Francesco Di Gennaro

Tuberculosis and diabetes: Current state and future perspectives

This review outlines the association between tuberculosis and diabetes, focusing on epidemiology, physiopathology, clinical aspects, diagnosis and treatment, and evaluates future perspectives, with particular attention to developing countries.

An intricate case of multidrug resistant Plasmodium falciparum isolate imported from Cambodia

BackgroundImported cases of multidrug resistant Plasmodium falciparum and treatment failure with artemisinin-based regimens, although rare, have been described also in Western countries and their management is often challenging. This is also due to an inadequate knowledge and implementation of health prevention measures.Case reportA complex case of imported malaria caused by Plasmodium vivax/P. falciparum isolates in a patient who was not taking chemoprophylaxis while he was travelling in Cambodia is reported in this article. After failures of artemisinin-based and both oral and intravenous quinine-based regimens, a multidrug resistant P. falciparum was detected. The patient was successfully treated with atovaquone–proguanil.ConclusionsThis experience highlights the importance of a careful management that should be based not only on the most up-to-date guidelines, but also on the awareness of a rapidly evolving scenario.

Chest wall stabilization and reconstruction: short and long-term results 5 years after the introduction of a new titanium plates system

BACKGROUND We report short and long-term results with the dedicated Synthes(®) titanium plates system, introduced 5 years ago, for chest wall stabilization and reconstruction. METHODS We retrospectively analyzed (January 2010 to December 2014) 27 consecutive patients (22 males, 5 females; range 16-83 years, median age 60 years), treated with this system: primary [3] and secondary [8] chest wall tumor; flail chest [5]; multiple ribs fractures [5]; sternal dehiscence-diastasis [3]; sternal fracture [1]; sternoclavicular joint dislocation [1]; Poland syndrome [1]. Short-term results were evaluated as: operating time, post-operative morbidity, mortality, hospital stay; long-term results as: survival, plates-related morbidity, spirometric values, chest pain [measured with Verbal Rating Scale (VRS) and SF12 standard V1 questionnaire]. RESULTS Each patient received from 1 to 10 (median 2) titanium plates/splints; median operating time was 150 min (range: 115-430 min). Post-operative course: 15 patients (55.6%) uneventful, 10 (37%) minor complications, 2 (7.4%) major complications; no post-operative mortality. Median post-operative hospital stay was 13 days (range: 5-129 days). At a median follow-up of 20 months (range: 1-59 months), 21 patients (78%) were alive, 6 (22%) died. Three patients presented long-term plates-related morbidity: plates rupture [2], pin plate dislodgment [1]; two required a second surgical look. One-year from surgery median spirometric values were: FVC 3.31 L (90%), FEV1 2.46 L (78%), DLCO 20.9 mL/mmHg/min (76%). On 21 alive patients, 7 (33.3%) reported no pain (VRS score 0), 10 (47.6%) mild (score 2), 4 (19.1%) moderate (score 4), no-one severe (score >4); 15 (71.5%) reported none or mild, 6 (28.5%) moderate pain influencing quality of life. CONCLUSIONS An optimal chest wall stabilization and reconstruction was achieved with the Synthes(®) titanium plates system, with minimal morbidity, no post-operative mortality, acceptable operating time and post-operative hospital stay. Long-term restoration of a normal respiratory function was achieved, with minimal plates-related morbidity and chest pain.

Local Food Resources to Fight Children Malnutrition and Infectious Diseases in Mozambique

Objective: To develop sustainable recipes, using local food resources, as a possible solution to manage children malnutrition and nutritional lack in Mozambique, thus preventing infectious diseases. Methods: Our work was based on the Dietary Reference Intake (DRI) reports for children aged 4-8 years old. After having listed more than 60 commonly consumed local foods in Mozambique, we developed some recipes, indicating composition, energy and nutrients values. Information on nutrients concentrations was taken from the National Nutrient Database for Standard References, the Food Composition Tables for Mozambique and the Research Center for Aliments and Nutrition. In the recipes, the traditional way of listing ingredients was reported, which were then turned into international, standardized values. Results: We elaborated some different local food recipes, easy to prepare, at low cost and useful in a systematic approach in order to fight malnutrition in Sofala Province, Mozambique. Each recipe included functions and daily Recommended Dietary Allowance (RDA) of: water, proteins, lipids, carbohydrates, fibers, sodium, potassium, iron, calcium, phosphorus and vitamins. We suggested recipes richer in vitamins and micro/macro nutrients for breakfast, while those providing high caloric intake were more indicated for the main meal. The resulting recipes have been made understandable, for both local and international population, thanks to the coexistence of traditional and international description of ingredients. Conclusion: Local recipes approach is a possible promising tool among the most cost-effective/high impact interventions against child malnutrition and mortality from infectious diseases in Mozambique.

The At Risk Child Clinic (ARCC): 3 Years of Health Activities in Support of the Most Vulnerable Children in Beira, Mozambique

The concept of “children at risk” changes worldwide according to each specific context. Africa has a large burden of overall risk factors related to childhood health and development, most of which are of an infective or social origin. The aim of this study was to report and analyze the volumes of activities of fifteen At Risk Child Clinics (ARCCs) within the Beira District (Mozambique) over a 3 year-period in order to define the health profile of children accessing such health services. We retrospectively analyzed the data from all of the children accessing one of the 15 Beira ARCCs from January 2015 to December 2017. From this, 17,657 first consultations were registered. The motivations for accessing the services were in order of relevance: HIV exposure (n. 12,300; 69.7%), other risk conditions (n. 2542; 14.4%), Moderate Acute Malnutrition (MAM) (n. 1664; 9.4%), Severe Acute Malnutrition (SAM) (n. 772; 4.4%), and TB exposure (n. 542; 3.1%). During the first consultations, 16,865 children were screened for HIV (95.5%), and 7.89% tested HIV-positive. In our three years of experience, HIV exposure was the main indication for children to access the ARCCs in Mozambique. ARCCs could represent a strategic point to better understand health demands and to monitor the quality of care provided to this vulnerable population group, however significant effort is needed to improve the quality of the data collection.

Teenage pregnancies in Mozambique: the experience of “Servicios Amigos dos Adolescentes” clinics in Beira

The purpose of this article is to provide insights into the demand for pregnancy-related health services by adolescent girls and young women in Mozambique. We analysed the patient registers for the first year of operation (2014) of the Servicios Amigos dos Adolescentes (SAAJ) [Friendly Services for Adolescents] clinics in Beira, Mozambique. These registers provide details of the service demands of, and services provided to the 8 290 adolescent girls and young women who accessed the 6 SAAJ clinics in 2014. Analysis of that record, with disaggregation of the patients according to age (9 years or less; 10–14; 15–19; 20–24; 25 and older), show that 3 021 (36%) were pregnant or had previously been pregnant; most being girls in the 15–19 age band (59%). Being pregnant or having been pregnant previously was associated with dropping out of school. Of all the girls and women, 60% agreed to HIV testing and counselling; the HIV prevalence rate amongst this group was 4–5% amongst adolescents and 25% amongst women 25 years and older. A minority of the girls and women who were pregnant or had been pregnant previously agreed to HIV testing and counselling. Notwithstanding the limitations for analysis, the results were alarming: substantially high HIV prevalence rates were indicated (2% amongst 10–14 year old girls; 8% amongst 15–19 year olds; 10% amongst 20–24 year olds; and 28% amongst >24 year olds). The data from the SAAJ clinics and results pertain only to conditions in Beira. However, as the first empirical assessment of pregnancy-related service demand amongst adolescent girls and young women in the country and involving a relatively large sample, we contend that this study affirms the need for expansion of sexual and reproductive health (SRH) services, including HIV services, for adolescent girls and young women in Mozambique.

Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique

Introduction Data regarding the association between diabetes mellitus (DM) and tuberculosis (TB) in Africa are scarce. DM screening among TB patients in Mozambique was carried out. Methods The study was implemented from January to August 2016 in three Urban Health Centers in Beira, Mozambique and recruited adult (>18 years) patients newly diagnosed with pulmonary TB. Results Three hundred and one patients were enrolled (67.4%, males mean age 31.7(SD 11 years). Diabetes was diagnosed in only 3 patients (1%) and impaired glucose tolerance (IGT) in an additional 6 subjects (2%). Conclusion A lower than expected prevalence of DM was observed, which could be explained by the lack of traditional risk factors for DM (overweight, age over 45 years, hypertension and smoking) in Mozambique.

Pulmonary and mediastinal paragangliomas: rare endothoracic malignancies with challenging diagnosis and treatment

Background Pulmonary and mediastinal paragangliomas are rare tumors that may have neuroendocrine activity or be non-functional, incidental, in asymptomatic patients, or causing mass effect symptoms. Although being low-grade tumors, they can display an aggressive behaviour, developing local infiltration and distant metastases. We report our experience with three endothoracic paragangliomas and a Literature review, to point out diagnostic difficulties and problems related to surgical treatment. Methods From 2009 to 2017, we treated 3 patients with histological diagnosis of paraganglioma: 2 pulmonary, 1 mediastinal. No one presented catecholamine-secreting syndromes; pulmonary cases were asymptomatic, while the mediastinal one had aspecific cough and dyspnea. Imaging diagnosis was based on chest computerized tomography (CT) and magnetic resonance imaging (MRI) scan. No patient had preoperative histological diagnosis. Intraoperative pathological examination was suggestive for malignancy: in pulmonary cases, wedge resection and lobectomy were performed; the middle mediastinal mass was completely removed after challenging dissection, isolation and section of numerous vascular pedicles. Results Postoperative course was uneventful in all cases. No patient received adjuvant treatments. At a median follow-up of 47 months (range, 6-102 months), two patients are alive, without local or distant recurrence; one patient died 6 months after surgery, due to disease progression. Conclusions Endothoracic paragangliomas, rare and often asymptomatic tumors, are of difficult diagnosis and should be considered malignant tumors, due to the potential aggressive behaviour of cases with high mitotic index and the frequent possibility of recurrence and metastases. Surgical resection is the treatment of choice and careful intraoperative manipulation is recommended, due to the high vascularity of these tumors, to prevent complications. After complete excision, long-term prognosis is generally good. However, even after surgical removal, a close, periodical and life-long follow-up is mandatory.

Prevalence and Predictors of Malaria in Human Immunodeficiency Virus Infected Patients in Beira, Mozambique

Co-infection between malaria and HIV has major public health implications. The aims of this study were to assess the malaria prevalence and to identify predictors of positivity to malaria Test in HIV positive patients admitted to the health center São Lucas of Beira, Mozambique. A retrospective cross-sectional study was performed from January 2016 to December 2016. Overall, 701 adult HIV patients were enrolled, positivity to malaria test was found in 232 (33.0%). These patients were found to be more frequently unemployed (76.3%), aged under 40 (72.0%), with a HIV positive partner (22.4%) and with a CD4 cell count <200 (59.9%). The following variables were predictors of malaria: age under 40 (O.R. = 1.56; 95%CI: 1.22–2.08), being unemployed (O.R. = 1.74; 95%CI: 1.24–2.21), irregularity of cotrimoxazole prophylaxis’s (O.R. = 1.42; 95%CI: 1.10–1.78), CD4 cell count <200 (O.R. = 2.01; 95%CI: 1.42–2.32) and tuberculosis comorbidity (O.R. = 1.58; 95%CI: 1.17–2.79). In conclusion, high malaria prevalence was found in HIV patients accessing the out-patients centre of São Lucas of Beira. Our findings allowed us to identify the profile of HIV patients needing more medical attention: young adults, unemployed, with a low CD4 cell count and irregularly accessing to ART and cotrimoxazole prophylaxis.

Potential Diagnostic Properties of Chest Ultrasound in Thoracic Tuberculosis—A Systematic Review

Background: Chest ultrasound (CUS) has been shown to be a sensitive and specific imaging modality for pneumothorax, pneumonia, and pleural effusions. However, the role of chest ultrasound in the diagnosis of thoracic tuberculosis (TB) is uncertain. We performed a systematic search in the medical literature to better define the potential role and value of chest ultrasound in diagnosing thoracic tuberculosis. Aim: To describe existing literature with regard to the diagnostic value of chest ultrasound in thoracic tuberculosis. Methods: MEDLINE, EMBASE, and Scopus databases were searched for relevant articles. We included studies that used chest ultrasound for the diagnosis or management of any form of thoracic tuberculosis, including pulmonary, pleural, mediastinal, and military forms. Results: We identified five main fields of chest ultrasound application: (1) Detection, characterization, and quantification of TB; (2) detection of residual pleural thickening after evacuation; (3) chest ultrasound-guided needle biopsy; (4) identification of pathologic mediastinal lymph nodes in children; and (5) identification of parenchymal ultrasound patterns. Effusion was also detected, in early stages, with signs of organization in 24–100% of patients. A low to moderate (10–23%), false negative rate was reported for chest ultrasound-guided needle biopsy. CUS was able to identify mediastinal lymph nodes in as many as 67% of patients with negative chest radiography. Conclusions: Very few studies with important methodological limitations analyze the role of chest ultrasound in the diagnosis of TB. The scarce available data suggests potential targets of future diagnostic or feasibility trials, such as the detection of tuberculosis–related pleural effusion, residual pleural thickening, lymphadenopathy, TB parenchymal patterns, or the use of CUS in biopsy guidance.