio culturales entre los países que participan y se ocupará de generar redes de instituciones en colaboración estrecha para realizar programas de entrenamiento e intercambio de saberes en producción de información y difusión (incluyendo los aspectos técnicos y éticos). El proyecto NECOBELAC incluye al Istituto Superiore di Sanità (ISS) de Italia, coordinador del mismo, el Consejo Superior de Investigaciones Científicas (CSIC) de España, la Universidad de Nottingham (SHERPA) del Reino Unido, BIREME de Brasil, el Instituto de Salud Pública (ISP) de Colombia y la Universidade de Minho, de Portugal.

A collaboration network involving 6 countries in Europe, Latin-America and the Caribbean has embarked on a project (Network of Collaboration Between Europe and Latin American Caribbean Countries-NECOBELAC; www.necobelac.eu) aimed at improving scientific writing open access and scholarly communication to spread know-how regarding current and future issues and information related to health. The NECOBELAC project is sponsored by the European Community (7th Framework Programme) and will last for 3 years. The project recognises the challenge arising from socio-cultural differences between the participating countries and will deal with generating networks involving institutions working in close collaboration for carrying out training and know-how exchange programmes aimed at producing open access information and spreading it (including technical and ethical aspects). The NECOBELAC project currently involves the Istituto Superiore di Sanità - ISS from Italy (coordinating the project), the Consejo Superior de Investigaciones Científicas (CSIC) from Spain, the University of Nottingham (SHERPA) from the United Kingdom, BIREME from Brazil, the Instituto de Salud Pública (ISP) from Colombia and the Universidade de Minho from Portugal.

Co-existence of integumentary lesions and lung x-ray abnormalities in patients with paracoccidioidomycosis (PCM).

In paracoccidioidomycosis (PCM), the primary lung infection remains silent. In this study, attempts were done to define the primary target organ by correlating lung radiographic abnormalities with the time course of mucosal/skin lesions concurrently exhibited at diagnosis by 63 patients in whom microscopy and/or isolation of Paracoccidioides brasiliensis from respiratory secretions had been positive. Mucosal and skin lesions were found in 65.1% and 12.7% of the patients, respectively. Odynophagia and dysphagia were present in 38.1% each. All patients had lung interstitial infiltrates, and 31.7% had also alveolar lesions; fibrosis was recorded in 46% of them. An inverse correlation was shown for fibrosis and presence of either odynophagia or dysphagia. Cluster analyzes strongly supported two sets of patients: those with mucosal damage, odynophagia/dysphagia, and alveolo-interstitial infiltrates and those with dermal lesions, dyspnea, and lung fibrosis. These groups may represent novel stages in the natural course of PCM.

Pulmonary paracoccidioidomycosis.

Paracoccidioidomycosis (formerly known as South American blastomycosis) is produced by the thermally dimorphic fungus Paracoccidioides brasiliensis. Most often this mycosis runs a chronic progressive course affecting preferentially the lungs followed by the skin, mucous membranes, adrenals, and reticuloendothelial organs. Acute-subacute presentations can be observed in children and immunosuppressed patients. Occasionally, self-limited infections have been documented. Two types of clinical presentations are described, the acute-subacute (juvenile) and the chronic (adult) forms of the disease. Paracoccidioidomycosis predominates in adult males (13:1); this gender difference is not observed in children or adolescents. The mycosis is limited geographically to various Latin American countries, with the greatest number of cases originating in Brazil, The fungus's natural habitat has not been precisely defined, although it is supposed to be a soil-inhabiting microorganism. No outbreaks have been reported. P. brasiliensis is capable of entering into prolonged periods of latency as is demonstrated by its diagnosis in patients who have moved outside the recognized endemic areas. This review updates clinicians and laboratory workers on the characteristics of a mycosis seldom reported outside of the Latin American countries.

Integración regional andina en salud / Health in Andean regional integration

Despite their shared history, the Andean countries are socially and politically diverse, with heterogeneous health realities and complex integration processes. General developments such as the Latin American Free Trade Association and Latin American Integration Association have existed for decades, along with others of a regional scope, like the Andean Community of Nations, Caribbean Community, and Central American Common Market. The health field has a specific instrument in the Andean Region called the Hipólito Unánue Agreement, created in 1971. Integration processes have concentrated on economic aspects, based on preferential customs agreements that have led to an important long-term increase in trade. Less progress has been made in the field of health in terms of sharing national experiences, knowledge, and capabilities. Analysis of experiences in health has shown that integration depends on the countries' respective strengths and to a major extent on national political processes.

A pesar su historia compartida, los países de la Región Andina presentan una diversidad social y política que genera realidades sanitarias heterogéneas y procesos de integración complejos. Se han dado por décadas procesos generales, como la Asociación Latinoamericana de Libre Comercio y la Asociación Latinoamericana de Integración, o de alcance regional como la Comunidad Andina de Naciones, la Comunidad del Caribe y el Mercado Común Centroamericano. En el campo específico de la salud se cuenta con un instrumento en la Región Andina, el Convenio Hipólito Unánue, creado en 1971. Estos procesos de integración se han concentrado en los aspectos económicos, con base en acuerdos de preferencias arancelarias, los cuales han generado, en el largo plazo, un intercambio comercial apreciable. En el campo de la salud se ha avanzado menos, en términos de procesos que ponen en común experiencias nacionales, conocimientos y capacidades. El análisis de las experiencias de integración en salud muestra que esta depende de las fortalezas de cada país y, en gran parte, de los procesos políticos nacionales.

Percepciones, actitudes y prácticas en malaria en el Amazonas Colombiano / Perceptions, practice and attitudes concerning malaria in the Colombian Amazon region

OBJETIVO: El objetivo del estudio fue obtener información sobre las percepciones, actitudes y las prácticas que las personas del Amazonas Colombiano tienen sobre la etiología de la malaria, el diagnóstico, la profilaxis, la terapéutica, la prevención, y la percepción del riesgo para contraer la malaria. MÉTODOS: Se realizó un estudio cualitativo y se utilizó como técnica de investigación grupos focales, en total se realizaron 23, cada uno contó con la participación de 6 a 10 personas clasificadas de acuerdo a unas variables de inclusión pertinentes para el estudio. RESULTADOS: El estudio encontró que las personas que mejor conocen las medidas preventivas y de control son quienes tienen un riesgo alto para adquirir malaria, pero sin embargo no las ponen en práctica. Existen dificultades de acceso al diagnóstico y tratamiento de la malaria y problemas de automedicación en poblaciones de alto riesgo. CONCLUSIONES: Los factores comportamentales de las poblaciones expuesta a la malaria, pueden facilitar u obstaculizar las intervenciones de control en el Departamento del Amazonas Colombiano.

Assessing options for an innovative malaria control program on the basis of experience with the new Colombian Health Social Security System / Evaluación de opciones para un programa innovador de control de la malaria, con base en la experiencia del Sistema de Seguridad Social en Salud de Colombia

OBJETIVOS: Diseñar y proponer modelos alternativos para los programas municipales y Departamentales de control de la malaria, con base en evidencias obtenidas sobre el proceso de la malaria en la Costa Pacífica de Colombia y sobre las problemáticas claves del programa de control de la malaria antes y después de la reforma del sistema de salud de 1993. MÉTODOS: Se realizó un estudio evaluativo, de comparación antes y después de la reforma de 1993, y de diseño de modelos. Por programa de control se entendió la institución, el grupo humano y la administración que están a cargo de las actividades de control. El estudio se llevó a cabo durante el año 2002 y 2003, en los Departamentos de la Costa Pacífica colombiana. Se incluyeron las cuatro capitales departamentales, 28 municipios maláricos y 5 de control. Se obtuvo información primaria y secundaria, por medio de encuestas y entrevistas semiestructuradas, reuniones comunitarias y revisión documental en secretarías de salud, programa de Enfermedades Transmitidas por Vectores-ETV, Programa Ampliado de Inmunizaciones-PAI, Empresas Promotoras de Salud-EPS, Administradoras del Régimen Subsidiado-ARS e Instituciones Prestadoras de Servicios-IPS. RESULTADOS: Se obtuvieron los siguientes resultados: 1. Ilustración y análisis de las tendencias de la malaria en el país y la Costa Pacífica, y las correspondientes transformaciones institucionales del programa. 2. Caracterización del programa de control antes de 1993. 3. Modalidades departamentales de la descentralización del programa. 4. Identificación de los efectos de la reforma del sistema y caracterización de las problemáticas del programa de control. 5. Comparación con el programa PAI6. Análisis comparado del programa e identificación de brechas actuales en la capacidad de manejo. 7. Percepción de los actores sobre el programa de control. 8. Valores y retos de un programa de control innovador. 9. Diseño de un modelo para adecuación del programa de control. DISCUSIÓN: Las problemáticas y debilidades de los programas de control de la malaria se atribuyen con frecuencia, y de manera desarticulada, a la falta de conocimiento y habilidades gerenciales del personal que labora en el programa, a la carencia de un sistema de información y comunicación, a la debilidad de los municipios o del personal. Si bien estos factores han incidido, una aproximación más global e institucional permite ubicar los programas en un contexto social, político y cultural.(AU)

OBJECTIVES: Designing and proposing alternative models for municipal and Departmental malaria control programmes based on evidence obtained concerning the process of malaria on the Colombian Pacific Coast and regarding key problems in the malaria control programme before and following health system reform in 1993. METHODS: An evaluative study was carried out, comparing the situation before and following the 1993 reform; model design was also compared. Control programme is understood as being the institution, the human group and administration in charge of control activities. The study was carried out in 2002 and 2003, in the Departments along the Colombian Pacific Coast; the four departmental capitals, 28 malarial and 5 control municipalities were included primary and secondary information was obtained by means of surveys and semi-structured interviews, community meetings and reviewing documentation in the secretariats of health, the Vector-borne disease control programme-VBDC, the Expanded Immunisation Programme-EIP, Health Promoting Entities-HPE, Subsidised Regime Administrators-SRA and Service-Providing Entities-SPE. RESULTS: The following results were obtained: 1. Illustrating and analysing malarial tendencies in the country and on the Pacific Coast, and the corresponding institutional transformations in the programme; 2. Characterising the control programme which existed before 1993; 3. Characterising departmental modes of decentralising the programme; 4. Identifying the effects of reforming the system and characterising control programme problems; 5. Comparing the programme with the Expanded Immunisation Programme (EIP); 6. Comparative analysis of the programme and identifying current gaps in management capability; 7. Actors' perceptions regarding the control programme; 8. Values and challenges for an innovative control programme; and 9. Designing a model for up-dating/adapting the control programme. DISCUSSION: Malaria control programmes' problems and weaknesses are frequently and inarticulately attributed to the lack of knowledge and management skill of personnel working in such programmes, the lack of an information and communication system or weaknesses in the municipalities or personnel. These factors may well have had an effect; however, a global and institutional approach leads to locating the programmes within a social, political and cultural context. This allows interpreting control programmes' current problems, amidst decentralisation and reform processes, and linking this interpretation to modelling and opening a space for innovation in such programmes. The study's main limitations spring from particularities regarding Pacific Coast control programmes and weakness in health information systems.(AU)

Evaluación del programa de control de la malaria en la Amazonía Colombiana / Evaluation of the malaria control program in the Colombian Amazon region

OBEJTIVO: Evaluar el programa de control de la malaria en el Departamento del Amazonas Colombiano, antes y después de la creación del Sistema General de Seguridad Social en Salud-SGSSS. MÉTODOS: El estudio se llevó a cabo en las cabeceras municipales de Leticia y Puerto Nariño, y en los corregimientos de Tarapacá y La Pedrera. Participaron los actores e instituciones relacionadas con el programa de control de la malaria en el Departamento. Se recolectó información primaria y cualitativa, mediante entrevistas semi-estructuradas a los actores, encuestas aplicadas a instituciones y grupos focales seleccionados de la comunidad. RESULTADOS: Antes y después de la creación del SGSSS el programa de control de la malaria en el Amazonas ha tenido grandes dificultades especialmente relacionadas con la accesibilidad geográfica, los desplazamientos de población, la falta de continuidad del programa, el seguimiento y evaluación de las actividades. En la actualidad, los municipios requieren el apoyo administrativo de la Secretaría de Salud Departamental, el recurso humano es insuficiente y de alta rotación, existe poca participación intersectorial y ciudadana, y se destinan pocos recursos a las actividades de promoción y prevención. Existe insuficiente aseguramiento al SGSSS e inapropiado manejo de las aseguradoras, poca capacidad estructural de las instituciones prestadoras de los servicios-IPS y una red diagnóstica de baja cobertura. CONCLUSIONES: Los actores e instituciones que están relacionados con el programa de control de la malaria no están articuladas en un plan específico que garanticen el control adecuado de la malaria. El estudio muestra que el SGSSS no ha contribuido de manera decisiva a mejorar la situación de transmisión de la malaria en la Amazonía colombiana.

OBJECTIVE: The purpose of this study was to evaluate the malaria control program in the Amazonas department, Colombia, before and after the creation of the General System for Social Security in Health (SGSSS). METHODS: The study was carried out in the municipalities of Leticia an Puerto Nariño, and in the villages of Tarapacá and La Pedrera with the participation of the people and institutions related to malaria control in the department. Primary and qualitative information was collected through semi-structured interviews applied to the people, and through surveys applied to both institutions and selected focal groups from the community. RESULTS: The malaria control program in the department of Amazonas has had great difficulties, both before and after the creation of the SGSSS, particularly related to the geographic accessibility, the displacement of population, the lack of continuity of the program, and the follow-up and evaluation of control activities. Currently, the municipalities require administrative support from the departmental health secretariat, human resources are insufficient and of high rotation, there is little citizen and intersectorial participation and scarce resources are allocated to promotion and prevention activities. Insurance to the SGSSS is insufficient and health insurance companies are inadequately managed, there is little structural capacity of health service providing institutions (IPS) and the diagnostic network has low coverage. CONCLUSIONS: The people and institutions involved with malaria control are not articulated in a specific plan which can guarantee the adequate malaria control. The study demonstrates that the SGSSS has not contributed in a decisive manner to improve the malaria transmission situation in the Colombian Amazon region.(AU)

Equidad en la Política de Reforma del Sistema de Salud / Reform and equity in the access to and use of health services in Bogotá, Colombia

En el presente estudio nos propusimos evaluar el impacto de la transformación del Sistema Nacional de Salud en Sistema de Seguridad Social en Salud, sobre la equidad en el acceso, la utilización y la calidad de los servicios de salud. Interpretamos la equidad como la igualdad de todos los individuos frente a las oportunidades de acceso real a los servicios de salud. Llevamos a cabo un estudio transversal para detectar las diferencias que pudiesen existir entre los afiliados y los no afiliados, y los tipos de afiliación en términos de acceso y utilización de los servicios de salud. Se aplicó una encuesta a 364 hogares con 1.324 personas mayores de 9 años sobre aspectos sociodemográficos y laborales, afiliación a la seguridad social, tipo de afiliación (régimen contributivo y subsidiado) utilización de los servicios de salud, atención y gasto en salud. En hospitales de nivel 1, 2 y 3 se escogieron al azar 297 usuarios del servicio de consulta externa y se les aplicó una encuesta sobre afiliación, conocimiento de derechos, oportunidad de atención, calidad del servicio, satisfacción general y participación social. Una vez que se controló para género, edad, estrato de vivienda, ocupación e ingreso se encontraron numerosas diferencias no justificadas en la necesidad, la consulta, el sitio al que se acude, el motivo para no consultar, la atención recibida y la utilización de servicios. Estos problemas de equidad remiten al diseño, la estructura y la operación del modelo de competencia regulada.(AU)

In the present study we intended to evaluate the impact of the transformation of the national health system into the Social Security Health System upon the equity in access to health services as well as their use and quality. We interpreted equity as the equal opportunity for all people of gaining real access to health services. A cross-sectional study was designed to detect the differences, which might exist between affiliated and non-affiliated people, and the differences in access to and use of health services according to the nature of affiliation. A survey was carried out in 364 households comprising 1324 people aged 9 years or older, in which socio-demographic and labor aspects, affiliation to social security, nature of the affiliation (contributive or subsidized regime), use of health services, attention and expenditure in health services were studied. 297 randomly chosen patients of the outpatient clinics of hospitals of levels 1,2 and 3 were asked to answer a survey about affiliation, awareness of their rights, opportunity and quality of the health service, general satisfaction and social participation. Numerous differences, which could not be justified by necessity, cause for requesting attention, place where people demanded health services, attention received or use of health services, were found once adjustments for gender, age, housing stratum, occupation and income were made. These problems in equity relate to the design, structure and operation of the model of regulated competition.(AU)