Estimating the vaccine-preventable burden of hospitalized pneumonia among young Mozambican children.

Polysaccharide-protein conjugate vaccines against Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae have proven efficacy against radiologically confirmed pneumonia. Measurement of pneumonia incidence provides a platform to estimate of the vaccine-preventable burden. Over 24 months, we conducted surveillance for radiologically confirmed severe pneumonia episodes among children <2 years of age admitted to a rural hospital in Manhiça, southern Mozambique. Study children were tested for HIV during the second year of surveillance. Severe pneumonia accounted for 15% of 5132 hospital admissions and 32% of in-hospital mortality among children <2 years of age. Also, 43% of chest radiographs were interpreted as radiologically confirmed pneumonia. HIV-infection was associated with 81% of fatal pneumonia episodes among children tested for HIV. The minimum incidence rate of radiologically confirmed pneumonia requiring hospitalization was 19 episodes/1000 child-years. Incidence rates among HIV-infected children were 9.3-19.0-fold higher than HIV-uninfected. Introduction of Hib and pneumococcal conjugate vaccines would have a substantial impact on pneumonia hospitalizations among African children if vaccine effects are similar to those observed in clinical trials.

La adherencia al tratamiento grupal más vareniclina y el éxito al año en el abandono tabáquico / Adherence to treatment and success after a year in the abandonment of tobacco addiction

Objetivo: Conocer la tasa de cesación de un programade deshabituación tabáquica con terapia grupal ytratamiento farmacológico e identifi car predictores deéxito del tratamiento.Pacientes y método: estudio prospectivo descriptivo-analítico de una cohorte. Las variables estudiadasfueron: edad, sexo, profesión, edad del primer consumo,número de cigarrillos/día, test de Fagerström,situaciones de especial consumo, motivación actual(puntuación del 0 al 10), test de Russell, intentos previos,convivencia con fumadores, consumo de otrassustancias, enfermedades tabacodependientes, ejerciciofísico, cooximetría, Índice de Masa Corporal, usode fármacos modalidad y adherencia al tratamiento. Seiniciaron terapias de grupo de entre 15-20 personascon un total de 8 sesiones al año. La última sesión alaño se da fi nalizado el tratamiento y se contacta telefónicamenteen caso de no asistir al taller.Se consideró éxito al año la abstinencia autodeclaraday confi rmada mediante cooximetría (monóxido decarbono < 10 ppm). Se aplicó un análisis de regresiónlogística univariante y multivariante, determinando lasodds ratios con los intervalos de confi anza del 95%.Resultados: La población de estudio estaba compuestapor 193 individuos, el 55 % varones y el 45%mujeres, con un media de edad de 45 años. La edadmediana del primer consumo era de 15 años, el test deFagerström era de 6 y el 85% de los individuos cumplióbien el tratamiento. Las tasas de éxito fueron del91% a los 15 días y de un 49% de éxito al año. Lasvariables: dosis completa tratamiento (OR: 9,83); IMC(OR: 1,24); conciencia de dependencia (1,28) y porcentajede fumadores en el trabajo (OR: 0,98) se hanasociado de forma independiente con el éxito al año(modelo multivariado)...(AU)

Objective: To know cessation rate of a program forbecoming unaccustomed to tobacco with group therapyand pharmacological treatment and to identify predictingitems of success of the treatment.Patients and method: prospective study of a descriptive-analytical cohort. The studied variables were: age,sex, profession, age of fi rst consumption, number ofcigarettes/ day, Fagerström’s test, situations of specialconsumption, current motivation (punctuation from0 to 10), Russell’s test, previous attempts, coexistencewith smokers, consumption of other substances,tobacco dependent diseases, physical exercise, cooximetría,Index of Corporal Mass, use of medicamentsmodality and adherence to the treatment.Group therapies began formed by groups between15-20 people with a total of 8 sessions a year. Thetreatment was considered fi nalized the last session ofthe year and contacted telephonically in case of notbeing present at the workshop.Results: success after a year. Auto-declared abstinenceconfi rmed by cooximetria was considered to be asuccess (carbon monoxide <10 ppm). A regression logisticanalysis univariante and multivariant was applied,determining the odds ratios with the confi dence intervalsof 95%. The studied population was formed by193 individuals, 55% males and 42% females, with anaverage age of 45. The medium age of fi rst consumptionwas 15 and Fagerström’s test was of 6. The 84,7%of the individuals fulfi lled well the treatment. The ratesof success were of 91% after 15 days and of 49 % ofsuccess after a year. The variables: complete treatmentdose (OR: 9,83); IMC (OR: 1,24); consciousness ofdependency (1,28) and percentage of smokers at work(OR: 0,98) they have been associated independentlywith success after a year (multi-varied model)...(AU)

Surveillance of acute bacterial meningitis among children admitted to a district hospital in rural Mozambique.

BACKGROUND: Acute bacterial meningitis (ABM) remains an important cause of mortality among African children. Epidemiologic data with regard to ABM infection are necessary for prioritizing public health interventions. METHODS: We strengthened hospital-based surveillance of ABM among children admitted to Manhiça District Hospital (Maputo, Mozambique). Cerebrospinal fluid (CSF) samples were collected from children admitted to the hospital who met clinical criteria of ABM. Laboratory determinations were performed. Clinical information and outcome of cases were recorded. RESULTS: During the first 12 months of surveillance, which began in January 2006, CSF samples were collected from 642 children <15 years of age with suspected meningitis (18% of all pediatric patients admitted to the hospital during that time). ABM was confirmed in 43 (7%) of the 642 cases. Haemophilus influenzae type b (Hib) (14 cases), pneumococcus (9 cases), and meningococcus (7 cases) represented approximately 70% of confirmed cases. Four of the 9 pneumococci were serotypes covered by the 7-valent pneumococcal conjugate vaccine. The case fatality rate among patients with ABM was 24% (8 of 33 with known outcome); an additional 8 patients left the hospital before discharge. The incidence of ABM was 85 per 100,000 population, which peaked at 2-12 months of age at 1078 cases per 100,000 population. All 9 pneumococci isolates were susceptible to chloramphenicol, and 8 were susceptible to penicillin (the additional 1 had intermediate resistance). For the 10 Hib isolates tested, only 1 was susceptible to chloramphenicol, and 5 were susceptible to ampicillin. CONCLUSION: These data reinforce the importance of ABM as a cause of hospital admission and death in rural sub-Saharan Africa. Most observed ABM cases could have been prevented by current pneumococcal and Hib conjugate vaccines.

Invasive pneumococcal disease in children<5 years of age in rural Mozambique.

OBJECTIVES: To estimate the incidence and epidemiological characteristics of invasive pneumococcal disease (IPD) in children<5 years of age living in a rural area of southern Mozambique. METHODS: As part of the clinical management of children admitted to Manhiça District Hospital, prospective surveillance for invasive bacterial disease was conducted from June 2001 to May 2003. The level of antibiotic resistance of the isolates was also analysed. RESULTS: Pneumococcus was the most commonly isolated bacterium, accounting for 212 episodes. The estimated crude incidence rate of IPD in the study area among children<5 years of age was 416/100,000 per child-year at risk. The youngest age group (<3 months) had the highest incidence (779/100,000). Cases were detected during both rainy and dry seasons. The most common clinical diagnosis was pneumonia, made in 146/212 (69%) of the episodes of IPD. The overall case fatality rate was 10%, being highest among children with pneumococcal meningitis (5/9=56%). Pneumococcal isolates were highly susceptible to penicillin (86% susceptible and 14% with intermediate resistance) and chloramphenicol (98% susceptible). In contrast, up to 37% of the isolates tested were non-susceptible to cotrimoxazole. CONCLUSIONS: Incidence rates of IPD and associated mortality shown in this study highlight the need for pneumococcal vaccines in rural Africa, which must be effective in infants and young children.

Analysis of CGG variation through 642 meioses in Fragile X families.

Fragile X syndrome is the commonest familial form of inherited mental retardation. The molecular defect is an expansion of the CGG trinucleotide repeats in the 5' untranslated region of the FMR1 gene that is inherited in an unstable fashion in fragile X families. In an attempt to provide more information about the CGG tract intergenerational variation, we have evaluated 642 transmissions in 175 Fragile X families. PCR and Southern blot (StB12.3) was used to analyse the CGG number. Among premutated alleles, 90.2% showed expansion, two-thirds to a full mutation while the rest remained in the premutation range, 5.5% of alleles did not vary and finally 4.3% of them reduced in size. Premutated females showed an increased risk of expansion to the full mutation depending on the CGG tract. The estimated risk for 80 triplets is more than seven times that of a woman carrying 59 CGG, the risk being 100% for alleles of >100 repeats. Fifty-nine repeats was the smallest allele that expanded to full mutation. Contractions were detected more frequently in males than in females, being statistically significant. This study contributes to the literature by increasing the data available regarding transmissions in Fragile X families and it allows us to perform more precise genetic counselling for women with the CGG repeat in the premutation range.

Long-term biochemical response after bisphosphonate therapy in Paget's disease of bone. Proposed intervals for monitoring treatment.

OBJECTIVES: To monitor the long-term evolution of Paget's disease activity after treatment with tiludronate by using serum total alkaline phosphatase (TAP) and more sensitive markers such as bone alkaline phosphatase (BAP), procollagen type I N propeptide (PINP) and urinary N-terminal cross-linking telopeptide of type I collagen (NTX); to analyse the predictors of long-term response to therapy; and to study the most appropriate intervals of time for monitoring the response to therapy. METHODS: Thirty-two patients with Paget's disease were included in the study. All received 400 mg of oral tiludronate daily for 3 months. A total of 21 patients completed the study. In these patients, serum TAP, BAP and PINP and urinary NTX were measured at baseline and at 1, 6, 12 and 24 months after discontinuation of therapy. Quantitative bone scintigraphy was performed at baseline and at 6 and 24 months after the end of treatment, obtaining a scintigraphic activity index (SAI). Patients were classified into two groups depending on the long-term response to treatment: Group 1, patients who presented a persistent and significant decrease in disease activity at this time, n = 12 (57%) and Group 2, patients who presented a relapse in the activity of the disease at 24 months after treatment, n = 9 (43%). The relapse of disease activity was defined as a significant increase of SAI (>13%) between 6 and 24 months after the end of treatment, whereas the response to therapy was defined as a significant reduction in SAI (>13%) at 6 months after the end of treatment. In addition, these results were compared with the biochemical evolution of bone markers. RESULTS: Biochemical markers and SAI decreased significantly after therapy and the nadir response was observed at 6 months. At this time 100% of patients responded to therapy. The persistent long-term response was associated with lower baseline indices of bone turnover (serum BAP<60 ng/ml or TAP<600 IU/l). The intervals of time for monitoring depended on the marker used: no patient from Group 1 presented a biochemical relapse in serum TAP at 1 and 2 yr after the end of treatment whereas 33 and 45% of these patients showed relapsed serum BAP at these time points. Moreover, all patients from Group 2 presented a biochemical relapse of serum BAP at 2 yr whereas in only 33% of these patients did serum TAP relapse at this time. CONCLUSION: Most of the Pagetic patients treated with tiludronate presented a long-term response, which persisted 2 yr after the end of treatment. The nadir response to treatment was observed 6 months after discontinuation of therapy whereas the relapse of disease activity was already observed 1 yr after the end of therapy and depended on both the baseline disease activity and the bone marker used in the evaluation.

[Is there a place for otorhinolaryngology in primary care? Analysis of different areas]. / Qué papel tiene la otorrinolaringología en la asistencia primaria? Un análisis de variación en áreas concretas.

Otolaryngological disorders do have a high incidence, and prevalence and require specific physical examinations amongst general population. As a result, it is believed that it would be efficient to have otorhinolaryngologists within the primary care system. The main aim of this study was to assess the differences in hospital referrals comparing primary care units with and without ENT specialists. The study was carried out in Osona County (Catalonia, Spain). We studied the referrals to the hospital from two different primary care units, one with otorhinolaryngology services and the other without them. We analysed the morbidity, follow up and demographic variables of first visits in the hospital ENT department referred by these two primary care units. The primary care organisation without ENT specialist tends to refer more patients (3.96 first visits more per 1000 inhabitants a year, CI 95% 2.84-5.09) with ENT problems than the primary care one with ENT specialist. The difference is mainly due to an higher number of referrals that do not require hospital treatment (i.e. acute otitis, patients without an ENT clear diagnosis). In the area with ENT specialist, GP's also tend to refer patients directly to the hospital, hampering the organisation efficiency. The referrral pattern of GPs from the two organisations is quite similar, and they refer a high percentage of patients that do not need ENT hospital care. The study shows that ENT specialists in primary care units refer less patients with ENT disorders that can be successfully diagnosed and treated outside the hospital.

¿Qué papel tiene la Otorrinolaringología en la asistencia primaria? Un análisis de variación en áreas concretas / Is there a place for otolaryngology in prymary care? Analysis of different areas

La patología otorrinolaringológica es de alta incidencia y prevalencia y requiere una exploración especializada morfo-funcional para poder realizar la mayoría de diagnósticos. Estas premisas permiten pensar que la presencia del médico especialista en otorrinolaringología en la asistencia primaria aumenta su eficacia. El objetivo de este estudio es valorar las diferencias en la derivación hospitalaria, en una área geográfica concreta, entre dos sistemas de asistencia primaria con y sin otorrinolaringólogo. Diseño: Se trata de un estudio de cohortes histórico, llevado a cabo en la comarca de Osona (Barcelona), utilizando el análisis estadístico de áreas concretas. Método: Se estudian las derivaciones a un único hospital de referencia de dos redes de asistencia primaria de áreas concretas, una con especialista otorrinolaringólogo y la otra sin él. Se analizan las diferencias en morbilidad, seguimiento y variables demográficas de todas las primeras visitas al servicio de otorrinolaringología del hospital de referencia. Resultados: El área de asistencia primaria sin otorrinolaringólogo deriva más pacientes con problemas otorrinolaringológicos que el área de asistencia primaria con otorrinolaringólogo (3,96 primeras visitas más por 1.000 habitantes-año) (CI95 2,84 - 5,09). La diferencia es debida principalmente al aumento de derivaciones que no requieren asistencia hospitalaria (otitis aguda, pacientes sin patología). En el área con otorrinolaringólogo, los médicos generalistas de asistencia primaria también derivan pacientes directamente al hospital, situación que impide una mayor eficiencia de la organización. Conclusiones: El estudio muestra que el empleo de médicos otorrinolaringólogos en la asistencia primaria disminuye el número de derivaciones al nivel hospitalario y aumenta el número de patologías otorrinolaringológicas resueltas fuera del hospital (AU)

Otolaryngological disorders do have a high incidence, and prevalence and require specific physical examinations amongst general population. As a result, it is believed that it would be efficient to have otorhinolaryngologists within the primary care system. The main aim of this study was to assess the differences in hospital referrals comparing primary care units with and without ENT specialists. The study was carried out in Osona County (Catalonia, Spain). We studied the referrals to the hospital from two different primary care units, one with otorhinolaryngology services and the other without them. We analysed the morbidity, follow up and demographic variables of first visits in the hospital ENT department referred by these two primary care units. The primary care organisation without ENT specialist tends to refer more patients (3.96 first visits more per 1000 inhabitants a year, CI 95% 2.84-5.09) with ENT problems than the primary care one with ENT specialist. The difference is mainly due to an higher number of referrals that do not require hospital treatment (i.e. acute otitis, patients without an ENT clear diagnosis). In the area with ENT specialist, GP's also tend to refer patients directly to the hospital, hampering the organisation efficiency. The referrral pattern of GPs from the two organisations is quite similar, and they refer a high percentage of patients that do not need ENT hospital care. The study shows that ENT specialists in primary care units refer less patients with ENT disorders that can be successfully diagnosed and treated outside the hospital (AU)