Nutrition supplementation plus standard of care versus standard of care alone or standard of care plus unconditional cash transfer in the prevention of chronic malnutrition in Southern Angola: study protocol for the MuCCUA study, a cluster randomized controlled trial.

BACKGROUND: Chronic malnutrition is a condition associated with negative impacts on physical and cognitive development. It is multi-causal and can start very early in life, already in utero, thus it is especially challenging to find appropriate interventions to tackle it. The government of Angola is implementing a standard of care program with potential to prevent it, and the provision of cash transfers and the supplementation with small quantity lipid-based nutrients (SQ-LNS) are also promising interventions. We aimed to evaluate the impact of the standard of care program alone and of the standard of care plus a cash transfer intervention in the lineal growth of children less than 2 years old and compare it to the effectiveness of a nutrition supplementation plus standard of care program in Southern Angola. METHODS/DESIGN: The three-arm parallel cluster randomised controlled trial is set in four communes of Huila and Cunene provinces. Clusters are villages or neighbourhoods with a population around 1075 people. A total of twelve clusters were selected per arm and forty pregnant women are expected to be recruited in each cluster. Pregnant women receive the standard of care alone, or the standard of care plus unconditional cash transfer or plus nutritional supplementation during the first 1000 days, from pregnancy to the child reaching 24 months. The primary outcome is the prevalence of stunting measured as height-for-age Z-score (HAZ) < -2 in children below 2 years. Impact will be assessed at 3, 6, 12, 18 and 24 months of children's age. Secondary outcomes include mortality, morbidity, caring, hygiene and nutrition behaviours and practices, and women and children's dietary diversity. Quantitative data are also collected on women's empowerment, household food security, expenditure and relevant clinical and social events at baseline, endline and intermediate time points. DISCUSSION: The results will provide valuable information on the impact of the standard of care intervention alone as well as combined with an unconditional cash transfer intervention compared to a nutrition supplementation plus standard of care intervention, carried out during the first 1000 days, in the children´s growth up to 2 years and related outcomes in Southern Angola. TRIAL REGISTRATION: Clinical Trials NCT05571280. Registered 7 October 2022.

Imported malaria in children in Madrid, Spain, 2007-2013.

BACKGROUND: The majority of malaria cases diagnosed in Europe in the last few years have occurred in people living in non-endemic areas travelling back to their home country to visit friends and relatives (VFRs). Children account for 15-20% of imported malaria, with known higher risk of severe disease. MATERIAL AND METHODS: A retrospective multicentre study was conducted in 24 hospitals in Madrid (Spain) including patients under 16 years diagnosed with malaria (2007-2013). RESULTS: A total of 149 episodes in 147 children were reported. Plasmodium falciparum was the species most commonly isolated. Twenty-five patients developed severe malaria and there was one death related to malaria. VFR accounted for 45.8% of our children. Only 17 VFRs had received prophylaxis, and 4 of them taken appropriately. They presented more frequently with fever (98% vs. 69%), a longer time with fever (55 vs. 26%), delay in diagnosis of more than three days (62 vs. 37%), and more thrombocytopenia (65 vs. 33%) than non-VFRs, and with significant differences (p<0.05). CONCLUSIONS: VFRs represent a large proportion of imported malaria cases in our study. They seldom took adequate prophylaxis, and delayed the visit to the physician, increasing the length of fever and subsequent delaying in diagnosis. Appropriate preventive measures, such as education and pre-travel advices should be taken in this population.

Evaluation of clinicians' knowledge and practices regarding medical radiological exposure: findings from a mixed-methods investigation (survey and qualitative study).

OBJECTIVES: To assess the impact of initiatives aiming to increase clinician awareness of radiation exposure; to explore the challenges they face when communicating with patients; to study what they think is the most appropriate way of communicating the long-term potential risks of medical radiological exposure to patients. DESIGN: A quantitative and qualitative evaluation through a survey and focal groups. SETTING: San Juan Hospital and Dr Peset Hospital (Southeast Spain) and clinicians from Spanish scientific societies. PARTICIPANTS: The surveys were answered (a) in person (216: all the radiologists (30), urologists (14) and surgeons (44) working at both participant hospitals; a sample of general practitioners from the catchment area of one hospital (45), and a consecutive sample of radiologists attending a scientific meeting (60)) or (b) electronically through Spanish scientific societies (299: radiologists (45), pneumologists (123), haematologists (75) and surgeons (40)). Clinicians were not randomly selected and thus the results are limited by the diligence of the individuals filling out the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Clinicians' knowledge and practices regarding medical radiological exposure, and what they considered most appropriate for communicating information to patients. RESULTS: Nearly 80% of the clinicians surveyed had never heard of the European recommendations. Fewer than 20% of the clinicians surveyed identified correctly the radiation equivalence dose of intravenous urography or barium enema. It was reported by 31.7% that they inform patients about the long-term potential risks of ionising radiation. All participants agreed that the most appropriate way to present information is a table with a list of imaging tests and their corresponding radiation equivalence dose in terms of chest X-rays and background radiation exposure. CONCLUSIONS: Medical radiological exposure is frequently underestimated and rarely explained to patients. With a clear understanding of medical radiological exposure and proper communication tools, clinicians will be able to accurately inform patients.

Evaluation of the environmental plasticity in the xerohalophyte Zygophyllum fabago L. for the phytomanagement of mine tailings in semiarid areas.

Phytomanagement by phytostabilisation of metal(loid)-enriched mine tailings in semiarid areas has been proposed as a suitable technique to promote a self-sustainable vegetal cover for decreasing the spread of polluted particles by erosion. The goal of this work was to evaluate the contribution of a pioneer plant species (Zygophyllum fabago) in ameliorating the soil conditions at two mine tailings piles located in a semiarid area in Southeast Spain. The ecophysiological performance of this plant species compared to a control population was assessed by analysing the nutritional and ecophysiological status. The presence of Z. fabago in mine tailings enhanced the soil microbial activity and increased the content of soil organic carbon within the rhizosphere (approx. 50% increasing). Metal(loid) concentrations in the tailings may play a minor role in the establishment of Z. fabago plants due to the low metal(loid) availability in the tailings (low CaCl2-extractable concentrations) and low uptake in the plants (e.g. up to 300 mg kg(-1) Zn in leaves). The lower δ13C and δ18O in the plants sampled at both tailings compared to the control ones may indicate softer stomatal regulation in relation to the control site plants and therefore lower WUE [corrected]. The Z. fabago plants may skip some energy-demanding mechanisms such as stomatal control and/or proline synthesis to overcome the environmental stresses posed at the tailings. The Z. fabago plants revealed high plasticity of the species for adapting to the low fertility soil conditions of the tailings and to overcome constraints associated to the dry season.

Prevalence and variables associated with solitary pulmonary nodules in a routine clinic-based population: a cross-sectional study.

OBJECTIVE: To determine the prevalence of solitary pulmonary nodules (SPNs) in chest radiology studies and patient's features associated with malignancy in a non-high-risk clinical population. METHODS: Patients ≥35 years were referred for thoracic imaging in two hospitals (2010-2011). Eight radiologists determined the presence and characteristics of SPN. Selected variables were collected from radiological register and medical records. Observer agreement in the diagnosis of SPN was assessed. RESULTS: 25,529 patients were included: 23,102 (90.5%) underwent chest radiograph and 2,497 (9.5%) a CT. The prevalence of SPN was 2.1% (95% CI 1.9 - 2.3) in radiographs and 17.0% (95% CI 15.5 - 18.5) in CT. In patients undergoing chest radiograph, detection of SPN with an irregular border was more frequent among smokers. In patients who had a CT, larger SPNs appeared to be associated with 60 years of age or over, diagnosis of a respiratory illness, or male gender. In addition, an irregular border was also more common among men. CONCLUSIONS: The prevalence of SPNs detected by both radiograph and CT was lower than that shown in screening studies. Patient characteristics such as age, sex, respiratory disease, or smoking habit were associated with nodule characteristics that are known to be related with malignancy. KEY POINTS: There is a lower SPN prevalence in the clinical population than in screening studies. SPN prevalence is associated with some patient characteristics: sex, age, imaging test. Nodule characteristics related to malignancy were associated with some patient characteristics.

Incidental findings in imaging diagnostic tests: a systematic review.

The objective of this review is to summarise the available evidence on the frequency and management of incidental findings in imaging diagnostic tests. Original articles were identified by a systematic search of the MEDLINE, EMBASE and Cochrane Library Plus databases using appropriate medical headings. Extracted variables were study design; sample size; type of imaging test; initial diagnosis; frequency and location of incidental findings; whether clinical follow-up was performed; and whether a definitive diagnosis was made. Study characteristics were assessed by one reviewer and checked by a second reviewer. Any disagreement was solved by consensus. The relationship between the frequency of incidental findings and the study characteristics was assessed using a one-way ANOVA test, as was the frequency of follow-up of incidental findings and the frequency of confirmation. 251 potentially relevant abstracts were identified and 44 articles were finally included in the review. Overall, the mean frequency of incidental findings was 23.6% (95% confidence interval (CI) 15.8-31.3%). The frequency of incidental findings was higher in studies involving CT technology (mean 31.1%, 95% CI 20.1-41.9%), in patients with an unspecific initial diagnosis (mean 30.5, 95% CI 0-81.6) and when the location of the incidental findings was unspecified (mean 33.9%, 95% CI 18.1-49.7). The mean frequency of clinical follow-up was 64.5% (95% CI 52.9-76.1%) and mean frequency of clinical confirmation was 45.6% (95% CI 32.1-59.2%). Although the optimal strategy for the management of these abnormalities is still unclear, it is essential to be aware of the low clinical confirmation in findings of moderate and major importance.

Maternal glucose tolerance status influences the risk of macrosomia in male but not in female fetuses.

OBJECTIVE: To elucidate whether the risk of macrosomia, large for gestational age (LGA) and small for gestational age (SGA) is influenced by maternal body mass index and glucose tolerance differently in male and female fetuses. METHODS: A population study was conducted in 16 general hospitals from the Spanish National Health Service that included 9270 consecutive women with singleton pregnancies and without a former diagnosis of diabetes mellitus who delivered 4793 male and 4477 female newborns. Logistic regression analyses were performed to predict the effect of body mass index (BMI) category and glucose tolerance on macrosomia, large for gestational age newborns (LGA) and small for gestational age newborns (SGA) Separate analyses according to foetal sex were carried out for each outcome. The results were adjusted for maternal age, gestational age and pregnancy-induced hypertension. RESULTS: There were significant differences between males and females in the percentage of infants who had macrosomia, LGA or SGA. Maternal BMI category was positively associated with the risk of macrosomia and LGA in both male and female newborns. In addition, there was a negative association between maternal BMI and SGA that only reached significance in males. In contrast, gestational diabetes was only a predictor of macrosomia exclusively in male fetuses (OR 1.67, 95% CI 1.12 to 2.49) CONCLUSIONS: There is sexual dimorphism in the risk of abnormal birth weight attributed to maternal glucose tolerance status. A closer surveillance of foetal growth might be warranted in pregnant women with abnormal glucose tolerance carrying a male fetus.

Effect of education on overall and cause-specific mortality in injecting drug users, according to HIV and introduction of HAART.

BACKGROUND: We assessed the impact of education on long-term overall and cause-specific mortality among 6575 injecting drug users (IDUs) according to HIV status and introduction of highly active antiretroviral therapy (HAART). METHODS: Community-based cohort study of IDUs recruited in three AIDS prevention centres (1987-1996). Causes of death were ascertained in clinical centres and Mortality Registry and classified as AIDS, drug use related, injuries, or liver diseases. Poisson regression models including education and calendar period interaction and adjusted by sex, age, and HIV were used. RESULTS: In 73 901 person-years of follow-up, there were 1493 deaths (20.2/1000 person-years): 761 related to AIDS, 234 to drug use, 179 to injuries, and 93 to liver diseases. IDUs with university studies had a lower risk of death (RR 0.52; 95% CI 0.36-0.77) than those without studies: this difference was higher after (RR 0.45; 95% CI 0.25-0.80) than before 1997 (RR 0.68; 95% CI 0.41-1.13). Compared to before 1997, while decreases in the risk of AIDS mortality were seen during 1997-2004 for both lower (RR 0.49; 95% CI 0.41-0.58) and higher (RR 0.33; 95% CI 0.23-0.48) educated, only those higher educated experienced a reduction in drug-use mortality (RR 0.54; 95% CI 0.28-1.05) and death from injuries (RR 0.52; 95% CI 0.23-1.21). CONCLUSIONS: Independently of HIV status, lower education predicts a higher risk of death in IDUs and its impact is stronger after 1997. Education has a protective effect on most causes of death and it cannot be entirely attributable to the access or use of HAART.

Trends in HIV testing, serial HIV prevalence and HIV incidence among people attending a Center for AIDS Prevention from 1988 to 2003.

AIM: To analyse trends in HIV testing, serial HIV prevalence and HIV incidence among people who underwent voluntary testing in a Center for AIDS Prevention in Valencia, Spain. METHODS: Open cohort study including all subjects who went to the Center for AIDS Prevention from 1988 to 2003. Information on sociodemographic variables and HIV test results was collected. Serial prevalence and incidence rates were calculated, and joinpoint regression was used to identify changes in trends over time. RESULTS: 21,241 subjects were analysed; 67% men, 27% injecting drug users (IDUs), 43% heterosexuals and 13% men who have sex with men (MSM). From 1988 to 1990, IDUs accounted for 57% of clinic attenders, decreasing to 14% by 1997-2003, accompanied by an increase in heterosexuals. Overall, HIV prevalence for the whole period was 15%, dropping from 35% to <10% after 1999 and to 3% by 2003, when HIV prevalence was 26% in IDUs, 6% in MSM and 2% in heterosexuals. Total HIV incidence was 2.5%. From 1988 to 1990, HIV incidence ranged from 6% to 8%, and a gradual and progressive decline observed from 1990 onwards. From 1995 onwards, HIV incidence was <2%. The highest incidence rate is seen in IDUs, 7-12% in the first period and 4-5% at the end. Among MSM, a change in the decreasing trend is seen by 1998, and increases in incidence are detected by 2002-3. CONCLUSIONS: Serial HIV prevalence has markedly decreased from 1988 in all transmission categories, although it is still high. With regard to HIV incidence, the drop has been marked too, although a worrying increase, that requires further follow-up, has been detected in MSM in the past 2 years.

Analysis for crystals in synovial fluid: training of the analysts results in high consistency.

BACKGROUND: Identification of monosodium urate (MSU) and calcium pyrophosphate dehydrate (CPPD) crystals in synovial fluid samples is diagnostic of gout and CPPD crystal related arthropathy. Various studies have shown poor consistency in results of crystal analysis. OBJECTIVE: To determine whether training of the analysts increases the consistency. METHODS: An expert rheumatologist gave a course on crystal detection and identification. The four trained observers then blindly and independently examined synovial fluid samples previously classified by the expert which had been obtained from patients with both crystal arthropathies and other non-crystal related inflammatory joint conditions. RESULTS: 194 observations were made on 64 synovial fluid samples: 96 without crystals (49.4%), 55 with CPPD crystal (28.4%), and 43 with MSU crystals (22.2%). For crystal detection (presence or absence of crystals), sensitivity was 95.9% and specificity 86.5%. For identification of MSU crystals, sensitivity was 95.3% and specificity 97.2%. For identification of CPPD crystals, sensitivity was 92.7% and specificity 92.1%. The kappa index of agreement with the reference standard between the observers was 0.84 for any crystal detection, 0.93 for MSU crystal sample identification, and 0.79 for CPPD crystal sample identification. CONCLUSIONS: For trained observers, the detection and identification of crystals in synovial fluid is a consistent procedure.

[Antipyretic effectiveness of ibuprofen and paracetamol]. / Eficacia de ibuprofeno y paracetamol como antitérmicos.

OBJECTIVE: To compare the antipyretic effectiveness of ibuprofen and paracetamol and to evaluate the possible influence of patients' sex, weight, height and underlying disease on effectiveness. PATIENTS AND METHODS: A total of 166 children with fever, defined as a temperature equal to or above 38 degrees C, were enrolled. Of these, 80 were given paracetamol at a dose of 15 mg per kg and 86 were given 7 mg of ibuprofen per kg. Temperature was recorded at 60, 120,180 and 240 minutes after drug administration. Data were statistically analyzed, including analysis of paired data. RESULTS: Ninety percent of the children became afebrile at some time during the study with both paracetamol and ibuprofen. Seventy-four percent of the patients remained afebrile 4 hours after drug administration. The mean temperatures obtained with ibuprofen versus paracetamol were 37.66 +/- 0.73 vs 37.8 +/- 0.65, p = 0.22 one hour after drug administration; 37.09 +/- 0.83 vs 37.29 +/- 0.71, p = 0.14 two hours after drug administration; 37.12 +/- 1.05 vs 37.28 +/- 0.87, p = 0.64 three hours after drug administration; and 37.40 +/- 1.12 vs 37.46 +/- 1.00, p = 0.72 four hours after drug administration. The maximum rate of temperature decrease was achieved during the first 60 minutes after drug administration (-1.32 +- 0.83 with ibuprofen vs -1.09 +/- 0.77 with paracetamol, p = 0.10). In children aged between 5 and 12 years, ibuprofen achieved significantly lower temperatures than paracetamol (38.00 +/- 0.65 vs 37.45 +/- 0.43, p = 0.02 at 1 hour; 36.71 +/- 0.66 vs 37.60 +/- 0.93, p = 0.01 at 2 hours; 36.80 +/- 0.79 vs 37.67 +/- 1.12, p = 0.03 at 3 hours). Analysis by weight, height or underlying disease revealed no significant differences. CONCLUSIONS: Both ibuprofen and paracetamol proved to be successful in reducing temperature. The effectiveness of ibuprofen and paracetamol was similar, except in children aged more than 5 years old, in whom ibuprofen was more effective. Weight, sex and underlying disease had no influence on effectiveness.