Llorenç Quintó

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.

A prognostic model for predicting survival in cirrhosis with ascites

BACKGROUND/AIMS Parameters evaluating renal function and systemic hemodynamics are of prognostic significance in cirrhosis with ascites but are rarely used in the evaluation of survival of these patients. The aim of the current study was to develop a prognostic model to estimate survival of patients with cirrhosis and ascites. METHODS 216 Cirrhotic patients admitted to hospital for the treatment of ascites were evaluated. Thirty-two demographic, clinical and laboratory variables, including parameters assessing liver and renal function and systemic hemodynamics, were analyzed as predictive factors of survival by using a Cox regression model. RESULTS Four variables had independent prognostic value: renal water excretion, as assessed by measuring diuresis after water load, mean arterial pressure, Child-Pugh class, and serum creatinine. According to these features a prognostic index was calculated that allows to estimate survival in patients with cirrhosis and ascites. The model accurately predicted survival in an independent series of 84 patients with cirrhosis and ascites. CONCLUSION A prognostic model that uses four easily available variables and predicts prognosis in cirrhotic patients with ascites has been developed. This model may be useful in the evaluation of patients with ascites for liver transplantation.

Community-acquired bacteremia among children admitted to a rural hospital in Mozambique.

Background: Although community-acquired bacteremia is an important cause of childhood mortality in Africa, recognition of disease burden and potential impact of bacterial vaccines is limited. Methods: Blood cultures for bacterial pathogens were conducted systematically among children <15 years of age admitted to Manhiça District Hospital, from 2001 to 2006. Results: Blood-stream infections were identified in 8% (1550/19,896) of pediatric hospital admissions. Nontyphoidal Salmonella (NTS) and Pneumococcus were the most prevalent pathogens isolated (26% and 25% of 1550 cases, respectively). Until 28 days of life, Staphylococcus aureus (39%) and group B Streptococcus (20%) predominated. Incidence of community-acquired bacteremia per 100,000 child-years was 1730/105 in children <1 year old, 782/105 in 1–4 year oldd, and 49/105 in children 5 years and older. Case-fatality of bacteremia was 12%. Community-acquired bacteremia associated mortality accounted for 21% (162/788) of hospital deaths. Resistance to antibiotics commonly used in Mozambique was high among invasive isolates of Haemophilus influenzae, Escherichia coli, and NTS. Conclusions: Community-acquired bacteremia is an important cause of pediatric hospital admission and death in rural African hospitals. The high burden of disease, mortality, and pattern of antibiotic resistance associated with bacteremia underscore the need for prevention in Sub-Saharan Africa.

Impact of the recurrence of hepatitis C virus infection after liver transplantation on the long-term viability of the graft.

BACKGROUND The impact of hepatitis C virus (HCV) infection recurrence after orthotopic liver transplantation (OLT) on graft viability is still not accurately defined. Our study aims to evaluate the magnitude and rate of progression of HCV-induced liver damage after OLT in a single institution cohort of 122 HCV-infected recipients. METHODS All patients transplanted at our institution between 1988 and 1996 with positive serum HCV antibodies before OLT, minimum postoperative survival of 6 months, and without hepatitis B virus coinfection or severe non-HCV-related graft complications were retrospectively included in the study. RESULTS HCV infection recurrence was almost universal, and genotype 1b was observed in 87% of the cases. After a median histological follow-up of 43 months (range: 7-96), evidences of HCV-induced histological damage were found in 94% of the cases. The actuarial rates of severe graft damage (including cirrhosis, fibrosing cholestatic hepatitis, and submassive liver necrosis) were 15%, 33%, and 44% at 3, 5, and 7 years, respectively, and among these patients, 52% developed decompensated liver disease during the follow-up and 36% lost their grafts. The biochemical severity at the onset of the recurrent hepatitis and the development of cholestasis or cytomegalovirus disease were independent predictors of severe HCV-related graft damage. No differences were found in graft and patient survival when positive-HCV OLT recipients were compared with a coetaneous cohort of 215 non-HCV OLT recipients. CONCLUSIONS HCV infection recurrence leads to severe liver damage and subsequently to clinical decompensation in a significant proportion of OLT recipients. Some clinical and biochemical characteristics can predict the severity of HCV-induced graft damage.

An Autopsy Study of Maternal Mortality in Mozambique: The Contribution of Infectious Diseases

Background Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. Methods and Findings We conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV-positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths. Conclusions In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.

Efficacy of chloroquine, amodiaquine, sulphadoxine–pyrimethamine and combination therapy with artesunate in Mozambican children with non‐complicated malaria

This paper reports a two‐phase study in Manhiça district, Mozambique: first we assessed the clinical efficacy and parasitological response of Plasmodium falciparum to chloroquine (CQ), sulphadoxine–pyrimethamine (SP) and amodiaquine (AQ), then we tested the safety and efficacy in the treatment of uncomplicated malaria, of three combinations: AQ + SP, artesunate (AR) + SP and AQ + AR. Based on the WHO (1996, WHO/MAL/96.1077) in vivo protocol, we conducted two open, randomized, clinical trials. Children aged 6–59 months with axillary body temperature ≥37.5 °C and non‐complicated malaria were randomly allocated to treatment groups and followed up for 21 days (first and second trial) and 28 days (first trial). The therapeutic efficacy of AQ (91.6%) was better than that of SP (82.7%) and CQ (47.1%). After 14 days, 69% of the strains were parasitologically resistant to CQ, 21.4% to SP and 26% to AQ. Co‐administration of AQ + SP, AR + SP and AQ + AR was safe and had 100% clinical efficacy at 14‐day follow‐up. The combination therapies affected rapid fever clearance time and reduced the incidence of gametocytaemia during follow‐up.

Enteroaggregative Escherichia coli Strains as a Cause of Traveler's Diarrhea: A Case-Control Study

To elucidate the importance of enteroaggregative Escherichia coli (EAggEC) strains as a cause of travelers diarrhea in Spanish travelers, a prospective case-control 1:1 study was done in a university hospital clinic for travelers. EAggEC strains were isolated from 23 of 165 case-patients and from 4 of 165 controls (P = .0003). In 16 patients, this was the only isolate recovered. Six of the EAggEC-positive isolates from the case-patients and 2 from the controls were positive for the enteroaggregative stable toxin type 1 gene. Other enteropathogens were also isolated. Shigella and enterotoxigenic E. coli strains showed significant differences between cases and controls (P = .0023 and P < .0001, respectively). Geographic distribution of the EAggEC strains was homogeneous, and the clinical symptom, secretory diarrhea, did not differ statistically with that for the enterotoxigenic E. coli strains. EAggEC strains are a cause of secretory diarrhea in Spaniards traveling to developing countries.

Genetic variability among group A and B respiratory syncytial viruses in Mozambique: identification of a new cluster of group B isolates.

Respiratory syncytial virus (RSV) is the major cause of acute lower respiratory tract infection in children and vulnerable adults, but little is known regarding RSV infection in Africa. In this report, a recent RSV outbreak in Mozambique was studied and results showed that 275 of 3192 (8.6%) nasopharyngeal aspirates tested were RSV-positive by ELISA. RSV presents two antigenic groups (A and B) with a high genetic and antigenic variability between and within them. Analysis by a new RFLP assay of RT-PCR amplified N protein gene products showed a higher prevalence of group B RSV than that of group A (85% versus 15%). However, genetic variability of the G protein gene was higher among group A RSV strains. The frequency and pattern of glycosylation sites were also quite different between both groups. In addition, two different phylogenetic clusters of Mozambican viruses were found within each group, but only sequences from cluster B-I were relatively distinct from previously described isolates. The implications of such differences in the antigenic and immunogenic characteristics of each group are discussed.

Etiology and epidemiology of viral pneumonia among hospitalized children in rural Mozambique: a malaria endemic area with high prevalence of human immunodeficiency virus.

Background: The role of viruses in pediatric pneumonia remains poorly studied in sub-Saharan Africa, where pneumonia-associated mortality is high. Methods: During a 1-year hospital-based surveillance, a nasopharyngeal aspirate (NPA) was collected from children aged <5 years admitted to hospital in rural Mozambique with clinically severe pneumonia. Identification of 12 respiratory viruses was performed by polymerase chain reactions (PCR). Study children were also tested for invasive bacterial infection (IBI), Plasmodium falciparum parasitemia, and HIV. Results: Almost half (394/807) of the children hospitalized with clinically severe pneumonia had at least one respiratory virus detected. A total of 475 viruses were detected among these 394 children, the most prevalent ones were rhinovirus (41%), adenovirus (21%), and respiratory syncytial virus (11%). Eleven percent of viral infected children had concomitant IBI, 15% had malaria parasites, and 25% had HIV coinfection. Viral infection was 5.5 to 16 times more prevalent among HIV-infected children and incidence rate ratios varied according to virus. Inhospital mortality of viral cases was 9%, being highest among cases with IBI coinfection (odds ratio = 7) or HIV infection (odds ratio = 7). Conclusions: Study results highlight the high prevalence of respiratory viruses among hospitalized pneumonia cases in Mozambique. HIV infection is an important contributor to the high burden of disease and associated mortality of viral pneumonia. IBI also contributes to a worse prognosis of viral cases. Strategies to prevent mother-to-child transmission of HIV as well as introduction of Hib and pneumococcal vaccines could have a substantial impact on reduction of viral pneumonia and associated mortality among children in rural Africa.

Invasive non‐typhoidal Salmonella in Mozambican children

Objective  To describe the epidemiology and clinical presentation of invasive non‐typhoidal Salmonella (NTS) in Mozambique.