Dear Editor

Cuba represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialized countries (1). However the economic crisis which began in 1991 after the withdrawal of the Soviet Union wreaked havoc on many aspects of Cuban society. Although the impact on health indices was relatively modest and now are recovering, the Cuban’s health care system is still suffering the consequences of a very long period of severe shortage. Perhaps less evident is the crisis’ impact on professional performance where a number of causes are involved and include limited resources, lack of technical discipline and particularly, poor mechanisms of evaluation/compensation. Taking into account this situation the health system in Cuba is working, at the same time with the recapitalization of their technology, in new mechanisms to achieve the performance of their enormous work force and health’s infrastructure.

The first experience on performance’s management began in 1999 at the University Hospital in Cienfuegos, an institution located on the central and south region of Cuba. After a redefinition of the hospital’s vision and mission a task force was created to define a set of core performance indicators for each group from professionals to simple workers. As result of a comprehensive and participative consultation process a new standards were generated which are improving year by year and include: work quantity, quality and results; knowledge; communication skill; human relationship; behavioural attitude towards postgraduate studies; personal image; creativity, attendance, and working hours efficiency; fulfilments of the established regulations and level of patients satisfaction. Individual performance assessment results of each employee were analysed in private meetings with the participation of the evaluated worker and his/her supervisor. The final marks in those individual interviews included a positive agreement between two different points of view: on one side, previous self evaluations of workers and, on the other side, the evaluator’s criteria. This open procedure, face to face, helpfully solved the distress frequently reported in other types of performance assessment (2).

Cienfuegos´s hospital is now a top-ranking Cuban hospital although its main strength is not the technology. Undoubtedly the management of poor performance, such as has been described by Mayberry (3), has played a crucial role. The next step is using this evidence to introduce the pay for performance in order to achieve an adequate balance between process and results and between results and tangible incentives, a new policy that Cuba needs to implement.

References:

1.Cooper R, Kenelly J, Ordúñez P. Health in Cuba. Int J of Epi 2006; 35:817–824.

2.Alvarez FC, Ordúñez PO, Espinosa AD. Introducción de la evaluación del desempeño individual en un hospital cubano. Metodología y resultados. Rev Calidad Asistencial.. 2006; 21(2): 102-110.

3.Mayberry JF. The management of poor performance. Postgrad. Med. J. 2007; 83:105-108.

Dear Editor,

Although adult respiratory distress syndrome (ARDS) is a complication common to both ketotic and non-ketotic diabetic decompensation (1), being arguably attributable to the development of adverse osmotic gradients which generate pulmonary oedema (2), the fact that ARDS is much commoner in diabetic ketoacidosis (DKA) than in hyperosmolar non-ketotic (HONK) diabetic decompensation (3)(4)(5) suggests that the discrepancy in prevalence might be attributable to risk factors unique to DKA. Support for the view that acidosis may be an important risk factor comes from the documentation that the association of tachypnoea and metabolic acidosis can give rise to pulmonary oedema in the animal model of ARDS (6). In humans it has been suggested that the microangiopathy, and, hence, increased capillary permability, documented in the skeletal muscle of diabetic patients might have, as its corollary, an increase in capillary permeability in the presence of ketoacidosis (7). Accordingly, metabolic acidosis and its corollary, ketoacidosis, might be the additional risk factor rendering patients with DKA more liable than their counterparts with HONK to ARDS.

References
(1) Kearney T and Dang C. Diabetic and endocrine emergencies. Postgraduate Medical Journal 2007:83:79-86
(2) Kitabachi AE and Wall BM. Diabetic ketoacidosis. Medical Clinics of North America 1995:79:9-37
(3) Lorber D. Nonketotic hypertonicity in diabetes mellitus. Medical Clinics of North America 1995:79:39-52
(4)Carroll P and Matz R. Adult respiratory distress syndrome complicating severely uncontrolled diabetes mellitus:report of nine cases and a review of the literature Diabetes care 1982:5:574-80
(5) Marshall SM and Alberti KGMM. Hyperosmolar non-ketotic diabetic coma. The Diabetes Annual 1988;4:235-247
(6) Sinha R., Tinka MA., Hizou R et al. Metabolic acidosis and lung mechanics in dogs. American review of Respiratory diseases 1972:106-881
(7) Brun-Buisson CJL., Bonnet F., Bergeret S., Lemaire F., Rapin M. Recurrent high-permeability pulmonary edema associated with diabetic ketoacidosis. Critical Care Medicine 1985:13:55-56

Dear Editor,

I am an SHO in the 'old' system. I believe the MMC has certain advantages but I have some serious concerns as well.

The maintenance of a personal portfolio and more time and attention from the educational supervisors sounds quite good. The concerns are:

1. The training period for acquiring the generic skills varies from person to person. The move from time- based to competency-based training resulting in the curtailing of SHO training raises serious concerns.

2. Considering a particular speciality, for example medicine, six months gives more time to enjoy the specialty, learn the basics, acquire specific skills and finally decide which specialty to pursue for further training.

3. With the old SHOs undergoing a transition now, the competition is unfair because SHOs with one year's experience are competing with those with 2.5-3 years' experience at the ST2 level.

4. F2 trainees have protected teaching times which range from half a day up to a full day which will compromise the quality of the patient care. Doctors should have protected teaching times, but ward work and patient care should not be compromised at any cost because that is the difference between a medical student and a PRHO or an SHO.

5. The role of membership exams is still not very clear.

Dear Editor,

The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimatization by increasing the ventilation but it does not mask the symptoms. Only dexamethasone masks the symptoms of AMS and symptoms can recur if people take dexamethasone for severe AMS then stop it when the symptoms improve and ascend up again. Hence people can take dexamethasone themselves for severe AMS only when they are descending. [2,3]

Diamox is a very useful medication in altitude illness. It has been used not only in prevention and treatment of Acute Mountain Sickness (125 mg twice a day for mild AMS and 250 mg twice a day for severe AMS) but also as adjuvant treatment (to what is mentioned in the article) in High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE). The use of diamox as adjuvant makes sense because the sole problem in these pathological processes is hypoxia and diamox improves oxygenation by causing hyperventilation.

When people get HAPE or HACE, they should descend immediately. It must be emphasized here that they must descend with a friend (or porters to carry them down to avoid exertion). We had few cases of both Nepali porters and foreign trekkers in the Everest region where HAPE patients were advised to go down alone by their team mates. However, they were not able to walk and were found by others in bad condition lying helpless on the way after several hours and had to be carried to the clinic (at Pheriche).

The author has not mentioned the usefulness of Sildenafil(Viagra) and Salmeterol in the treatment and prevention of HAPE. [4] Sildenafil helps by decreasing the pulmonary artery pressure and Salmeterol helps in reabsorption of the oedema fluid.

References:

1. Clarke C. Acute mountain sickness: medical problems associated with acute and subacute exposure to hypobaric hypoxia. Postgraduate Medical Journal 2006;82:748-753

2. Levine B, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med 1989;321:1707-13. [Abstract]

3. Ferrazzini Z, Maggiorini M, Kriemler S, Bartsch P, Oelz O. Successful treatment of acute mountain sickness with dexamethasone. BMJ 1987; 294:1380-83.

4. West JB. The Physiologic Basis of High-Altitude Illness. Ann Intern Med. 2004;141:789-800.