[A computer program for the geographic distribution of fluvial mollusks of medical interest in Cuba]

The need to know the distribution of mollusks considered to play an important medical role in Cuba through a geographic representation motivated us to develop a software capable of acting as a system for the retrieval of geographic information in which the requested data would be presented in maps. The system has been called DMIM and it is a useful tool for malacological studies, and assessment and planning of programs for the control of intermediate host mollusks, as well as for teaching purposes.

[Importance of Tarebia granifera in the control of a population of Biomphalaria peregrina introduced in Cuba]

It was observed that the Tarebia granifera plays a significant role in the control of a Biomphalaria peregrina population introduced in a permanent water body. The densities of this planorbid, which had reached high levels, were notably reduced by two important events: an increase of the water level due to heavy rains, and the introduction of the competitor, whose effectiveness had been tested in a different habitat. Knowledge on the ecology and biology of the competitor and the host in permanent water bodies helped to elaborate the measures of control which led to the reduction of the host densities while those of the competitor increased.

[Mass breeding of Romanomermis culicivorax (Nematoda: Mermithidae) in the tropical conditions of Cuba]

To develop the process of mass production on a large scale of the parasite nematode Romanomermis culicivorax Ross and Smith, 1976, under the control tropical conditions of Cuba, it was taken into consideration the standardization of a certain number of variables, such as: utilization of eggs in the process of infectation, dosage, types of water, types of substrate, temperature, culture methods, and storage methods of culture batches. High performances in nematoda and approximately the same amount of females and males were obtained when mosquito larvae of the species Culex quinquefasciatus Say, 1823, were exposed to parasite's infective larvae.

The WHO antenatal care randomised controlled trial: rationale and study design

The World Health Organisation and collaborating institutions in developing countries are conducting a multicentre randomised controlled trial to evaluate a new antenatal care (ANC) programme, consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. These activities are distributed, for practical reasons, over four visits during the course of pregnancy and are aimed at achieving predetermined goals. The study is taking place in four countries, Argentina, Cuba, Saudi Arabia and Thailand. Recruitment of study subjects started on 1 May 1996. All 53 ANC clinical units had been enrolled by December 1996. Clinics in each country were randomly allocated (cluster randomisation) to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for ANC at these clinics over an average period of 18 months will have been recruited. As women attending the control clinics receive the 'best standard treatment' as currently offered in these clinics, individual informed consent is requested only from women attending the intervention clinics. Authorities of the corresponding health districts and all participating clinics have provided written institutional informed consent before randomisation. The primary outcome of the trial in relation to maternal conditions is the rate of a morbidity indicator index, defined as the presence of at least one of the following conditions for which ANC is relevant: (a) pre-eclampsia or eclampsia during pregnancy or within 24 h of delivery; (b) postpartum anaemia (haemoglobin < 90 g/L); or (c) severe urinary tract infection/pyelonephritis, defined as an episode requiring antibiotic treatment and/or hospitalisation. The primary fetal outcome is the rate of low birthweight (< 2500 g). Adverse maternal and fetal outcomes are expected for approximately 10% of the control group. Several maternal and perinatal secondary outcomes are also considered. A comprehensive cost-effectiveness analysis and women's and providers' satisfaction evaluation are performed concurrently with the trial. Health-care programmes should be rigorously evaluated by randomised controlled trials, which are feasible in developing countries and should be conducted before introducing new treatments or health interventions.

Methodological considerations in the design of the WHO Antenatal Care Randomised Controlled Trial

We discuss methodological issues arising in a recent evaluation trial of a new antenatal care programme, as sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction, and WHO's Division of Reproductive Health (Technical Support). The randomisation unit for the trial is the antenatal care clinic, with 53 clinics located in four countries randomly allocated to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for antenatal care over an average period of 18 months will have been recruited.

The practice of antenatal care: comparing four study sites in different parts of the world participating in the WHO Antenatal Care Randomised Controlled Trial

In the preparation of a randomised controlled trial to evaluate a new programme of antenatal care (ANC) in different parts of the world, we conducted a baseline survey of the ANC procedures in all 53 clinics participating in the trial. There were two components of this survey: (1) description of clinic characteristics and services offered: the staff of each clinic was interviewed and direct observation was made by field supervisors, and (2) the actual use of services by pregnant women attending these clinics: we reviewed a random sample of 2913 clinical histories. The clinical units surveyed were offering most of the activities, screening, laboratory tests and interventions recommended as effective according to the Cochrane Pregnancy and Childbirth Database (PCD), although some of these were not available in some sites. On the other hand, some tests and interventions that are considered not effective according to these criteria are reportedly offered. There was a difference across sites in the availability and offer to low-risk women of vaginal examination, evaluation of pelvic size, dental examination, external version for breech presentation and formal risk score classification, and a notable difference in the type of principal provider of ANC. There was a large variation in the actual use of screening and laboratory tests and interventions that should be offered to all women according to Cochrane PCD criteria: some of these are simply not available in a site; others are available, but only a fraction of women attending the clinics are receiving them. The participating sites all purport to follow the traditional 'Western' schedule for ANC, but in three sites we found that a high percentage of women initiate their ANC after the first trimester, and therefore do not have either the recommended minimum number of visits during pregnancy or the minimum first trimester evaluation. It is concluded that the variability and heterogeneity of ANC services provided in the four study sites are disturbing to the profession and cast doubts on the rationale of routine ANC.

[Hyperbaric oxygenation and neurological recovery in children with organic brain damage]

INTRODUCTION AND OBJECTIVE

In order to determine the effects of hyperbaric oxygenation, 14 Cuban children (8 boys and 6 girls) with affected lesions on the Central Nervous System (CNS), were prospectively studied between September 1994 and September 1995; the patients came from the external consultation of Neuropediatric of the Academic Pediatrics Hospital, Tuna Martyrs, Cuba.

PATIENTS AND METHODS

They were evaluated from the neuropediatric and neurophysiologic point of view and submitted to treatment with hyperbaric oxygenation (HBO). Five patients showed a injury to the CNS by severe asphyxia, seven by generalized infections of CNS, one patient with cerebral damage by craneoencephalic traumatism and other with vasoclusive cerebral crisis of siclemic. The average age of the children was of 4.8 +/- 3.4 years. The symptoms and signs were depending on the type on cerebral damage and its evolution. 100% of the children presented infantile cerebral paralysis (ICP) and epilepsy, most of the children were in treatment with antiepileptic drugs, buy they weren't balanced.

RESULTS AND CONCLUSIONS

Satisfactory response was observed in patients that were oxygenated within the first year of the lesion, with better and faster results.

Blood loss with mifepristone--misoprostol abortion: measures from a trial in China, Cuba and India

OBJECTIVE

We compared bleeding patterns following early mifepristone-misoprostol abortion with those following early surgical abortions ( < or = 56 days gestation LMP). We analyzed women's reports of their bleeding and clinical measures of blood loss, and modeled the relationships between different bleeding measures and indicators of success and satisfaction.

METHOD

Using data from a multicenter trial held in China, Cuba and India, we fit bivariate and multivariate models to analyze bleeding patterns, controlling for a range of demographic, experiential and medical factors (n = 1373).

RESULT

Medical abortion patients perceived their bleeding to be heavier than did the surgical patients; however, there were few statistically significant differences in clinical measures of blood loss between the two groups, and blood loss rarely represented a medical problem. Nationality, far more than actual levels of bleeding, influenced women's impressions about blood loss. Although medical abortion patients saw their bleeding as heavier than did the surgical patients, their perceptions of heavier bleeding did not prevent them from having higher satisfaction levels. One exception was that if bleeding exceeded prior expectations, women with the medical method were more likely to be dissatisfied. Pain and cramps, which often accompanied bleeding, were an independently significant factor in predicting satisfaction with the method.

CONCLUSION

In order for women to know what to expect with medical abortion, they must be informed beforehand about the level of bleeding that generally accompanies the procedure vs. excessive bleeding that would signal a clinical problem.

Conceptual bases and methodology for the evaluation of women's and providers' perception of the quality of antenatal care in the WHO Antenatal Care Randomised Controlled Trial

In this paper, we describe the conceptual bases and methodology used to assess women's and providers' perception of the quality of antenatal care, as part of a large randomised trial in four developing countries. Information has been obtained by applying both qualitative and quantitative methodologies. The focus group discussions and in-depth interviews have contributed useful insights into the cultural milieu in which care is provided, users' and providers' expectations, and their concept of quality. Based on these findings, we developed two standardised questionnaires, one being administered to a representative sample of pregnant women (n = 1600) and the other for all care providers. In this paper we present some of the findings of the focus group discussions and in-depth interviews with women in one country as an example of the kind of information we have obtained. Women expressed their point of view concerning a reduced number of visits, type of provider, information that they get during clinical encounters and interpersonal relations with health professionals. The qualitative information, together with the data we obtain from the surveys, will highlight the aspects that will have be to considered if the new model of care is to be introduced on a routine basis.

Methods for economic evaluation alongside a multicentre trial in developing countries: a case study from the WHO Antenatal Care Randomised Controlled Trial

The WHO is testing a new rationalised programme of antenatal care in a multicentre randomised trial. The motivation for this trial arose from the current uncertainty about the effectiveness of different approaches to provision of routine antenatal care. Decision makers also lack information about the costs of providing routine antenatal care and the cost-effectiveness of one programme over another. Such information will be needed before the final choice of programme can be made. The WHO trial provides an ideal opportunity to estimate and compare the incremental costs and cost-effectiveness of the new programme in four countries (Argentina, Cuba, Saudi Arabia, Thailand). A separate economic component has been organised to measure the costs of antenatal care. Methods for cost identification and measurement, and methods for economic analysis in the context of an international study are based on current recommendations for the conduct of economic evaluations alongside trials. However, several aspects require further development. In particular, this includes defining standard methods for costing in different countries; measuring women's costs of access to care; and making comparisons across international settings. The economic evaluation will also inform similar multicentre international trials and investigate issues of generalisability beyond trial settings.

Managing data for a randomised controlled clinical trial: experience from the WHO Antenatal Care Trial. WHO Antenatal Care Trial Research Group

The World Health Organisation, in collaboration with four developing countries, is conducting a randomised controlled clinical trial to evaluate a new programme of antenatal care. In a city or region in Argentina, Cuba, Saudi Arabia and Thailand, 53 clinical units were randomly allocated to provide either the new programme or the programme currently in use. This paper describes the organisation of the data management system used to collect the data. Each woman participating in the trial is uniquely identified, and information such as her name, address and expected delivery date is recorded in the trial 'subject number list'. If the clinic belongs to the intervention group, information about the woman's eligibility is recorded on the classification form. Details of the outcome of the pregnancy are indicated on two additional case report forms: the antenatal hospital admission form and the summary form. When forms are completed by the investigators, they are submitted to the country data coordinating centre (CDCC). The CDCCs are responsible for the processing of the country study forms. This includes verification of the batch of forms, data capture into computer files, data verification, data validation, production of query sheets for data problems, maintenance and updating of study master files. All operations on data such as additions or modifications are performed using transaction processing. At monthly intervals, recruitment reports and transaction files are sent to the trial coordinating centre in Geneva. All transaction files are processed to accumulate data on the trial's consolidated master files. A monthly report including number of women recruited in the trial, adverse events reported by the countries, recruitment charts by clinic and analyses on eligible women in the intervention group is prepared and submitted to the data safety and monitoring committee. A workshop was organised in 1995, before the start of the trial, to introduce the data management system to the four participating countries. Annual site visits were made to each CDCC to monitor progress. Additional visits were made when major or critical problems could not be solved by the CDCC. At the closure of data collection, a visit is made to review and assess all data management procedures including form filling, maintenance of registers, computer files, query sheets, data modifications. In addition, final cleaning of the data is performed, and an analysis file is produced for inclusion in the centralised trial analyses and in the country-specific analyses. Based on the experience gained in this trial, the decentralised data management model can be advocated only if CDCCs that will be involved in the trial are already in place with competent and experienced staff. Uniformity of the data management system and of standard operating procedures across countries is also a crucial issue for the effective management of the data collection phase.

Monitoring data and safety in the WHO Antenatal Care Trial

A committee to monitor data and safety in a large clinical trial should have members with expertise in biostatistics, epidemiology and the clinical field relevant to the trial. Its mandate should cover both logistics and the safety of study subjects, issues which to some extent overlap. While a steering committee and field staff members ideally should be blinded to the experimental and control arms of a randomised clinical trial, the data and safety monitoring committee (DSMC) should have full access to interim trial data to fulfil its role as watchdog. One initial question to be resolved concerns if and when to advise stopping a trial because of danger to study subjects, or on the other hand obvious benefits, in one trial arm. The DSMC of the WHO Antenatal Care Trial decided not to establish any definite stopping rules before implementation. After a scrutiny of the adopted procedures for data collection and handling, the DSMC received monthly reports of recruitment, and individual summary reports of three adverse events by site and trial arm: maternal deaths, fetal deaths and cases of eclampsia. At the time of writing (December 1997) recruitment to the trial is almost complete, but data collection will continue throughout most of 1998, until every index pregnancy has ended in birth or miscarriage. So far, the balance of untoward events between the intervention and control arms have not given cause for alarm.

Quality of life, gender and schizophrenia: a cross-national survey in Canada, Cuba, and U.S.A

Although gender differences in schizophrenic symptom expression have been widely established, no systematic studies have documented if these differences extend to the perception of quality of life. This survey gathered international data on the perception of quality of life among 102 outpatient men and women with schizophrenia from Canada, Cuba, and the United States. Using portions of Lehman's Quality of Life Interview, quality of life was assessed on the domains of social relationships, health, living situation, leisure, finances and general quality of life. Gender differences were tested with ANOVA where site was treated as a nested variable and separate t-tests comparing men and women within each country. Although no differences were found for the combined sample, differences were observed between men and women in Canada and Cuba on the social relationship domain. In Canada, women with schizophrenia reported a higher quality of life for social relationships. In contrast, Cuban men with schizophrenia reported higher quality of life for social relationships than Cuban women. Findings from the three sites show no differences for the other domains. With the possible exception of social relationships, these findings suggest no discernable differences in the perception of quality of life for men and women with schizophrenia. Overall, men and women with schizophrenia were only somewhat satisfied with some aspects of life. These findings have implications for developing comprehensive community care that includes quality of life promotion.

Genetic evidence of two species in the Biomphalaria havanensis complex (Gastropoda. Planorbidae) from Cuba

In Cuba, several species of freshwater gastropods belonging to the genus Biomphalaria have been described according to morphological characters. However, the taxonomy of this group remains unclear and a number of synonyms are often cited in the literature. This is the case for B. havanensis whose taxonomical status is not well established. Multilocus enzyme electrophoresis at 18 loci was carried out on adult snails of B. havanensis from the type locality in Havana and from several other sites harbouring a morphologically slightly different form, referred to here as Biomphalaria sp. Another local distinct species B. helophila was used as an outgroup. Allelic distribution showed the presence of nine and 12 diagnostic loci between B. havanensis and Biomphalaria sp. and B. helophila, respectively. We detected eight fixed alleles between Biomphalaria sp. and B. helophila. The genetic divergence estimated by absolute genetic distances strongly supports the assumption that Biomphalaria sp. is quite different from the sympatric B. havanensis, morphologically the closest species.

Unusual antigenic and genetic characteristics of human respiratory syncytial viruses isolated in Cuba

The G protein of 23 strains of human respiratory syncytial virus isolated in Havana, Cuba, between October 1994 and January 1995 was analyzed at the antigenic and genetic level. All viruses reacted with 10 of 11 antibodies specific for the Long strain. Moreover, the G protein gene of the Cuban isolates had only five nucleotide differences from the sequence of the Long gene. The homogeneity of the Cuban isolates and their resemblance to an ancient strain, such as Long, are at odds with previous findings for viruses isolated in countries with a temperate climate and different socioeconomic status. The G proteins of three of four other viruses isolated in Havana 2 years later (1996) were also identical to those of the 1994-to-1995 isolates, and the fourth virus had a single extra nucleotide difference. This, again, is unusual, since no identical viruses had been isolated in different epidemics previously. The singular characteristics of the Cuban isolates reported here are discussed in terms of the epidemiological, climatic, and socioeconomic characteristics of Cuba.

[Infection by Schistosoma intercalatum and probable hybridization with Schistosoma haematobium in East Africa. Report of a case]

It is reported the infection due to Schistosoma intercalatum and the probable hybridization with Schistosoma haematobium in a patient from the eastern region of Africa, where it has not been demonstrated before. The main clinical manifestations were abdominal pain and diarrhea with blood. The diagnosis was possible thanks to the finding in the microscopic examination of the characteristic eggs of Schistosoma intercalatum in faeces and urine by the modified technique of Ziehl-Neelsen.

Capablanca's stroke: an early case of neurogenic heart disease. Cuban-world-champion of chess 1921-1927

The great chess master Jose Raul Capablanca died of a stroke in New York city in 1942. An analysis of his death is instructive in the discussion of cardiac repercussions of hypertensive cerebral hemorrhage, particularly regarding the close relationship between subendocardial hemorrhage and its probable source - sympathetic activation - caused by stroke.

[Confirmation of the presence in Cuba of human T-cell lymphotropic virus type I using the polymerase chain reaction]

The first cases diagnoses in Cuba as HTLV-I/II seropositives (human T lymphotropic virus) were studied by polymerase chain reaction aimed at differentiating the type of virus causing the infection. 3 kits of primer oligonucleotides were used and the amplification products were detected by hybridization with specific oligoprobes. 100% of the cases were HTLV-I positives. No HTLV-II positivity was found. It was confirmed the presence in Cuba of this retrovirus, even though the seroprevalence is low if it is taken into consideration that the Caribbean is an endemic zone for HTLV-1.