Infection by Strongyloides stercoralis in immigrants with Chagas disease: evaluation of eosinophilia as screening method in primary care

OBJECTIVES

To evaluate co-infection of Strongyloides stercoralis and Trypanosoma cruzi and to assess eosinophilia as a screening test for the detection of S. stercoralis infection in patients with Chagas disease (CD).

METHODS

A retrospective diagnostic validation study was performed on serum samples from primary care patients diagnosed with CD in the southern Barcelona metropolitan area. All samples with eosinophilia (n = 87) and a random sample of non-eosinophilic sera (n = 180) were selected. Diagnosis of CD was based on positive serology by means of two tests: ORTHO® T. cruzi ELISA test, and BIO-FLASH® Chagas or Bioelisa CHAGAS. SCIMEDX ELISA STRONGY-96 was used to diagnose strongyloidiasis.

RESULTS

Strongyloides stercoralis serology was positive in 15% of patients of whom 95% showed eosinophilia, vs. 21% of those with negative serology (P < 0.001), with differences in the mean eosinophil count (0.49 vs. 0.27 × 10⁹ /l). Only 1.1% of patients with CD but without eosinophilia presented positive serology for S. stercoralis, whereas 44% of patients with CD and eosinophilia did (P < 0.001). Sensitivity and specificity values for eosinophilia were thus 95% and 79%, respectively. PPV was 42.5% and NPV, 98.9%.

CONCLUSIONS

The prevalence of co-infection by T. cruzi and S. stercoralis is not negligible and has probably been underestimated for years in many areas, due to frequently subclinical infections. Therefore, serology seems mandatory for these patients and the use of eosinophilia as initial screening could facilitate the task, decreasing the number of analyses to be performed.

Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia

BACKGROUND

In a context of increasing demand and pressure on the public health expenditure, appropriateness of colonoscopy indications is a topic of discussion. The objective of this study is to evaluate the appropriateness of colonoscopy requests performed in a primary care (PC) setting in Catalonia.

METHODS

Cross-sectional descriptive study. Out-patients >14 years of age, referred by their reference physicians from PC or hospital care settings to the endoscopy units in their reference hospitals, to undergo a colonoscopy. Evaluation of the appropriateness of 1440 colonoscopy requests issued from January to July 2011, according to the EPAGE-II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy).

RESULTS

The most frequent indications of diagnostic suspicion requests were: rectal bleeding (37.46 %), abdominal pain (26.54 %), and anaemia study (16.78 %). The most frequent indications of disease follow-up were adenomas (58.1 %), and CRC (31.16 %). Colonoscopy was appropriate in 73.68 % of the cases, uncertain in 16.57 %, and inappropriate in 9.74 %. In multivariate analysis, performed colonoscopies reached an OR of 9.9 (CI 95 % 1.16-84.08) for qualifying as appropriate for colorectal cancer (CRC) diagnosis, 1.49 (CI 95 % 1.1-2.02) when requested by a general practitioner, and 1.09 (CI 95 % 1.07-1.1) when performed on women.

CONCLUSIONS

Appropriateness of colonoscopy requests in our setting shows a suitable situation in accordance with recognized standards. General practitioners contribute positively to this appropriateness level. It is necessary to provide physicians with simple and updated guidelines, which stress recommendations for avoiding colonoscopy requests in the most prevalent conditions in PC.

Unlinked anonymous testing to estimate HIV prevalence among pregnant women in Catalonia, Spain, 1994 to 2009

This paper estimates the prevalence of human immunodeficiency virus (HIV) infections in women giving birth and women voluntarily terminating pregnancy over a period of sixteen years in Catalonia. Samples for HIV antibody detection were collected from the Neonatal Early Detection Programme for congenital metabolic diseases that covers 99% of infants born in Catalonia. The sampling method collected information of 50% of births every year and of all women attending three clinics for voluntary interruption of pregnancy. Using two sequential immunoassays we analysed unlinked anonymous blood spot samples from 549,689 newborns between 1994 and 2009 and from 31,904 women who voluntarily interrupted pregnancy between 1999 and 2006. HIV prevalence among women giving birth decreased from 3.2 per 1,000 in 1994 to 1.7 per 1,000 in 2009 (p<0.01) and the mean age of infected mothers increased from 26 years in 1994 to 32 years in 2009 (p=0.001). A decrease in HIV prevalence was also observed in women voluntarily terminating pregnancy, from 2.3 per 1,000 in 1999 to 1.0 per 1,000 in 2006 (p<0.01). In contrast, estimated HIV prevalence in mothers born outside Spain increased from 2.2 per 1,000 in 2002 to 3 per 1,000 in 2009 (p<0.01) and their average age increased from 27 years in 2003 to 31 years in 2009 (p<0.01).

Unlinked anonymous testing to estimate HIV prevalence among pregnant women in Catalonia, Spain, 1994 to 2009

This paper estimates the prevalence of human immunodeficiency virus (HIV) infections in women giving birth and women voluntarily terminating pregnancy over a period of sixteen years in Catalonia. Samples for HIV antibody detection were collected from the Neonatal Early Detection Programme for congenital metabolic diseases that covers 99% of infants born in Catalonia. The sampling method collected information of 50% of births every year and of all women attending three clinics for voluntary interruption of pregnancy. Using two sequential immunoassays we analysed unlinked anonymous blood spot samples from 549,689 newborns between 1994 and 2009 and from 31,904 women who voluntarily interrupted pregnancy between 1999 and 2006. HIV prevalence among women giving birth decreased from 3.2 per 1,000 in 1994 to 1.7 per 1,000 in 2009 (p<0.01) and the mean age of infected mothers increased from 26 years in 1994 to 32 years in 2009 (p=0.001). A decrease in HIV prevalence was also observed in women voluntarily terminating pregnancy, from 2.3 per 1,000 in 1999 to 1.0 per 1,000 in 2006 (p<0.01). In contrast, estimated HIV prevalence in mothers born outside Spain increased from 2.2 per 1,000 in 2002 to 3 per 1,000 in 2009 (p<0.01) and their average age increased from 27 years in 2003 to 31 years in 2009 (p<0.01).

Utility of geriatric assessment tools to identify 85-years old subjects with vitamin D deficiency

OBJECTIVES

To calculate the prevalence of hypovitaminosis D in subjects aged 85 years old and to study the relationship between some common geriatric evaluation scales and vitamin D status.

DESIGN

Prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

312 subjects aged 85 years old.

MEASUREMENTS

Geriatric assessment was based on comorbidity, functional status according to the Barthel Index (BI) and Lawton Index (LI), cognitive status measured by the Spanish version of the Mini-Mental State Examination (MEC), nutritional risk according to the Mini Nutritional Assessment (MNA), and gait using the Tinetti Gait Scale. Serum 25(OH)D concentrations were used to assess vitamin D status. Hypovitaminosis D was considered as < 25 ng/ml and deficiency < 11 ng/ml.

RESULTS

Mean serum 25(OH)D level was 28 ± 30 ng/ml. The prevalence of hypovitaminosis D was 52.5% (38.1% insufficiency and 14.4% deficiency). Men had higher levels than women (32.2 ± 44 vs. 25.2 ± 25 ng/ml; p=0.04). The bivariate analyses identified an association between MNA scores and hypovitaminosis D, and showed that females ande participants with poor BI, Tinetti and MNA scores were associated with deficiency. Logistic regression analysis confirmed a significant association between poor MNA scores and both hypovitaminosis D (p < 0.04, OR 1.066, 95% CI 1.002-1.135) and vitamin D deficiency (p < 0.0001, OR 1.192, 95% CI 1.099-1.293).

CONCLUSIONS

More than half the population aged 85 years has a vitamin D deficit and 14.4% show a deficiency. A lower score on the MNA scale is associated with a greater likelihood of having lower vitamin D serum values.

Gestational diabetes mellitus in a cohort of HIV-1 infected women

OBJECTIVES

We undertook a prospective study to estimate the prevalence of gestational diabetes mellitus (GDM) and associated risk factors in a cohort of 669 HIV-1 infected women.

METHODS

The O'Sullivan and glucose tolerance tests were performed during regular visits of 609 mothers.

RESULTS

The median age of the cohort was 30.7 years (range 16-44), with most women having had heterosexual contact (67%). The majority were in Centers for Disease Control (CDC) category A (71%) and 53% exhibited hepatitis C co-infection. Median viral load and CD4 count at third trimester were 545 cells/microL (range 139-1690 cells/microL) and 1.9 log (range 1.7-5.4), respectively. Seventy-four per cent of the patients were treated with highly active antiretroviral therapy (HAART), of whom 41% received a protease inhibitor (PI). An above-average prevalence of 7% [95% confidence interval (CI) 5.2-9.5] for positive GDM diagnosis was found. Risk factors associated with GDM in univariate analysis included older age, hepatitis C co-infection, stavudine and PI exposure. However, only older age [adjusted odds ratio (AOR) 1.09, 95% CI 1-1.1] and PI exposure (AOR 2.4, 95% CI 1-5.3) remained as independent risk factors for GDM development in multivariate analysis.

CONCLUSIONS

In our cohort, the prevalence of GDM appears to be increased, with older age and PI exposure contributing as significant independent risk factors.

Evaluation of a commercial enzyme immunoassay for HIV screening in urine

A cross-sectional study was conducted to evaluate the utility of a commercial enzyme immunoassay (EIA) as a screening test for detecting HIV-1 antibody in urine in a population at risk for HIV infection in Catalonia, Spain. Paired urine and serum samples were collected consecutively from 99 patients who attended two drug-dependency treatment centres and 151 patients who attended a sexually transmitted diseases (STD) clinic in Barcelona. Antibodies against HIV in urine samples were detected using the Calypte HIV-1 Urine EIA (Calypte Biomedical Corporation, Berkeley, CA, USA) and confirmed by urine-based Western blot (WB) analysis. Sera were analysed using Bioelisa HIV-1+2 EIA (Biokit Laboratories, Barcelona, Spain), and the results were verified using serum-based WB analysis. Results of both urine and serum testing were available for 246 of 250 participants. For 52 individuals the results of both urine and serum testing were positive and for five the results were discordant (2 with urine-negative/serum-positive results and 3 with urine-positive/serum-negative results). The respective sensitivity and specificity values obtained for the urine EIA were 100% and 96.2% for intravenous drug users (IDUs) and 80% and 99.3% for persons attending the STD clinic. According to the 1997 UNAIDS/WHO strategy I recommendations, these values are acceptable for surveillance purposes, particularly in populations with a high prevalence of HIV infection.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

[Determinants of HIV mother-to-child transmission in Catalonia, Spain [1997-2001]: is it possible to eliminate it?]

OBJECTIVES

To identify and describe the factors that have led to new cases of HIV infection through mother-to-child transmission since the introduction of antiretroviral therapy in HIV-seropositive pregnant women (1997-2001) in Catalonia.

METHODS

Systematic review of cases identified in the pediatric services of all the hospitals in Catalonia.

RESULTS

Twenty-eight cases of pediatric HIV infection were identified: 9, 9, 8, 2 and 0 per year of birth from 1997 to 2001, respectively. Of 16 mothers with a diagnosis of known HIV infection before or during pregnancy, nine underwent antiretroviral prophylaxis during pregnancy (compliance was good in five, unknown in one and poor in one) and seven did not undergo prophylaxis (six refused it and no information was available in one). Of 12 mothers diagnosed after delivery, pregnancy was not monitored in five and was little or well-monitored in the remaining seven. Of mothers with well-monitored pregnancy, a serological HIV test was not performed in six and was negative in the first trimester in one.

CONCLUSIONS

Mother-to-child transmission of HIV has decreased in the last few years in Catalonia, but infections have sometimes occurred through poor implementation of preventive measures. Pregnant women should be offered an HIV diagnostic test not only in the first trimester but also at the end of pregnancy if HIV exposure is suspected. In women with unmonitored pregnancies, rapid diagnostic tests for HIV should be used in the delivery room.

[Reporting new HIV cases in Catalonia, Spain: is technical consensus feasible?]

OBJECTIVE

To describe the process performed in Catalonia (Spain) to design an information system for monitoring new cases of HIV infection.

METHODS

A survey was used to evaluate perception of the need for notification of HIV infection by health care professionals (n = 106), as well as their opinions of the various possibilities for the implementation of the notification system. As a result of this evaluation, a specific technical report defining the objectives and technical characteristics of the new notification system was produced. The feasibility of the system in health centres was evaluated through discussions with health care professionals, health authorities and Non-Governmental Organizations, and a second survey was designed to evaluate the use of a personal identification code (PIC) from the individual health card (IHC). This process took plabe between 1998 and 2000.

RESULTS

A total of 84.5% of the health care professionals believed that HIV notification should be mandatory and confidential; 90.4%, were of the opinion that notification would enable identification of the epidemiological characteristics of infected individualos, and 75% believed that these individuals would have to be identified by name. Finally, 66% of the health care professionals believed that the use of the PIC from the IHC would be feasible as the personal identifier in HIV notification. A final proposal was draw up and 1 January, 2001 was set as the date to initiate the pilot phase of the new HIV notification system.

CONCLUSIONS

Most of the health care professionals surveyed expressed the need for notification of HIV infection, and for such notification to receive institutional endorsement. They also believed that, as with other diseases of individualized mandatory reporting, notification should be carried out with a single personal identifier. The information obtained from notification of HIV infection is essential for the optimal planning of preventive programs and the provision of health services. The main difficulties observed were that HIV infection has not been included among the diseases of mandatory reporting, as well as the low implantation of the PIC in the hospitals' clinical registries. All the sectors involved have an important role to play in creating the conditions necessary for the notification system of new cases of HIV infection to be feasible and useful.

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

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 Society's 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.

[Schistosomiasis imported by Spanish travelers: clinico-epidemiologic study of 80 cases]

BACKGROUND

Swimming in rivers or lakes is a risk activity, in areas where the life cycle of schistosomiasis occurs. This report presents and analyzes the clinical presentation and epidemiological data of 80 Spanish travellers.

PATIENTS AND METHODS

Descriptive longitudinal and retrospective study that includes clinicoepidemiological and the laboratory data and imaging diagnosis. Patients were seen at the Section of Tropical Medicine, Hospital Clínic i Provincial, Barcelona.

RESULTS

Most patients acquired the infection in the Dogon country of Mall. 25% of them presented with symptoms related to the genital tract. In some groups, 45% of travellers that swam, contracted the infection. The most prevalent species diagnosed was S. haematobium and 10 travellers presented with mixed infections.

CONCLUSIONS

The trip to the Dogon country should be considered as "a risk activity". Travellers Advice Clinics should include the subject of swimming in infected waters in their routine counselling. Genital tract localizations were registered for three species of schistosome. The classical clinical presentation of schistosomiasis in the endemic areas differs considerably from that seen in travellers.

Morphometric variability of Schistosoma intercalatum eggs: a diagnostic dilemma

Variability of Schistosoma intercalatum eggs in shape and size, and their similarity to those of S. haematobium presented a problem of species identification when egg morphology was the diagnostic criterion used in a study of human schistosomiasis conducted on São Tomé and Principe. More than 2500 egg measurements were obtained by light micoscopy to gather data relating to size variability of S. intercalatum eggs, to evaluate whether factors such as age of host, sex of host and intensity of infection are correlated with variability, and the data were compared with previously published measurements on different isolates and strains of S. intercalatum: the range in length (104-203 microns) embraces most of the measurements reported in other studies of S. intercalatum eggs. There was no correlation either between age and sex of the host, or intensity of infection with variability of egg size. Comparison between measurements of the eggs of S. haematobium, S. intercalatum and S. bovis eggs are presented.

Schistosomiasis in the Republic of São Tomé and Principe: characterization of Schistosoma intercalatum

This paper reports the morphological and biochemical characterization of the species of Schistosoma infecting humans in the Republic of São Tomé and Principe. The eggs are typical in shape and size of S. intercalatum, measuring on average between 174.5 microns and 189.1 microns. The eggs are voided in the faeces and not the urine of infected people. The parasite experimentally develops in several different species of Bulinus belonging to the B. forskalii group, including B. forskalii, with a minimum prepatent period of 25 d, and also in snails of the B. reticulatus group (B. wrighti); it is incompatible with snails of the B. africanus and B. truncatus/B. tropicus complex. A survey of 5 different habitats at intervals of 2 weeks over a period of one year showed that populations of B. forskalii increased during the dry period of June, July and August in 1988, and in 3 of the habitats snails were present throughout the year. Hence transmission may take place in these habitats throughout the year. Preliminary evidence suggests that water velocity is a limiting factor confining Bulinus to the north-east of the island where the terrain is less mountainous. Development of schistosomes from São Tomé was followed in experimentally infected hamsters. The cross-over point (the point at which the paired male and female worms are of the same average length) occurred at about 49 d after infection: eggs were first seen in the uteri of the female worms 48 d after infection. The parasite from São Tomé developed in sheep and produced viable eggs.(ABSTRACT TRUNCATED AT 250 WORDS)

Schistosomiasis in the Republic of São Tomé and Principe: human studies

The only schistosome species found in stool specimens in the local population of the republic of São Tomé is Schistosoma intercalatum. An initial survey of schoolchildren showed an overall prevalence of 10.9%, with some schools reaching 29%. No S. haematobium egg was found in 782 urine specimens from the local population, although some were seen in the urine of Angolan soldiers stationed near the capital city. One village in the endemic area, San Marçal, had an S. intercalatum prevalence of 43%, with 14 persons > 40 years of age harbouring severe infections. The transmission area is restricted to the north-east of the main island, where 5 foci apparently account for most of the infections. Seven cases recorded from Principe may be explained by the fact that the children were attending school at São Tomé. Women carrying out domestic activities are more at risk of contracting the infection because of longer periods of water contact than men. The morbidity produced by the infection is restricted to splenomegaly and blood in the stools. High prevalences have been found of Ascaris lumbricoides and Trichuris trichiura, and hookworm and Stronglyloides stercoralis were also observed. Praziquantel was well tolerated and appears to be a good tool for control purposes, although reinfection in the transmission area apparently occurs rapidly. Control strategies based on chemotherapy should take into account an older age group as well as the schoolchildren. Focal mollusciciding and the introduction of washing facilities may also have a role to play in control. The possible recent introduction of the infection to the island is discussed.

Hematospermia: a new etiology of clinical interest

Ten Spanish male tourists developed hematospermia and ultrasonographic evidence of involvement of the prostate and/or seminal vesicles after recreational exposure in bodies of fresh water in the Dogon country of Mali. Schistosoma eggs were detected in the ejaculate of five men, in the others, eggs were observed in the urine or feces. Three different species were observed: S. intercalatum, S. haematobium, and S. mansoni. Hemospermia and clinical prostatitis may be frequently unrecognized clinical manifestations of the early stages of infection in previously nonexposed persons. Travelers to endemic areas should be advised on the potential dangers of swimming and other exposure in bodies of freshwater.