Programa educativo para favorecer la adherencia terapéutica en pacientes hipertensos de Manzanillo / Educative program to promote therapeutic adherence in patients with hypertension from Manzanillo / Programa educativo para promoção da adesão terapêutica em hipertensos de Manzanillo

RESUMEN Introducción: En investigaciones realizadas en el contexto cubano, se han puesto en evidencia las dificultades que presentan los pacientes hipertensos con la adherencia a los tratamientos. Objetivo: Evaluar la efectividad de un programa educativo, basado en el Modelo de Creencias de Salud, para favorecer la adherencia terapéutica en los pacientes hipertensos del Consultorio Médico de Familia No. 6, del Policlínico Universitario "Ángel Alfonso Ortiz Vázquez", del municipio Manzanillo, Granma. Método: Se realizó un estudio de intervención, cuasi experimental, en el período septiembre 2018 - abril 2019. El universo estuvo constituido por los 80 pacientes hipertensos que se encontraban en la adultez media. La muestra quedó conformada por 18 pacientes. En el proceso investigativo se emplearon el cuestionario MBG (Martín-Bayarre-Grau) y una encuesta elaborada por las autoras. El procesamiento estadístico se realizó mediante números absolutos y porcientos, y la prueba de hipótesis de homogeneidad haciendo uso del test de Chi-cuadrado. Los resultados se presentan resumidos en tablas. Resultados: Después de aplicar el programa, predominaron los pacientes con una adherencia parcial con un 55,6 %. El 83,3 % poseía una susceptibilidad percibida alta y el 94,4 % una severidad percibida alta. El 100 % percibió muchos beneficios tanto del tratamiento farmacológico como del higiénico-dietético y el 77,8 % notó pocas barreras. Conclusiones: El programa educativo fue efectivo pues se incrementa la adherencia terapéutica en los pacientes hipertensos, se eleva la susceptibilidad y severidad percibidas acerca de las complicaciones de la hipertensión y los beneficios percibidos con respecto al tratamiento superan las barreras.

ABSTRACT Introduction: Various research approach conducted in Cuba have revealed all difficulties experienced by hypertensive patients related to their adherence to treatment. Objective: To assess the effectiveness of the educative program. The program was based on the Health Belief Model, aimed to promote therapeutic adherence in patients with hypertension registered at the No. 6 family doctor´s office associated to the Policlínico Universitario "Ángel Alfonso Ortiz Vázquez", in Manzanillo, Granma. Method: A study which included a quasi-experimental and an exercise intervention was carried out from September 2018 through April 2019. The universe of study consisted of 80 middle - age adults with hypertension. The sample included 18 patients. In the research process was used the Martín Bayarre Grau questionnaire, including in addition an enquiry performed by the authors. The statistic process was performed using absolute numbers and percentages, and was used the Chi-square test for homogeneity hypothesis test. The results are summarized in tables. Results: After program applied, patients with partial adherence, a 55.6%, were predominant. The 83.3% had a high perceived susceptibility and 94.4% had a high perceived severity. The 100% perceived many benefits from both pharmacological and hygienic-dietary treatment and 77.8% noted few barriers. Conclusions: The educative program was successfully effective, increasing therapeutic adherence in hypertensive patients, increasing the perceived susceptibility and severity of hypertensive complications, and the perceived benefits concerning treatment overcame the barriers.

RESUMO Introdução: Em investigações realizadas no contexto cubano, foram destacadas as dificuldades que os hipertensos apresentam para adesão aos tratamentos. Objetivo: Avaliar a eficácia de um programa educativo, baseado no Modelo de Crenças em Saúde, para promover a adesão terapêutica em hipertensos da Clínica Médica de Família nº 6, da Policlínica Universitária "Ángel Alfonso Ortiz Vázquez", do município de Manzanillo, Granma. Método: Foi realizado um estudo quase experimental de intervenção no período de setembro de 2018 a abril de 2019. O universo foi constituído por 80 hipertensos que se encontravam na metade da idade adulta. A amostra foi composta por 18 pacientes. No processo investigativo, foram utilizados o questionário MBG (Martín-Bayarre-Grau) e um questionário elaborado pelos autores. O processamento estatístico foi realizado por meio de números absolutos e percentuais e o teste de hipótese de homogeneidade pelo teste do Qui-quadrado. Os resultados estão resumidos em tabelas. Resultados: Após a aplicação do programa, houve predomínio de pacientes com adesão parcial com 55,6%. 83,3% tinham uma sensibilidade percebida alta e 94,4% uma severidade percebida alta. 100% perceberam muitos benefícios do tratamento farmacológico e higiênico-dietético e 77,8% perceberam poucas barreiras. Conclusões: O programa educativo foi eficaz, pois a adesão terapêutica em hipertensos aumentou, a suscetibilidade percebida e a gravidade das complicações da hipertensão aumentaram e os benefícios percebidos com relação ao tratamento ultrapassaram as barreiras.

La responsabilidad civil en las relaciones jurídicas originadas por la prestación de servicios médicos / Civil liability in legal relationships arising while performing medical services

RESUMEN Introducción: la responsabilidad médica se inserta en las llamadas responsabilidades de profesionales; para fijar sus contornos es necesario precisar la naturaleza jurídica de la relación médico-paciente y la responsabilidad civil por los daños causados en el ejercicio de la actividad médica. Objetivo: determinar la naturaleza de la relación médico-paciente para precisar el criterio de imputación de responsabilidad y la extensión de los daños resarcibles. Métodos: se realizó una revisión doctrinal de importantes juristas cubanos y españoles, análisis de la legislación y jurisprudencia comparada y valoración de la legislación cubana. La búsqueda fue realizada en textos originales con vinculación directa a la temática. Desarrollo: la relación médico-paciente es, cualquiera que sea su causa, una relación jurídica a la que el Derecho le confiere tutela. Su naturaleza jurídica tiene su base en la obligación de medios que surge entre los sujetos; en tal sentido resulta importante la ubicación de la responsabilidad médica como responsabilidad profesional y el análisis de los daños causados, así como el criterio de imputación dominante. Los daños causados por la actuación negligente del personal médico pueden ser de índole patrimonial o moral; ambos deben ser reparados e indemnizados según las normas vigentes. Conclusiones: el criterio de imputación predominante en la responsabilidad civil del médico debe ser el subjetivo, valorando siempre su pericia y destreza en el ejercicio de su profesión; asunto este poco tratado en los currículos de las carreras, por lo que esta revisión se une a otras destinadas a desarrollar una cultura jurídica entre estudiantes y profesionales de la salud.

ABSTRACT Background: medical liability is inserted in the so-called responsibilities of professionals; to determine its framework it is necessary to specify the legal nature of the doctor-patient relationship and the civil responsibility for the damages caused in the exercise of the medical activity. Objectives: to determine the nature of the doctor-patient relationship to specify the criterion of imputation of responsibility and the extent of compensable damages. Methods: a doctrinal review of important Cuban and Spanish jurists, analysis of comparative legislation and jurisprudence and valuation of Cuban legislation was carried out. The search was carried out in original texts with direct link to the subject. Development: the doctor-patient relationship is, whatever its cause, a legal relationship to which the law confers guardianship. Its legal nature is based on the obligation of means that arises among the subjects; in this sense it is important the location of medical responsibility as professional responsibility and the analysis of the damages caused, as well as the dominant imputation criteria. The damages caused by the negligent action of the medical personnel can be of patrimonial or moral nature; both must be repaired and compensated according to current regulations. Conclusions: the predominant imputation criterion in the physician's civil responsibility must be the subjective one, always assessing his expertise and skill in the exercise of his profession; this issue is not much discussed in the curricula of the careers, so this review joins others aimed at developing a legal culture among students and health professionals.

Desogestrel versus antagonist injections for LH suppression in oocyte donation cycles: a crossover study.

To study whether ovarian response to corifollitropin among oocyte donors (OD) is different when oral desogestrel (DSG) is used to block the luteinizing hormone (LH) surge when compared to GnRH-antagonist use. This is a retrospective, cohort study at a private, university-based, IVF center including 35 OD. Patients underwent two stimulation cycles under corifollitropin alfa (CFT), one under an antagonist and another under DSG, between February 2015 and May 2017. In antagonist cycles, daily ganirelix was administered since a leading follicle reached 14 mm. In the DSG cycles, daily oral DSG was prescribed. The main outcome measure was oocytes retrieved. Compared to antagonist cycles, cycles under DSG received fewer injections (10.3 ± 2.8 vs. 5.0 ± 2.1, p < .001), nominally lower total supplementary gonadotropin dose (497.4 ± 338.9I U vs. 442.9 ± 332.8 IU, p=.45) with a lower total cost of medication (1018.6 ± 191.0€ vs. 813.8 ± 145.9€, p<.001). There were no differences in the total number of retrieved oocytes between groups (17.4 ± 7.5 vs. 18.6 ± 8.9, p=.34). In the corresponding oocyte recipients, clinical pregnancy rate was similar between groups: 52.0% vs. 58.6%, respectively (p=.78). ODs' stimulation's response under DSG is similar when compared to (17.4 ± 7.5 vs. 18.6 ± 8.9, p=.34) but associated with less injections and lower medication costs. The main advantage of this strategy is its simplicity, an aspect of utmost importance in the management of ODs.

Obstetric and perinatal complications in an oocyte donation programme. Is it time to limit the number of embryos to transfer?

The aim of this study is to describe obstetric and perinatal complications in pregnancies from oocyte donation (OD) cycles, delivering in our centre and to determine the impact of maternal age. Retrospective observational study of a 225 singleton pregnancies, 113 multiple pregnancies and 447 live birth. Pearson's χ(2) test or Fisher's exact test were used for the statistical analysis. A higher incidence of obstetric complications was observed in multiple compared to singleton pregnancies with regard to preeclampsia (24.8% versus 8%), premature rupture of membranes (9.7% versus 1.8%), preterm delivery at <37 weeks (54.9% versus 10.2%) and caesarean section (81.4% versus 64%) (p < 0.05). If the age factor is added, the caesarean sections are higher in the single pregnancy group aged ≥40 years than in the group of <40 years (73.5% versus 49.4%) (p < 0.05). A higher incidence is found in multiple versus singleton pregnancies for low birth weight (<2500 g) (61.1% versus 8.2%), admissions to the intensive care unit (15.2% versus 4.7%) and perinatal mortality (13.5‰ versus 0‰) (p < 0.05). It is necessary to consider preconception counselling prior to an OD cycle to inform patients about the incidence complications observed and recommend to transfer only a single embryo.

Antagonist rescue of agonist IVF cycle at risk of OHSS: a case series.

We describe a series of in vitro fertilisation (IVF) long protocol cycles presenting a risk of ovarian hyperstimulation syndrome (OHSS) which were rescued with an antagonist at a university-based tertiary-care fertility centre. Nineteen IVF patients presenting a risk of OHSS during treatment with long protocol, between 2009 and November 2012 were included in the present study. After discussion of available options, the agonist was stopped and a daily gonadotropin-releasing hormone (GnRH) antagonist injection was initiated ("rescue protocol") and maintained until ovulation trigger. Fourteen patients were triggered with human chorionic gonadotropin (hCG) and five with GnRH agonist bolus, yielding competent oocytes. Seventeen embryo transfers were performed in the fresh cycles. One patient developed moderate OHSS. There were eight clinical pregnancies after the fresh IVF cycle (42% per patient), and six further pregnancies after frozen-thawed cycles, resulting in a 73% cumulative clinical pregnancy rate within one year. We conclude that the "rescue protocol with antagonist" of the long IVF cycle with a high risk of OHSS allows us to carry on with the cycle, without compromising its success or the patient safety, thus broadening the possibility of applying the long protocol.

GnRH antagonist rescue of a long-protocol IVF cycle and GnRH agonist trigger to avoid ovarian hyperstimulation syndrome: three case reports.

OBJECTIVE: To describe three clinical cases involving patients at high risk of severe ovarian hyperstimulation syndrome (OHSS) during IVF stimulation. DESIGN: Description of clinical management of IVF cycles and outcomes in patients at risk of developing OHSS. SETTING: Reproductive medicine unit, private hospital. PATIENT(S): Three infertile patients undergoing stimulation for IVF/intracytoplasmic sperm injection presenting high risk of OHSS. INTERVENTION(S): IVF patients treated under long protocol presenting high risk of OHSS had their cycles rescued by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus. MAIN OUTCOME MEASURE(S): OHSS symptoms, pregnancy. RESULT(S): None of the three patients developed OHSS. One patient got pregnant after fresh embryo transfer, one patient got pregnant after frozen embryo transfer, and one patient had no oocytes retrieved despite the detection of LH in urine after the GnRH bolus. CONCLUSION(S): When a patient undergoing an IVF cycle with long protocol is at high risk of severe OHSS, rescuing the cycle by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus could be considered without jeopardizing the safety of the patient while retaining the opportunity for success of the cycle. Further broader studies are needed.

An elevated level of physical activity is associated with normal lipoprotein(a) levels in individuals from Maracaibo, Venezuela.

Coronary artery disease is the main cause of death worldwide. Lipoprotein(a) [Lp(a)], is an independent risk factor for coronary artery disease in which concentrations are genetically regulated. Contradictory results have been published about physical activity influence on Lp(a) concentration. This research aimed to determine associations between different physical activity levels and Lp(a) concentration. A descriptive and cross-sectional study was made in 1340 randomly selected subjects (males = 598; females = 712) to whom a complete clinical history, the International Physical Activity Questionnaire, and Lp(a) level determination were made. Statistical analysis was carried out to assess qualitative variables relationship by chi2 and differences between means by one-way analysis of variance considering a P value <0.05 as statistically significant. Results are shown as absolute frequencies, percentages, and mean +/- standard deviation according to case. Physical activity levels were ordinal classified as follows: low activity with 24.3% (n = 318), moderate activity with 35.0% (n = 458), and high physical activity with 40.8% (n = 534). Lp(a) concentration in the studied sample was 26.28 +/- 12.64 (IC: 25.59-26.96) mg/dL. Lp(a) concentration according to low, moderate, and high physical activity levels were 29.22 +/- 13.74, 26.27 +/- 12.91, and 24.53 +/- 11.35 mg/dL, respectively, observing statistically significant differences between low and moderate level (P = 0.004) and low and high level (P < 0.001). A strong association (chi2 = 9.771; P = 0.002) was observed among a high physical activity level and a normal concentration of Lp(a) (less than 30 mg/dL). A lifestyle characterized by high physical activity is associated with normal Lp(a) levels.

Biochemical and structural characterization of RHDV capsid protein variants produced in Pichia pastoris: advantages for immunization strategies and vaccine implementation.

Rabbit hemorrhagic disease virus (RHDV) VP60 capsid protein was recently expressed at approximately 1.5 gL(-1) associated with the disruption pellet of Pichia pastoris, thus requiring an additional process of extraction by solubilization. Consequently, the expression of a soluble variant of VP60 was undertaken in order to attain an easier approach for vaccine production. The VP60 gene was cloned without secretion signal under the transcriptional control of the AOX1 yeast promoter. The antigen obtained was intracellular and soluble at approximately 480 mg L(-1). Its characterization by size-exclusion HPLC, ultracentrifugation, and electron microscopy, showed the presence of high molecular weight structures similar in mass, size and buoyant density to native RHDV. The antigenic profile was similar to that from authentic virions as determined with monoclonal antibodies directed against RHDV conformational epitopes. These analyses, conducted on VP60 obtained insoluble in P. pastoris revealed the formation of protein aggregates rather than the presence of ordered multimeric structures. An immunization trial was conducted in which the soluble VP60 was employed by subcutaneous (s.c.) injection either purified by a single chromatographic step or contained within raw disruption supernatant, emulsified in Montanide 888. The insoluble variant was administered as a yeast extract powder by oral and s.c. routes. The earliest IgG response, titers and persistence of antibodies were studied by competition ELISA and hemagglutination inhibition (HI) assays. All rabbits immunized with the yeast-derived antigens developed a strong RHDV-specific response (including the "RHDVa" subtype) that lasted over one year after the primary immunization. Early HI titers up to 1/40 960 were generated. The immune response was similar to that induced by VP60 from Sf9 cells and superior to the response elicited with inactivated RHDV. Overall it was found that the soluble VP60 multimers, safely and easily produced in P. pastoris, are a valuable candidate for the rational implementation of a low-cost, scalable subunit vaccine against RHDV.