Infection by Strongyloides stercoralis in immigrants with Chagas disease: evaluation of eosinophilia as screening method in primary care

OBJECTIVES

To evaluate co-infection of Strongyloides stercoralis and Trypanosoma cruzi and to assess eosinophilia as a screening test for the detection of S. stercoralis infection in patients with Chagas disease (CD).

METHODS

A retrospective diagnostic validation study was performed on serum samples from primary care patients diagnosed with CD in the southern Barcelona metropolitan area. All samples with eosinophilia (n = 87) and a random sample of non-eosinophilic sera (n = 180) were selected. Diagnosis of CD was based on positive serology by means of two tests: ORTHO® T. cruzi ELISA test, and BIO-FLASH® Chagas or Bioelisa CHAGAS. SCIMEDX ELISA STRONGY-96 was used to diagnose strongyloidiasis.

RESULTS

Strongyloides stercoralis serology was positive in 15% of patients of whom 95% showed eosinophilia, vs. 21% of those with negative serology (P < 0.001), with differences in the mean eosinophil count (0.49 vs. 0.27 × 10⁹ /l). Only 1.1% of patients with CD but without eosinophilia presented positive serology for S. stercoralis, whereas 44% of patients with CD and eosinophilia did (P < 0.001). Sensitivity and specificity values for eosinophilia were thus 95% and 79%, respectively. PPV was 42.5% and NPV, 98.9%.

CONCLUSIONS

The prevalence of co-infection by T. cruzi and S. stercoralis is not negligible and has probably been underestimated for years in many areas, due to frequently subclinical infections. Therefore, serology seems mandatory for these patients and the use of eosinophilia as initial screening could facilitate the task, decreasing the number of analyses to be performed.

Association between affective disorders presenting before and during pregnancy and pre-term birth, considering socio-demographic factors, obstetric factors, health conditions, and use of medication

OBJECTIVE

To study the relationship between maternal affective disorders (AD) before and during pregnancy, and pre-term birth.

DESIGN

Retrospective observational study.

LOCATION

Sexual and reproductive health units at the Institut Català de la Salut (ICS) in Catalonia, Spain.

PARTICIPANTS

Pregnant women with a result of live-born child from 1/1/2012 to 30/10/2015.

INTERVENTIONS

Data were obtained from the ICS Primary Care electronic medical record.

MAIN MEASUREMENTS

Diagnosis of AD before and during pregnancy, months of pregnancy, and possible confusion factors were collected. Descriptive statistical analysis (median, interquartile range, and absolute and relative frequency), bivariate analysis (Wilcoxon test and Chi-square test), and multivariate analysis (logistic regression) were performed.

RESULTS

102,086 women presented valid information for the study. Prevalence of AD during pregnancy was 3.5% (4.29% in pre-term and 3.46% in term births; p<0.004). Pregnant women with pre-term births presented a higher age, smoking habit, lower inter-pregnancy interval, and a lower socio-economic status. Pre-term birth was significantly associated to previous history of stress and dissociative disorder (SDD), anxiety, obsessive-compulsive disorder (OCD) and eating disorders (ED), and use of antidepressants. It was also associated to abuse of alcohol, smoking, and use of psychoactive substances, as well as SDD, ED, use of antipsychotics, and divorce during pregnancy. Multivariate analysis confirmed the relationship between pre-term birth and history of AD, SDD, ED, and smoking, but not with AD during pregnancy.

CONCLUSIONS

Examining the previous history of SDD and ED in pregnant women, and SDD, and ED during pregnancy is highly relevant to avoid pre-term birth.

[Antibiotic susceptibility of Staphylococcus aureus and Streptococcus pneumoniae in healthy carrier individuals in primary care in Barcelona area]

Introducción

La información existente sobre la resistencia a los antibióticos se basa habitualmente en muestras de personas hospitalizadas. El objetivo fue evaluar la prevalencia de resistencia antibiótica de cepas de Staphylococcus aureus y Streptococcus pneumoniae de personas portadores nasales atendidas en las consultas de atención primaria según edad y sexo.

Diseño

Estudio transversal.

Emplazamiento

Siete centros de salud del área de Barcelona.

Participantes

Personas portadoras nasales a partir de 4 años de edad, sin signos de enfermedad infecciosa y que no habían tomado antibióticos ni habían estado hospitalizados en los 3 meses anteriores.

Mediciones principales

Se recogieron 3.969 frotis nasales válidos para identificación entre 2010 y 2011 y fueron enviados a un laboratorio central de microbiología para el aislamiento de ambos gérmenes. La resistencia a los antibióticos se estableció según los puntos de corte actuales de la guía del European Committee on Antimicrobial Susceptibility Testing.

Resultados

La prevalencia de S. aureus resistente a meticilina fue del 1,3% (IC 95%: 0,5-2,1%), con porcentajes de resistencia frente a fenoximetilpenicilina del 87,1% y a azitromicina del 11,6%, sin observar diferencias significativas según edad y sexo. Un 2,4% (IC 95%: 0,1-4,7%) de las cepas de neumococo fueron altamente resistentes a fenoximetilpenicilina y macrólidos, mientras que las mayores resistencias se observaron frente a cefaclor (53,3%), tetraciclina (20%) y cefuroxima (12,1%).

Conclusiones

Estos patógenos tienen resistencias más bajas en la comunidad que las que se observan en el medio hospitalario. Es importante que se conozca la resistencia antibiótica actual para poder hacer un uso más prudente de los antibióticos.

Multimorbidity as specific disease combinations, an important predictor factor for mortality in octogenarians: the Octabaix study

BACKGROUND

The population is aging and multimorbidity is becoming a common problem in the elderly.

OBJECTIVE

To explore the effect of multimorbidity patterns on mortality for all causes at 3- and 5-year follow-up periods.

MATERIALS AND METHODS

A prospective community-based cohort (2009-2014) embedded within a randomized clinical trial was conducted in seven primary health care centers, including 328 subjects aged 85 years at baseline. Sociodemographic variables, sensory status, cardiovascular risk factors, comorbidity, and geriatric tests were analyzed. Multimorbidity patterns were defined as combinations of two or three of 16 specific chronic conditions in the same individual.

RESULTS

Of the total sample, the median and interquartile range value of conditions was 4 (3-5). The individual morbidities significantly associated with death were chronic obstructive pulmonary disease (COPD; hazard ratio [HR]: 2.47; 95% confidence interval [CI]: 1.3; 4.7), atrial fibrillation (AF; HR: 2.41; 95% CI: 1.3; 4.3), and malignancy (HR: 1.9; 95% CI: 1.0; 3.6) at 3-year follow-up; whereas dementia (HR: 2.04; 95% CI: 1.3; 3.2), malignancy (HR: 1.84; 95% CI: 1.2; 2.8), and COPD (HR: 1.77; 95% CI: 1.1; 2.8) were the most associated with mortality at 5-year follow-up, after adjusting using Barthel functional index (BI). The two multimorbidity patterns most associated with death were AF, chronic kidney disease (CKD), and visual impairment (HR: 4.19; 95% CI: 2.2; 8.2) at 3-year follow-up as well as hypertension, CKD, and malignancy (HR: 3.24; 95% CI: 1.8; 5.8) at 5 years, after adjusting using BI.

CONCLUSION

Multimorbidity as specific combinations of chronic conditions showed an effect on mortality, which would be higher than the risk attributable to individual morbidities. The most important predicting pattern for mortality was the combination of AF, CKD, and visual impairment after 3 years. These findings suggest that a new approach is required to target multimorbidity in octogenarians.

[The Octabaix study. Baseline assessment and 5 years of follow-up]

This is a review of a prospective, community-based study with a follow-up period of 5years. It is a study of 328 participants aged 85 at baseline, of which 62% were female, 53% widows, and a third of them living alone. High blood pressure was observed in 75.9%, dyslipidaemia in 51.2%, and diabetes in 17.7%. At baseline the median Barthel Index was 95, the Spanish version of the Mini-Mental State Examination was 28, the Charlson index 1, the Mini Nutritional Assessment 25, the Gijón test 10, the visual analogue scale of the Quality of Life Test was 60, and with a mean of 6.1 prescription drugs. A lower quality of life was also associated with female gender, a phenotype of frailty, heart failure, and a high level of social risk. At 5years of follow-up, the mortality rate was high, with 138 (42.1%) of the population sample dying at the end of the period. It represents an annual mortality rate of 8.4%. Thus, a common denominator of this review has been the high importance of functionality and overall comorbidity factors associated with mortality in this very old age group, compared to other more traditional factors in younger populations. Several studies of frailty have also been assessed in this group, as well as falls, nutritional risk, diabetes and successful aging, including important aspects to better understand this population group.

Pregnancy as an opportunity to diagnose human-immunodeficiency virus immigrant women in Catalonia

INTRODUCTION

Mother-to-child transmission (MTCT) is relevant in the global epidemiology of human-immunodeficiency virus (HIV), as it represents the main route of infection in children. The study objectives were to determine the rate of HIV-MTCT and its epidemiological trend between the Spanish-born and immigrant population in Catalonia in the period 2000-2014.

METHODS

A prospective observational study of mother-child pairs exposed to HIV, treated in 12 hospitals in Catalonia in the period 2000-2014. HIV-MTCT rate was estimated using a Bayesian logistic regression model. R and WinBUGS statistical software were used.

RESULTS

The analysis included 909 pregnant women, 1,009 pregnancies, and 1,032 children. Data on maternal origin was obtained in 79.4% of women, of whom 32.7% were immigrants, with 53.0% of these from sub-Saharan Africa. The overall HIV-MTCT rate was 1.4% (14/1,023; 95% CI; 0.8-2.3). The risk of MTCT-HIV was 10-fold lower in women with good virological control (P=.01), which was achieved by two-thirds of them. The proportion of immigrants was significantly higher in the period 2008-2014 (P<.0001), for the HIV-diagnosis (P<.0001), and antiretroviral administration (P=.02) during pregnancy, and for undetectable viral load next to delivery (P<.001). There were no differences in the rate of MTCT-HIV among Spanish-born and immigrant women (P=.6).

CONCLUSIONS

There is a gradual increase in HIV pregnant immigrants in Catalonia. Although most immigrant women were diagnosed during pregnancy, the rate of MTCT-HIV was no different from the Spanish-born women.

Missed opportunities for HIV testing of patients diagnosed with an indicator condition in primary care in Catalonia, Spain

OBJECTIVE

To estimate the prevalence of HIV testing among patients diagnosed with an indicator condition (IC) for HIV, seen in primary care (PC) in Catalonia, and to estimate the prevalence of HIV infection among those patients.

DESIGN

Cross-sectional and population-based study in patients aged between 16 and 65 diagnosed with an IC within PC in Catalonia.

METHODS

Data used in this study were extracted from a large population-based public health database in Spain, the Information System for the Development of Research in Primary Care (SIDIAP). All participants registered in SIDIAP from 1 January 2010 to 31 August 2012 and with a diagnosis of an IC were screened to identify those with an HIV test within the following 4 months.

RESULTS

99 426 patients were diagnosed with an IC during the study period. In these patients, there were 102 647 episodes in which at least one IC was diagnosed. An HIV test was performed within 4 months in only 18 515 of the episodes in which an IC was diagnosed (18.5%). The prevalence of HIV infection was 1.46%. Women (OR 1.35, 95% CI 1.30 to 1.39), people aged 50 or over (OR 2.85, 95% CI 2.69 to 3.00) and patients having a single IC (OR 3.59. 95% CI 3.20 to 4.03) had the greatest odds of not having an HIV test.

CONCLUSIONS

The study highlights the persistence of missed opportunities for HIV testing within PC in Catalonia. Urgent engagement with PC professionals is required in order to increase HIV testing and prevent late HIV diagnoses.

Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia

BACKGROUND

In a context of increasing demand and pressure on the public health expenditure, appropriateness of colonoscopy indications is a topic of discussion. The objective of this study is to evaluate the appropriateness of colonoscopy requests performed in a primary care (PC) setting in Catalonia.

METHODS

Cross-sectional descriptive study. Out-patients >14 years of age, referred by their reference physicians from PC or hospital care settings to the endoscopy units in their reference hospitals, to undergo a colonoscopy. Evaluation of the appropriateness of 1440 colonoscopy requests issued from January to July 2011, according to the EPAGE-II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy).

RESULTS

The most frequent indications of diagnostic suspicion requests were: rectal bleeding (37.46 %), abdominal pain (26.54 %), and anaemia study (16.78 %). The most frequent indications of disease follow-up were adenomas (58.1 %), and CRC (31.16 %). Colonoscopy was appropriate in 73.68 % of the cases, uncertain in 16.57 %, and inappropriate in 9.74 %. In multivariate analysis, performed colonoscopies reached an OR of 9.9 (CI 95 % 1.16-84.08) for qualifying as appropriate for colorectal cancer (CRC) diagnosis, 1.49 (CI 95 % 1.1-2.02) when requested by a general practitioner, and 1.09 (CI 95 % 1.07-1.1) when performed on women.

CONCLUSIONS

Appropriateness of colonoscopy requests in our setting shows a suitable situation in accordance with recognized standards. General practitioners contribute positively to this appropriateness level. It is necessary to provide physicians with simple and updated guidelines, which stress recommendations for avoiding colonoscopy requests in the most prevalent conditions in PC.

Twenty years trends and socio-demographic characteristics of HIV prevalence in women giving birth in Catalonia (Spain)

BACKGROUND

Studies of the prevalence of HIV in sentinel populations are one of the key strategies to monitor the HIV epidemic. We describe HIV prevalence trends and identify differences across time in the sociodemographic characteristics of HIV-infected women giving birth in Catalonia.

METHODS

We used dried blood specimens, residual to newborn screening, which have been collected in Catalonia every 2 months since 1994. The total number of samples obtained until 2009 and in 2013 represented half of yearly newborns. From 2010 to 2012, the total number of samples obtained represented a quarter of yearly newborns. We studied the prevalence by year and place of current residence (Barcelona-city, cities>200,000 inhabitants and cities ≤ 200,000 inhabitants) and by the mother's birth country. A total of 624,912 infants were tested for HIV antibodies from January 1994 to December 2013.

RESULTS

HIV prevalence trends among women giving birth in Catalonia decreased until 2007. Thereafter, there was a change to a steady trend until 2013. However, among foreign women giving birth and living in cities ≤ 200,000 inhabitants, the prevalence of HIV increased from 2007 to 2013.

CONCLUSION

To ensure early identification and treatment of HIV-infected mothers, it is essential to maintain HIV surveillance programs and pre- and post-natal screening programs, both in Barcelona and in cities with 200,000 inhabitants or less, especially in immigrant women.

[Prevalence of nasal carriage of Staphylococcus aureus and Streptococcus pneumoniae in Primary Care and factors associated with colonization]

OBJECTIVE

To determine (i) the prevalence of Staphylococcus aureus (S.aureus) and Streptococcus pneumoniae (S.pneumoniae) nasal carriage in Primary Health Care patients in area of Barcelona, and (ii) the factors associated with S.aureus and S.pneumoniae colonization.

METHODS

Multi-center cross-sectional study conducted in 2010-2011 with the participation of 27 Primary Health Care professionals. Nasopharyngeal swabs were obtained from 3,969 patients over 4 years of age who did not present with any sign of infection.

DEPENDENT VARIABLES

S.aureus and/or S.pneumoniae carrier state.

INDEPENDENT VARIABLES

socio-demographic characteristics, health status, vaccination status, occupation, and living with children. A descriptive analysis was performed. The prevalence of carriers of S.aureus and/or S.pneumoniae was calculated and logistic regression models were adjusted by age.

RESULTS

In children from 4 to 14 years old, the prevalence of S.aureus carriers was 35.7%, of S.pneumoniae 27.1%, and 5.8% were co-colonized. In adults older than 14 years old, the prevalence was 17.8%, 3.5%, and 0.5%, respectively. In children, S.aureus carrier state was inversely associated with S.pneumoniae carrier state; S.pneumoniae was associated with younger age, and inversely associated with S.aureus carrier state. In adults, being a carrier of S.aureus was associated with male gender, younger age, and a health-related occupation, whereas S.pneumoniae carrier state was associated with living with children under 6 years of age. The proportion of co-colonized carriers was low (1.0%).

CONCLUSIONS

The proportion of S.aureus and S.pneumoniae carriers was higher in children than in adults. Age was the only factor associated with healthy carrier status for S.aureus and for S.pneumoniae.

Improvement of functional constipation with kiwifruit intake in a Mediterranean patient population: An open, non-randomized pilot study

Introducción: Consumir kiwi mejora el estreñimiento funcional en la población anciana sana de Nueva Zelanda y China. Nuestro objetivo es evaluar el efecto del kiwi en la población mediterránea con estreñimiento.Material y métodos: Estudio prospectivo longitudinal no cegado no aleatorizado. 46 pacientes adultos con estreñimiento (criterios Roma-III) fueron seguidos durante cinco semanas: dos previas y tres durante la intervención (3 kiwi/día) (Green kiwifruit, Actinidia deliciosa var Hayward). Autoinforme diario del número de deposiciones, consistencia y volumen heces y facilidad de evacuación. La evolución de las variables categóricas se testó con el test Bhapkar, las variables continuas mediante metodología de análisis de datos funcionales ajustando modelos basados en las ecuaciones de estimación generalizadas (GEE).Resultados: El porcentaje de pacientes con ≥3 deposiciones/semana aumentó de 82,61% (IC 95%: 69–91,2) en la primera semana hasta 97,78% (IC 95%: 87,4–99,9) al final de semana 2 de consumo, con una respuesta del 76,09% (IC 95%: 61,9–86,2) en la primera semana. El porcentaje de heces consideradas ideales pasó de 17,39% (IC 95%: 8,8–31) en la segunda semana a 33,33% (IC 95%: 21,3–48) en la semana 5. Según los modelos GEE, el número de deposiciones aumenta significativamente (valor p<0,001) en 0,398 unidades diarias en la primera semana de consumo, hasta 0,593 unidades diarias en la última semana. A partir de la primera semana se observa mejoras significativas en el volumen de las heces y en la facilidad de la defecación (valores p<0,001).Conclusiones: Consumir tres kiwis al día mejora significativamente la calidad de la evacuación (número deposiciones, volumen, consistencia y facilidad evacuación), en una población mediterránea de pacientes con estreñimiento.

A cross-sectional study of the appropriateness of colonoscopy requests in the Spanish region of Catalonia

INTRODUCTION

Colonoscopies are being requested with increasing frequency in the last few years, as they are used both as a diagnostic and therapeutic procedure in several gastrointestinal diseases. Our purpose is to describe the appropriateness of colonoscopy requests issued both from primary care centres and from hospitals, according to the EPAGE II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy).

METHODS AND ANALYSIS

Cross-sectional study. Colonoscopy requests issued since January 2011 and received at the endoscopy units of all six reference hospitals serving the primary care centres of the South Metropolitan and Central Catalonia districts will be collected (total=1500 requests). Variables to be collected include gender, date of birth, origin of the request and reference hospital, priority of the procedure, type of clinician requesting the procedure, date and indication of request, abdominal examination performed, anal inspection examination performed, date of last colonoscopy if applicable, diagnosis and date of diagnosis. Using the available information and the EPAGE II website, colonoscopy requests will be assigned as an appropriateness score. The association between the variables collected and the EPAGE II scores will be assessed using a Student's t test and a χ(2) test. A multilevel logistic model will be generated on the factors associated with the appropriateness of the requests.

ETHICS AND DISSEMINATION

Colonoscopy is a costly procedure and not free from complications. In order to increase cost effectiveness, reduce waiting lists and optimise resources, it is necessary to use tools such as the EPAGE II guidelines, which establish criteria to assess the appropriateness of colonoscopies. The purpose of this study is to describe the current situation and to discuss whether current clinical practice is appropriate. The results of the study will be published in the next few years. In consideration of the ethical principles and methods of the research study, approval was granted for the project.

Unlinked anonymous testing to estimate HIV prevalence among pregnant women in Catalonia, Spain, 1994 to 2009

This paper estimates the prevalence of human immunodeficiency virus (HIV) infections in women giving birth and women voluntarily terminating pregnancy over a period of sixteen years in Catalonia. Samples for HIV antibody detection were collected from the Neonatal Early Detection Programme for congenital metabolic diseases that covers 99% of infants born in Catalonia. The sampling method collected information of 50% of births every year and of all women attending three clinics for voluntary interruption of pregnancy. Using two sequential immunoassays we analysed unlinked anonymous blood spot samples from 549,689 newborns between 1994 and 2009 and from 31,904 women who voluntarily interrupted pregnancy between 1999 and 2006. HIV prevalence among women giving birth decreased from 3.2 per 1,000 in 1994 to 1.7 per 1,000 in 2009 (p<0.01) and the mean age of infected mothers increased from 26 years in 1994 to 32 years in 2009 (p=0.001). A decrease in HIV prevalence was also observed in women voluntarily terminating pregnancy, from 2.3 per 1,000 in 1999 to 1.0 per 1,000 in 2006 (p<0.01). In contrast, estimated HIV prevalence in mothers born outside Spain increased from 2.2 per 1,000 in 2002 to 3 per 1,000 in 2009 (p<0.01) and their average age increased from 27 years in 2003 to 31 years in 2009 (p<0.01).

Unlinked anonymous testing to estimate HIV prevalence among pregnant women in Catalonia, Spain, 1994 to 2009

This paper estimates the prevalence of human immunodeficiency virus (HIV) infections in women giving birth and women voluntarily terminating pregnancy over a period of sixteen years in Catalonia. Samples for HIV antibody detection were collected from the Neonatal Early Detection Programme for congenital metabolic diseases that covers 99% of infants born in Catalonia. The sampling method collected information of 50% of births every year and of all women attending three clinics for voluntary interruption of pregnancy. Using two sequential immunoassays we analysed unlinked anonymous blood spot samples from 549,689 newborns between 1994 and 2009 and from 31,904 women who voluntarily interrupted pregnancy between 1999 and 2006. HIV prevalence among women giving birth decreased from 3.2 per 1,000 in 1994 to 1.7 per 1,000 in 2009 (p<0.01) and the mean age of infected mothers increased from 26 years in 1994 to 32 years in 2009 (p=0.001). A decrease in HIV prevalence was also observed in women voluntarily terminating pregnancy, from 2.3 per 1,000 in 1999 to 1.0 per 1,000 in 2006 (p<0.01). In contrast, estimated HIV prevalence in mothers born outside Spain increased from 2.2 per 1,000 in 2002 to 3 per 1,000 in 2009 (p<0.01) and their average age increased from 27 years in 2003 to 31 years in 2009 (p<0.01).

Core indicators evaluation of effectiveness of HIV-AIDS preventive-control programmes carried out by nongovernmental organizations. A mixed method study

Background

The number of nongovernmental organizations working on AIDS has grown. There is great diversity in the type of activities and population groups that have been targeted. The purposes of this study are: to describe and analyze the objectives and HIV-AIDS preventive activities that are carried out by the AIDS-NGOs that work with AIDS in Catalonia and that receive subsidies from the Department of Health; and to develop a comprehensive proposal for measurable and agreed upon core quality evaluation indicators to monitor and assess those objectives and activities that can have an impact on the fight against inequalities and stigmatization, and incorporate the perspectives of the service providers and users.

Methods

A mixed method study has been carried out with professionals from the 36 NGOs that work with HIV/AIDS in Catalonia, as well as their users. This study achieved the completeness model using the following phases:

1. A systematic review of AIDS-NGOs annual reports and preparation of a catalogue of activities grouped by objectives, level of prevention and AIDS-NGOs target population; 2. A transversal study through an ad-hoc questionnaire administered to the AIDS-NGOs representatives; 3. A qualitative study with a phenomenological approach through focus groups, individual interviews and observations; 4. Consensus meetings between AIDS-NGOs professionals and the research team using Haddon matrices in order to establish a proposal of evaluation indicators.

Results

The information was classified according to level of prevention and level of intervention. A total of 248 objectives and 258 prevention activities were identified. 1564 evaluation indicators, addressed to 7 target population groups, were produced. Thirty core activities were selected. The evaluation indicators proposed for these activities were: 76 indicators for 15 primary prevention activities, 43 for 5 secondary prevention activities and 68 for 10 tertiary prevention activities.

Conclusions

The results could help to homogeneously assess the preventive-control activities carried out of AIDS-NGOs. The proposed indicators could help the professionals to improve the evaluation of the preventive-control AIDS-NGOs activities. Furthermore, the Haddon matrix enables us to identify deficiencies of activities at intervention levels and strategies to bear in mind in order to enhance the future AIDS prevention programs.

[Inappropriate prescription in the community elderly, are we aware of?]

OBJECTIVES

To analyse the prescription according to the STOPP (Screening Tool of Older Person's Prescriptions) and Beer's suitability criteria, and associated factors in patients over 85 years-old.

PATIENTS AND METHODS

Cross-sectional study of inappropriate prescribing to over 85 year-olds. The data recorded were: sociodemographic variables, cardiovascular risk factors, chronic illnesses, multiple medication (or polypharmacy) (4 or more) and geriatric assessment. The inappropriate prescription (IP) was evaluated according to total and cardiovascular prescription.

RESULTS

The mean number of drugs in the total of 78 subjects was 6.1 (3.3). Of the total number, 34.6% patients had 1 IP drug; 19.2% had 2; 15.4% had 3 or more, and in total 69.2% of patients had at least one IP drug, and 37.2% had 1 or more IP cardiovascular drugs. The therapeutic groups involved in the overall IP were benzodiazepines (BZP) 23.1%, loop diuretics 17.9%, selective serotonin reuptake inhibitors (SSRIs) 16.7%, and non-steroidal anti-inflammatory drugs (NSAIDs) made up 10.3% of the total criteria. The bivariate analyse found a relationship between the number of drugs and multiple medication (P=.030 in both) and total IP, with no significance found in cardiovascular IP. The multivariate analysis showed an association between multiple medication (OR: 1.22; 95% CI: 1.02-1.47; P=.031) and total IP, and dyslipaemia (OR: 0.30; 95% CI: 0.10-0.87; P=.026) and AHT (OR: 0.15; 95% CI: 0.03-0.78; P=.024) for cardiovascular IP.

CONCLUSIONS

More than half the over 85 year-old patients received an inappropriate prescription. Dyslipaemia and AHT are associated with an inappropriate cardiovascular prescription, and the most frequent drug groups were, BZP, diuretics, SSRIs, and NSAIDs.

Experiences about HIV-AIDS preventive-control activities. Discourses from non-governmental organizations professionals and users

OBJECTIVES

The main aim of this study was to identify the experiences of professionals in nongovernmental organizations (NGO) in Catalonia (Spain) working in HIV/AIDS prevention and control activities and potential areas of improvement of these activities and their evaluation. A further aim was to characterize the experiences, knowledge and practices of users of these organizations with regard to HIV infection and its prevention.

METHODS

A phenomenological qualitative study was conducted with the participation of both professionals and users of Catalan nongovernmental organizations (NGO) working in HIV/AIDS. Theoretical sampling (professional) and opportunistic sampling (users) were performed. To collect information, the following techniques were used: four focus groups and one triangular group (professionals), 22 semi-structured interviews, and two observations (users). A thematic interpretive content analysis was conducted by three analysts.

RESULTS

The professionals of nongovernmental organizations working in HIV/AIDS adopted a holistic approach in their activities, maintained confidentiality, had cultural and professional competence and followed the principles of equality and empathy. The users of these organizations had knowledge of HIV/AIDS and understood the risk of infection. However, a gap was found between knowledge, attitudes and behavior.

CONCLUSIONS

NGO offer distinct activities adapted to users' needs. Professionals emphasize the need for support and improvement of planning and implementation of current assessment. The preventive activities of these HIV/AIDS organizations are based on a participatory health education model adjusted to people's needs and focused on empowerment.

[Gender differences in health status in a population of over 85 year-olds: the Octabaix study]

OBJECTIVE

To examine gender differences according to health status in the oldest old people of the community.

DESIGN

Cross-sectional multicentre study, within the framework of a clinical trial on falls and malnutrition.

SETTING

7 primary health centres.

PARTICIPANTS

Non-institutionalised patients of 85 years or over.

METHODS

The data collected included, socioeconomic data, cardiovascular risk factors, Barthel Index (BI), cognitive status with the Mini-Mental State Examination (MMSE), Charlson Index to measure comorbidity, nutritional risk evaluated by Nutritional Assessment questionnaire (MNA), mean visual analogue self-rating scale in Euroqol- 5D (EQ-VAS) to assess health related quality life and, Gijón social risk test, and prescribed drugs.

RESULTS

A total of 312 subjects were included, of which 61.6% were women, 53% widows and a third of them lived alone. High blood pressure was observed in 76%, dyslipidemia in 51.2%, diabetes in 17.4%, median BI 95 (rank 0-100), MMSE 28 (0-35), Charlson index 1 (0-7), MNA 25 (10-30), Gijón test 10 (5-21), EQ-VAS 60 (0-100) and the mean prescription drugs 6.1±3.3. Women most frequently lived alone (P<.001), fell more (P<.006), had a greater nutritional (P<.016) and social risk (P<.001). Men were more likely to be married (P<.001), had better cognition (P<.003), better functional status (P<.018), and higher comorbidity (P<.001).

CONCLUSION

Being a 85 years old man is associated with being married, having better functionality and cognition, and a higher comorbidity. While being a woman is associated with living alone, a higher rate of falls, and nutritional and social risk. These results are important to help this group of elderly to maintain their position in the community.

Utility of geriatric assessment tools to identify 85-years old subjects with vitamin D deficiency

OBJECTIVES

To calculate the prevalence of hypovitaminosis D in subjects aged 85 years old and to study the relationship between some common geriatric evaluation scales and vitamin D status.

DESIGN

Prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

312 subjects aged 85 years old.

MEASUREMENTS

Geriatric assessment was based on comorbidity, functional status according to the Barthel Index (BI) and Lawton Index (LI), cognitive status measured by the Spanish version of the Mini-Mental State Examination (MEC), nutritional risk according to the Mini Nutritional Assessment (MNA), and gait using the Tinetti Gait Scale. Serum 25(OH)D concentrations were used to assess vitamin D status. Hypovitaminosis D was considered as < 25 ng/ml and deficiency < 11 ng/ml.

RESULTS

Mean serum 25(OH)D level was 28 ± 30 ng/ml. The prevalence of hypovitaminosis D was 52.5% (38.1% insufficiency and 14.4% deficiency). Men had higher levels than women (32.2 ± 44 vs. 25.2 ± 25 ng/ml; p=0.04). The bivariate analyses identified an association between MNA scores and hypovitaminosis D, and showed that females ande participants with poor BI, Tinetti and MNA scores were associated with deficiency. Logistic regression analysis confirmed a significant association between poor MNA scores and both hypovitaminosis D (p < 0.04, OR 1.066, 95% CI 1.002-1.135) and vitamin D deficiency (p < 0.0001, OR 1.192, 95% CI 1.099-1.293).

CONCLUSIONS

More than half the population aged 85 years has a vitamin D deficit and 14.4% show a deficiency. A lower score on the MNA scale is associated with a greater likelihood of having lower vitamin D serum values.

Evaluation of a combined strategy directed towards health-care professionals and patients with chronic obstructive pulmonary disease (COPD): information and health education feedback for improving clinical monitoring and quality-of-life

Background

Chronic obstructive pulmonary disease (COPD) is a health problem that is becoming increasingly attended-to in Primary Care (PC). However, there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines (CPG). The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality-of-life (QoL) of the patients via a feedback on their state-of-health. A training plan for the health-care professionals is based on CPG and health education.

Method/Design

Multi-centred, before-after, quasi experimental, prospective study involving an intervention group and a control group of individuals followed-up for 12 months. The patients receive attention from urban and semi-urban Primary Care Centres (PCC) within the administrative area of the Costa de Ponent (near Barcelona). All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub-areas to the group control. The intervention includes providing data to the health-care professionals (clinician/nurse) derived from a clinical history and an interview. A course of training focused on aspects of CPG, motivational interview and health education (tobacco, inhalers, diet, physical exercise, physiotherapy). The sample random includes a total of 801 patients (≥ 40 years of age), recorded as having COPD, receiving attention in the PCC or at home, who have had at least one clinical visit, and who provided written informed consent to participation in the study. Data collected include socio-demographic characteristics, drug treatment, exacerbations and hospital admissions, evaluation of inhaler use, tobacco consumption and life-style and health-care resources consumed. The main endpoints are dyspnoea, according to the modified scale of the Medical Research Council (MRC) and the QoL, evaluated with the St George's Respiratory Questionnaire (SGRQ). The variables are obtained at the start and the end of the intervention. Information from follow-up visits focuses on the changes in life-style activities of the patient.

Discussion

This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation, compared to standard clinical practice.

Trial Registration

Clinical Trials.gov Identifier: NCT00922545;

Gestational diabetes mellitus in a cohort of HIV-1 infected women

OBJECTIVES

We undertook a prospective study to estimate the prevalence of gestational diabetes mellitus (GDM) and associated risk factors in a cohort of 669 HIV-1 infected women.

METHODS

The O'Sullivan and glucose tolerance tests were performed during regular visits of 609 mothers.

RESULTS

The median age of the cohort was 30.7 years (range 16-44), with most women having had heterosexual contact (67%). The majority were in Centers for Disease Control (CDC) category A (71%) and 53% exhibited hepatitis C co-infection. Median viral load and CD4 count at third trimester were 545 cells/microL (range 139-1690 cells/microL) and 1.9 log (range 1.7-5.4), respectively. Seventy-four per cent of the patients were treated with highly active antiretroviral therapy (HAART), of whom 41% received a protease inhibitor (PI). An above-average prevalence of 7% [95% confidence interval (CI) 5.2-9.5] for positive GDM diagnosis was found. Risk factors associated with GDM in univariate analysis included older age, hepatitis C co-infection, stavudine and PI exposure. However, only older age [adjusted odds ratio (AOR) 1.09, 95% CI 1-1.1] and PI exposure (AOR 2.4, 95% CI 1-5.3) remained as independent risk factors for GDM development in multivariate analysis.

CONCLUSIONS

In our cohort, the prevalence of GDM appears to be increased, with older age and PI exposure contributing as significant independent risk factors.

Coverage of HIV testing among pregnant women in Catalonia, Spain: a comparison of self-reporting with medical records

BACKGROUND

to estimate the coverage of HIV testing during pregnancy in Catalonia, to identify factors associated with testing during pregnancy and to assess the recording of screening in medical records and the women's awareness about being tested.

METHODS

A survey was carried out in 2000 among pregnant women attending hospital, with face-to-face interview 24-48 hours post-delivery, and review of the medical records.

RESULTS

Out of 2,132 participants, 76% were from public and 24% from private hospitals. Medical records showed that 88.3% of the participants had a HIV test (94% in public, 71% in private hospitals), while for 3.7% and 18.5% in private and public, respectively, this information was not documented. Overall, 67% of women reported having been tested for HIV during that pregnancy, and unawareness of having been tested was detected in 10.7%. Educational level and prenatal care are determinants for being tested.

CONCLUSION

Catalonia has a good coverage of HIV testing among childbearing women, although it is lower in private hospitals. Frequently prenatal HIV testing is not documented in medical records and women are unaware of it. Improving the prenatal care and tailoring these programmes to specific populations, like migrants or marginalized groups, will result in a better understanding of HIV prevention and in an increase in HIV testing before delivery.

Evaluation of a commercial enzyme immunoassay for HIV screening in urine

A cross-sectional study was conducted to evaluate the utility of a commercial enzyme immunoassay (EIA) as a screening test for detecting HIV-1 antibody in urine in a population at risk for HIV infection in Catalonia, Spain. Paired urine and serum samples were collected consecutively from 99 patients who attended two drug-dependency treatment centres and 151 patients who attended a sexually transmitted diseases (STD) clinic in Barcelona. Antibodies against HIV in urine samples were detected using the Calypte HIV-1 Urine EIA (Calypte Biomedical Corporation, Berkeley, CA, USA) and confirmed by urine-based Western blot (WB) analysis. Sera were analysed using Bioelisa HIV-1+2 EIA (Biokit Laboratories, Barcelona, Spain), and the results were verified using serum-based WB analysis. Results of both urine and serum testing were available for 246 of 250 participants. For 52 individuals the results of both urine and serum testing were positive and for five the results were discordant (2 with urine-negative/serum-positive results and 3 with urine-positive/serum-negative results). The respective sensitivity and specificity values obtained for the urine EIA were 100% and 96.2% for intravenous drug users (IDUs) and 80% and 99.3% for persons attending the STD clinic. According to the 1997 UNAIDS/WHO strategy I recommendations, these values are acceptable for surveillance purposes, particularly in populations with a high prevalence of HIV infection.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

[Non-occupational post-exposure HIV prophylaxis. Knowledge and practices among physicians and groups with risk behavior]

BACKGROUND AND OBJECTIVE

Although occupational post-exposure HIV prophylaxis is widely admitted and used, the non-occupational post-exposure prophylaxis (NONOPEP) is controversial. Prevention of mother-to-child HIV transmission, experimental studies in animal models and retrospective studies in health workers, along with biological plausibility, would justify the use of NONOPEP in certain circumstances. Our objectives were: 1) To review the existence of recommendations; 2) To describe the attitudes, knowledge and practices of the professionals involved in the attention of non-occupational exposures to HIV; 3) To describe the attitudes and knowledge on such a prophylaxis by people with risk behaviours (homosexual men and intravenous drug users (IDU)); and 4) To describe the NONOPEP-related responses of telephone services of public attention on AIDS.

SUBJECTS AND METHOD

Descriptive study by means of a survey of each defined target population between September 1999 and July 2000, using self-administered questionnaires and personal interviews. Structured and simulated interviews were used to survey the telephone services.

RESULTS

To date, no official recommendations exist. 84% (97/116) of consulted doctors have taken care of some of non-occupational accidental exposure to HIV over the last six months. 77% (75/97) have prescribed NONOPEP, and 76% of doctors prescribing NONOPEP (57/75) have used the 1998 CDC recommendations for occupational exposures. Most frequent observed cases were related to needle sticks in the street and preservative breakage. The assessment of certain risk factors and therapeutic performance in cases of intermediate risk showed discrepancies among doctors. 41% (103/252) among homosexuals and 2% (3/160) among IDU on treatment know the NONOPEP. 15% (15/98) and 98% (70/118) respectively would take less prevention to avoid HIV infection if they took the NONOPEP. It was mentioned the possibility of NONOPEP in 20% (12/59) of calls to the information telephone services on AIDS.

CONCLUSIONS

HIV risk accidents susceptible of NONOPEP are relatively frequent. Without forgetting the greater importance of primary prevention, it is advisable to reach and agreement on homogeneous recommendations. It is also advisable to draw up a surveillance system to evaluate the application and eventually the effectiveness of these recommendations.

[Determinants of HIV mother-to-child transmission in Catalonia, Spain [1997-2001]: is it possible to eliminate it?]

OBJECTIVES

To identify and describe the factors that have led to new cases of HIV infection through mother-to-child transmission since the introduction of antiretroviral therapy in HIV-seropositive pregnant women (1997-2001) in Catalonia.

METHODS

Systematic review of cases identified in the pediatric services of all the hospitals in Catalonia.

RESULTS

Twenty-eight cases of pediatric HIV infection were identified: 9, 9, 8, 2 and 0 per year of birth from 1997 to 2001, respectively. Of 16 mothers with a diagnosis of known HIV infection before or during pregnancy, nine underwent antiretroviral prophylaxis during pregnancy (compliance was good in five, unknown in one and poor in one) and seven did not undergo prophylaxis (six refused it and no information was available in one). Of 12 mothers diagnosed after delivery, pregnancy was not monitored in five and was little or well-monitored in the remaining seven. Of mothers with well-monitored pregnancy, a serological HIV test was not performed in six and was negative in the first trimester in one.

CONCLUSIONS

Mother-to-child transmission of HIV has decreased in the last few years in Catalonia, but infections have sometimes occurred through poor implementation of preventive measures. Pregnant women should be offered an HIV diagnostic test not only in the first trimester but also at the end of pregnancy if HIV exposure is suspected. In women with unmonitored pregnancies, rapid diagnostic tests for HIV should be used in the delivery room.

Plasmodium falciparum multiple infections in Mozambique, its relation to other malariological indices and to prospective risk of malaria morbidity

We describe the frequency of Plasmodium falciparum clones infecting individuals living in a rural area of southern Mozambique and analyse the relationship between multiplicity of infection, age and other malariometric indices, including prospective risk of clinical malaria. The genotyping was based on the use of restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR) analysis of P. falciparum merozoite surface protein 2 (msp2). We analysed 826 samples collected during five cross-sectional surveys from residents of Manhiça ranging in age from 4 months to 83 years. We also determined the multiplicity of infection in samples obtained from 6-month-old infants (n = 79) and children <10 years (n = 158) who were then treated and followed prospectively for 1 year or 75 weeks, respectively. Multiplicity of infection did not vary significantly during the first year of life, but increased thereafter, and decreased during adulthood to the levels found in infants. With increasing multiplicity of infection, there was a statistically significant decrease in the risk of submicroscopic infections. There was also a significant correlation between multiplicity of infection and parasite density in infants, children <4 years of age and adults, suggesting that high densities increase the probability of discriminating more clones in complex infections. We found that the relationship between multiple infections and malaria morbidity is age-dependent. In infants, the risk of subsequent episodes of clinical malaria was related to the parasite density but not to baseline multiplicity of infection. In older children, however, the more clones a child carried, the more likely they were to have a clinical malaria episode, and this was true after adjusting for parasite densities. This change in the association between multiplicity and risk of clinical malaria may indicate a shift in the host response to P. falciparum.

[Reporting new HIV cases in Catalonia, Spain: is technical consensus feasible?]

OBJECTIVE

To describe the process performed in Catalonia (Spain) to design an information system for monitoring new cases of HIV infection.

METHODS

A survey was used to evaluate perception of the need for notification of HIV infection by health care professionals (n = 106), as well as their opinions of the various possibilities for the implementation of the notification system. As a result of this evaluation, a specific technical report defining the objectives and technical characteristics of the new notification system was produced. The feasibility of the system in health centres was evaluated through discussions with health care professionals, health authorities and Non-Governmental Organizations, and a second survey was designed to evaluate the use of a personal identification code (PIC) from the individual health card (IHC). This process took plabe between 1998 and 2000.

RESULTS

A total of 84.5% of the health care professionals believed that HIV notification should be mandatory and confidential; 90.4%, were of the opinion that notification would enable identification of the epidemiological characteristics of infected individualos, and 75% believed that these individuals would have to be identified by name. Finally, 66% of the health care professionals believed that the use of the PIC from the IHC would be feasible as the personal identifier in HIV notification. A final proposal was draw up and 1 January, 2001 was set as the date to initiate the pilot phase of the new HIV notification system.

CONCLUSIONS

Most of the health care professionals surveyed expressed the need for notification of HIV infection, and for such notification to receive institutional endorsement. They also believed that, as with other diseases of individualized mandatory reporting, notification should be carried out with a single personal identifier. The information obtained from notification of HIV infection is essential for the optimal planning of preventive programs and the provision of health services. The main difficulties observed were that HIV infection has not been included among the diseases of mandatory reporting, as well as the low implantation of the PIC in the hospitals' clinical registries. All the sectors involved have an important role to play in creating the conditions necessary for the notification system of new cases of HIV infection to be feasible and useful.

[Recommendations for non-occupational postexposure HIV prophylaxis. Spanish Working Group on Non-Occupational Postexposure HIV Prophylaxis of the Catalonian Center for Epidemiological Studies on AIDS and the AIDS Study Group]

Evidence is lacking on the possible efficacy and effectiveness of non-occupational postexposure prophylaxis (PEP). However, because of its biological plausibility, the use of antiretroviral (ARV) drugs to prevent the development of infection in certain cases of accidental or sporadic exposure has begun to be considered as common clinical practice. Previous studies performed in Spain have demonstrated both the demand and the prescription of ARV as PEP and especially the diversity and inconsistency in the criteria used. In this context, in April of 2000 the Centre for Epidemiological Studies on AIDS of Catalonia (CEESCAT) (Department of Health and Social Security of the Autonomous Government of Catalonia), in collaboration with the National AIDS Plan and the AIDS Study Group (GESIDA), promoted the creation of a working group for the drafting of recommendations for PEP against HIV outside the occupational health context. The recommendations have been made bearing in mind the exceptional character of the exposure, the time elapsed since exposure, as well as evaluation of the risk of infection according to the type of exposure and the information available on the source of infection. In addition, the recommendations include the immediate measures necessary, as well as the preventive measures and clinical follow-up required both for HIV and for other infectious agents. All PEP regimens should be started within 72 hours of exposure and appropriate daily doses of two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI), or two NRTIs and a non-nucleoside reverse transcriptase inhibitor (NNRTIs), should be administered for four weeks, bearing in mind the pharmacological and clinical situation of the source person. These recommendations should be updated periodically.

Clinical evaluation of an in-house IS6110 polymerase chain reaction for diagnosis of tuberculosis

The aim of this study was to clinically validate a heminested polymerase chain reaction (PCR) method, based on the IS6110 insertion segment of Mycobacterium tuberculosis complex, for the diagnosis of tuberculosis. Samples of pulmonary, extrapulmonary and blood origin were collected prospectively from 331 patients. All samples were processed to detect acid-fast bacilli by direct stain, culture and PCR. The gold standard comparison was a clinically based final case definition of tuberculosis corresponding to group 3 of the American Thoracic Society's classification system. The sensitivities of stain, culture and PCR were 41%, 65% and 59%, respectively. Overall specificity exceeded 97% for all techniques. The combination of PCR and direct stain achieved a sensitivity similar to that of culture alone. The PCR method detected 74 of 95 (78%) culture-positive results. In a hospital setting, PCR could be a useful, reliable tool for diagnosis of tuberculosis and may be introduced as a complementary routine diagnostic laboratory method.

[Schistosomiasis imported by Spanish travelers: clinico-epidemiologic study of 80 cases]

BACKGROUND

Swimming in rivers or lakes is a risk activity, in areas where the life cycle of schistosomiasis occurs. This report presents and analyzes the clinical presentation and epidemiological data of 80 Spanish travellers.

PATIENTS AND METHODS

Descriptive longitudinal and retrospective study that includes clinicoepidemiological and the laboratory data and imaging diagnosis. Patients were seen at the Section of Tropical Medicine, Hospital Clínic i Provincial, Barcelona.

RESULTS

Most patients acquired the infection in the Dogon country of Mall. 25% of them presented with symptoms related to the genital tract. In some groups, 45% of travellers that swam, contracted the infection. The most prevalent species diagnosed was S. haematobium and 10 travellers presented with mixed infections.

CONCLUSIONS

The trip to the Dogon country should be considered as "a risk activity". Travellers Advice Clinics should include the subject of swimming in infected waters in their routine counselling. Genital tract localizations were registered for three species of schistosome. The classical clinical presentation of schistosomiasis in the endemic areas differs considerably from that seen in travellers.

Morphometric variability of Schistosoma intercalatum eggs: a diagnostic dilemma

Variability of Schistosoma intercalatum eggs in shape and size, and their similarity to those of S. haematobium presented a problem of species identification when egg morphology was the diagnostic criterion used in a study of human schistosomiasis conducted on São Tomé and Principe. More than 2500 egg measurements were obtained by light micoscopy to gather data relating to size variability of S. intercalatum eggs, to evaluate whether factors such as age of host, sex of host and intensity of infection are correlated with variability, and the data were compared with previously published measurements on different isolates and strains of S. intercalatum: the range in length (104-203 microns) embraces most of the measurements reported in other studies of S. intercalatum eggs. There was no correlation either between age and sex of the host, or intensity of infection with variability of egg size. Comparison between measurements of the eggs of S. haematobium, S. intercalatum and S. bovis eggs are presented.

Schistosomiasis in the Republic of São Tomé and Principe: characterization of Schistosoma intercalatum

This paper reports the morphological and biochemical characterization of the species of Schistosoma infecting humans in the Republic of São Tomé and Principe. The eggs are typical in shape and size of S. intercalatum, measuring on average between 174.5 microns and 189.1 microns. The eggs are voided in the faeces and not the urine of infected people. The parasite experimentally develops in several different species of Bulinus belonging to the B. forskalii group, including B. forskalii, with a minimum prepatent period of 25 d, and also in snails of the B. reticulatus group (B. wrighti); it is incompatible with snails of the B. africanus and B. truncatus/B. tropicus complex. A survey of 5 different habitats at intervals of 2 weeks over a period of one year showed that populations of B. forskalii increased during the dry period of June, July and August in 1988, and in 3 of the habitats snails were present throughout the year. Hence transmission may take place in these habitats throughout the year. Preliminary evidence suggests that water velocity is a limiting factor confining Bulinus to the north-east of the island where the terrain is less mountainous. Development of schistosomes from São Tomé was followed in experimentally infected hamsters. The cross-over point (the point at which the paired male and female worms are of the same average length) occurred at about 49 d after infection: eggs were first seen in the uteri of the female worms 48 d after infection. The parasite from São Tomé developed in sheep and produced viable eggs.(ABSTRACT TRUNCATED AT 250 WORDS)

Schistosomiasis in the Republic of São Tomé and Principe: human studies

The only schistosome species found in stool specimens in the local population of the republic of São Tomé is Schistosoma intercalatum. An initial survey of schoolchildren showed an overall prevalence of 10.9%, with some schools reaching 29%. No S. haematobium egg was found in 782 urine specimens from the local population, although some were seen in the urine of Angolan soldiers stationed near the capital city. One village in the endemic area, San Marçal, had an S. intercalatum prevalence of 43%, with 14 persons > 40 years of age harbouring severe infections. The transmission area is restricted to the north-east of the main island, where 5 foci apparently account for most of the infections. Seven cases recorded from Principe may be explained by the fact that the children were attending school at São Tomé. Women carrying out domestic activities are more at risk of contracting the infection because of longer periods of water contact than men. The morbidity produced by the infection is restricted to splenomegaly and blood in the stools. High prevalences have been found of Ascaris lumbricoides and Trichuris trichiura, and hookworm and Stronglyloides stercoralis were also observed. Praziquantel was well tolerated and appears to be a good tool for control purposes, although reinfection in the transmission area apparently occurs rapidly. Control strategies based on chemotherapy should take into account an older age group as well as the schoolchildren. Focal mollusciciding and the introduction of washing facilities may also have a role to play in control. The possible recent introduction of the infection to the island is discussed.

Hematospermia: a new etiology of clinical interest

Ten Spanish male tourists developed hematospermia and ultrasonographic evidence of involvement of the prostate and/or seminal vesicles after recreational exposure in bodies of fresh water in the Dogon country of Mali. Schistosoma eggs were detected in the ejaculate of five men, in the others, eggs were observed in the urine or feces. Three different species were observed: S. intercalatum, S. haematobium, and S. mansoni. Hemospermia and clinical prostatitis may be frequently unrecognized clinical manifestations of the early stages of infection in previously nonexposed persons. Travelers to endemic areas should be advised on the potential dangers of swimming and other exposure in bodies of freshwater.