Antoni Trilla

Preoperative Staging and Tumor Resectability Assessment of Pancreatic Cancer: Prospective Study Comparing Endoscopic Ultrasonography, Helical Computed Tomography, Magnetic Resonance Imaging, and Angiography

OBJECTIVES:The objective of this study was to evaluate prospectively the efficacy of different strategies based on endoscopic ultrasonography (EUS), helical computed tomography (CT), magnetic resonance imaging (MRI), and angiography (A) in the staging and tumor resectability assessment of pancreatic cancer.METHODS:All consecutive patients with pancreatic carcinoma judged fit for laparotomy were studied by EUS, CT, MRI, and A. Results of each of the imaging techniques regarding primary tumor, locoregional extension, lymph-node involvement, vascular invasion, distant metastases, tumor TNM stage, and tumor resectability were compared with the surgical findings. Univariate, logistic regression, decision, and cost minimization analyses were performed.RESULTS:Sixty-two patients with pancreatic cancer were included. Helical CT had the highest accuracy in assessing extent of primary tumor (73%), locoregional extension (74%), vascular invasion (83%), distant metastases (88%), tumor TNM stage (46%), and tumor resectability (83%), whereas EUS had the highest accuracy in assessing tumor size (r = 0.85) and lymph node involvement (65%). The decision analysis demonstrated that the best strategy to assess tumor resectability was based on CT or EUS as initial test, followed by the alternative technique in those potentially resectable cases. Cost minimization analysis favored the sequential strategy in which EUS was used as a confirmatory technique in those patients in whom helical CT suggested resectability of the tumor.CONCLUSIONS:Helical CT and EUS are the most useful individual imaging techniques in the staging of pancreatic cancer. In those cases with potentially resectable tumors a sequential approach consisting of helical CT as an initial test and EUS as a confirmatory technique seems to be the most reliable and cost minimization strategy.

Sociodemographic, clinical, and psychiatric characteristics of transsexuals from Spain.

The aim of this study was to examine the characteristics of transsexuals from Spain. A total of 252 consecutive applicants for sex reassignment were evaluated using a standardized semistructured clinical interview and the Mini International Neuropsychiatric Interview (Spanish Version 5.0.0) to record demographic, clinical, and psychiatric data. Transsexualism was diagnosed in 230 patients, with a male to female (MF)/female to male (FM) ratio of 2.2:1. Transsexual patients frequently had low employment status, lived with their parents, and mainly had a sexual orientation toward same-sex partners. The most frequent psychiatric diagnoses were adjustment disorder and social phobia in both groups, and alcohol and substance-related disorders in the MF group. MF transsexuals were older than FM transexuals when requesting sex reassignment, but did not differ in age when starting hormonal therapy (often on their own); fewer MFs were in employment requiring high educational qualification, more were non-Spanish natives, and more had previous and current histories of alcohol and substance abuse or dependence. The basic characteristics of transsexuals from Spain were similar to those of other European countries, except for the higher proportion of patients living with their parents and the higher proportion of MFs who reported same-sex sexual orientation compared with previous studies.

Role of a research ethics committee in follow-up and publication of results

Follow-up of clinical trials is a commitment rarely fulfilled by research ethics committees (RECs). We assessed the output of clinical trials submitted in 1997 to our REC, and talked to principal investigators, sponsors, contract research organisations, or a combination of these. During 1997, our REC reviewed 166 clinical trials, and approved 158. The recruitment rate was lower than expected in 45% (64/143) of all initiated clinical trials; 64% (92/143) were finished in accordance with protocol. 3 years after, the results of only 21% (26/123) of finished clinical trials were published in peer-reviewed journals, rising to 31% (38/123) if in-press articles were included. RECs should devote more effort and resources to assess public dissemination of results of clinical trials.

Comparison of antimicrobial cycling and mixing strategies in two medical intensive care units.

Objective:To compare a mixing vs. a cycling strategy of use of anti-Pseudomonas antibiotics on the acquisition of resistant Gram-negative bacilli in the critical care setting. Design:Prospective, open, comparative study of two strategies of antibiotic use. Setting:Two medical intensive care units of a university hospital. Patients:A total of 346 patients admitted for ≥48 hrs to two separate medical intensive care units during an 8-month period. Interventions:Patients, who according to the attending physician’s judgment required an anti-Pseudomonas regimen, were assigned to receive cefepime/ceftazidime, ciprofloxacin, a carbapemen, or piperacillin-tazobactam in this order. “Cycling” was accomplished by prescribing one of these antibiotics during 1 month each. “Mixing” was accomplished by using the same order of antibiotic administration on consecutive patients. Interventions were carried out during two successive 4-month periods, starting with mixing in one unit and cycling in the other. Measurements and Main Results:Swabbing of nares, pharynx, and rectum and culture of respiratory secretions were obtained thrice weekly. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention. The scheduled cycling of antibiotics was only partially successful. Although the expected antibiotic was the most prevalent anti-Pseudomonas agent used within the corresponding period, it never accounted for >45% of all anti-Pseudomonas antimicrobials administered. During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07). No differences in the rate of acquisition of potentially resistant Gram-negative bacilli or incidence of intensive care unit-acquired infections and infections due to particular organisms were observed. Conclusions:In critically ill medical patients, a strategy of monthly rotation of anti-Pseudomonas &bgr;-lactams and ciprofloxacin may perform better than a strategy of mixing in the acquisition of P. aeruginosa resistant to selected &bgr;-lactams.

Nosocomial Infections in Spain: Results of Five Nationwide Serial Prevalence Surveys (EPINE Project, 1990 to 1994)

OBJECTIVE To determine trends in rates of nosocomial infections in Spanish hospitals. DESIGN Prospective prevalence studies, performed yearly from 1990 through 1994. SETTING A convenience sample of acute-care Spanish hospitals. PARTICIPANTS AND PATIENTS The number of hospitals and patients included were as follows: 1990, 125 hospitals and 38,489 patients; 1991, 136 and 42,185; 1992, 163 and 44,343; 1993, 171 and 46,983; 1994, 186 and 49,689. A core sample of 74 hospitals, which participated in all five surveys and included a mean of 23,871 patients per year, was analyzed separately. RESULTS The overall prevalence rate of patients with nosocomial infections in the five studies was as follows: 1990, 8.5%; 1991, 7.8%; 1992, 7.3%; 1993, 7.1%; and 1994, 7.2%. The prevalence rate of patients with nosocomial infection in the core sample of 74 hospitals was 8.9%, 8.0%, 7.4%, 7.6%, and 7.6%, respectively (test for trend, P = .0001). Patients admitted to intensive-care units had a 22.8% prevalence rate of nosocomial infection in 1994. The most common nosocomial infections by primary site were urinary tract infection and surgical site infections, followed by respiratory tract infections and bacteremia. More than 60% of all infections were supported by a microbiological diagnosis. CONCLUSIONS The EPINE project provides a uniform tool for performing limited surveillance of nosocomial infections in most Spanish acute-care hospitals. Its use helps to spread an accepted set of definitions and methods for nosocomial infection control in the Spanish healthcare system. The surveys indicated that the prevalence of nosocomial infections has been reduced over the last 5 years in a core sample of Spanish hospitals.

Characteristics of tuberculosis in HIV-infected patients: a case-control study.

To test the hypothesis that HIV infection can modify the clinical characteristics of tuberculosis, 65 consecutive cases of tuberculosis in HIV-seropositive patients diagnosed in Barcelona (Spain) were compared with 65 HIV-seronegative controls matched for age and sex. Thirty of the 65 cases were accepted as AIDS cases (August 1987 Centers for Disease Control criteria) only because of the tuberculosis. Among the cases 54 (83%) were parenteral drug addicts and 88% were males. The tuberculosis was pulmonary or pleural in 62 controls (96%) but in only 25 cases (39%; P less than 0.0001). Lymph nodes were involved in 25 cases (39%) and in none of the controls (P less than 0.0001). Disseminated forms of tuberculosis were present in seven cases (11%) and in no controls (P less than 0.007). Bone, joints and central nervous system involvement were also significantly (P less than 0.05) more frequent in cases. The treatment (isoniazid and rifampin for 6 months plus ethambutol and pyrazinamide during the first 2 months) was always effective. One relapse was detected after a median follow-up of 55 months in cases and none in controls after a median follow-up of 43 months. Twenty-five cases (39%) and 14 controls (22%) developed mild or severe side effects related to the treatment (P less than 0.004). In conclusion, most of the HIV-infected patients with tuberculosis were drug addicts with extrapulmonary or disseminated forms. A short course of treatment (6 or 9 months) may be enough but side effects were frequent.

New interventions to increase influenza vaccination rates in health care workers

BACKGROUND The most effective strategy for avoiding nosocomial influenza outbreaks is through vaccination of health care workers (HCWs). In Spain, HCW vaccination coverage rarely exceeds 25%. The objective of this study was to determine whether an active vaccination campaign promoting communication among HCWs increased influenza vaccination coverage rates and permitted a shorter campaign. METHODS This was a before-after trial, comparing free mobile vaccination teams without and with strategies promoting HCW involvement by means of weekly educational and promotional messages through electronic mail, including 2 prize draws for vaccinated HCWs and a Web page including pictures of vaccinated HCWs and all senior hospital management. Weekly coverages were publicized, the staff of mobile units was increased, and their routes in the hospital were advertised. The study population was >4500 HCWs (permanent and temporary staff) at a Spanish university hospital during the 2007-08 and 2008-09 influenza seasons. RESULTS Coverage was 23% (95% confidence interval [CI], 22.5%-24.9%) in the 2007-08 season and 37% (95% CI, 34.7%-37.4%) in 2008-09 season. The vaccination rate was highest in HCWs aged > or =65 years and in physicians. The weekly vaccination rates were significantly higher for the 2008-09 season compared with the 2007-08 season except for the first and third weeks; for example, in week 2, the rate was 1.7 HCWs per 100 persons-week (95% CI, 1.3-2.1) in 2007-08, compared with 3.7 HCWs per 100 persons-week (95% CI, 3.2-4.4) in 2009-09. Rate increases were concentrated in the first weeks of the program, with a peak occurring in week 3 during the 2007-08 season and in week 2 during the 2008-09 season. CONCLUSION This intervention improved influenza vaccination coverage of HCWs and allowed more rapid achievement of higher coverage.

The 1918 "Spanish flu" in Spain.

The 1918-1919 influenza pandemic was the most devastating epidemic in modern history. Here, we review epidemiological and historical data about the 1918-1919 influenza epidemic in Spain. On 22 May 1918, the epidemic was a headline in Madrids ABC newspaper. The infectious disease most likely reached Spain from France, perhaps as the result of the heavy railroad traffic of Spanish and Portuguese migrant workers to and from France. The total numbers of persons who died of influenza in Spain were officially estimated to be 147,114 in 1918, 21,235 in 1919, and 17,825 in 1920. However, it is likely that >260,000 Spaniards died of influenza; 75% of these persons died during the second period of the epidemic, and 45% died during October 1918 alone. The Spanish population growth index was negative for 1918 (net loss, 83,121 persons). Although a great deal of evidence indicates that the 1918 A(H1N1) influenza virus unlikely originated in and spread from Spain, the 1918-1919 influenza pandemic will always be known as the Spanish flu.

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

Abstract 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 Societys 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.

Cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) in Mozambique and the United Republic of Tanzania

OBJECTIVE To estimate the cost-effectiveness of malaria intermittent preventive treatment in infants (IPTi) using sulfadoxine-pyrimethamine (SP). METHODS In two previous IPTi trials in Ifakara (United Republic of Tanzania) and Manhiça (Mozambique), SP was administered three times to infants before 9 months of age through the Expanded Programme on Immunization. Based on the efficacy results of the intervention and on malaria incidence in the target population, an estimate was made of the number of clinical malaria episodes prevented. This number and an assumed case-fatality rate of 1.57% were used, in turn, to estimate the number of disability-adjusted life years (DALY) averted and the number of deaths averted. The cost of the intervention, including start-up and recurrent costs, was then assessed on the basis of these figures. FINDINGS The cost per clinical episode of malaria averted was US