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

Clara Menendez and colleagues analyze 139 complete autopsies following maternal deaths in Maputo, Mozambique and find a predominance of infectious and preventable causes

Minimally Invasive Autopsy Practice in COVID-19 Cases: Biosafety and Findings

Postmortem studies are crucial for providing insight into emergent diseases. However, a complete autopsy is frequently not feasible in highly transmissible diseases due to biohazard challenges. Minimally invasive autopsy (MIA) is a needle-based approach aimed at collecting samples of key organs without opening the body, which may be a valid alternative in these cases. We aimed to: (a) provide biosafety guidelines for conducting MIAs in COVID-19 cases, (b) compare the performance of MIA versus complete autopsy, and (c) evaluate the safety of the procedure. Between October and December 2020, MIAs were conducted in six deceased patients with PCR-confirmed COVID-19, in a basic autopsy room, with reinforced personal protective equipment. Samples from the lungs and key organs were successfully obtained in all cases. A complete autopsy was performed on the same body immediately after the MIA. The diagnoses of the MIA matched those of the complete autopsy. In four patients, COVID-19 was the main cause of death, being responsible for the different stages of diffuse alveolar damage. No COVID-19 infection was detected in the personnel performing the MIAs or complete autopsies. In conclusion, MIA might be a feasible, adequate and safe alternative for cause of death investigation in COVID-19 cases

Pathology and Telepathology Methods in the Child Health and Mortality Prevention Surveillance Network

This manuscript describes the Child Health and Mortality Prevention Surveillance (CHAMPS) network approach to pathologic evaluation of minimally invasive tissue sampling (MITS) specimens, including guidelines for histopathologic examination and further diagnostics with special stains, immunohistochemistry, and molecular testing, as performed at the CHAMPS Central Pathology Laboratory (CPL) at the Centers for Disease Control and Prevention, as well as techniques for virtual discussion of these cases (telepathology) with CHAMPS surveillance locations. Based on review of MITS from the early phase of CHAMPS, the CPL has developed standardized histopathology-based algorithms for achieving diagnoses from MITS and telepathology procedures in conjunction with the CHAMPS sites, with the use of whole slide scanners and digital image archives, for maximizing concurrence and knowledge sharing between site and CPL pathologists. These algorithms and procedures, along with lessons learned from initial implementation of these approaches, guide pathologists at the CPL and CHAMPS sites through standardized diagnostics of MITS cases, and allow for productive, real-time case discussions and consultations

How students perceive medical competences: a cross-cultural study between the Medical Course in Portugal and African Portuguese Speaking Countries

<p>Abstract</p> <p>Background</p> <p>A global effort has been made in the last years to establish a set of core competences that define the essential professional competence of a physician. Regardless of the environment, culture or medical education conditions, a set of core competences is required for medical practice worldwide. Evaluation of educational program is always needed to assure the best training for medical students and ultimately best care for patients. The aim of this study was to determine in what extent medical students in Portugal and Portuguese speaking African countries, felt they have acquired the core competences to start their clinical practice. For this reason, it was created a measurement tool to evaluate self-perceived competences, in different domains, across Portuguese and Portuguese-speaking African medical schools.</p> <p>Methods</p> <p>The information was collected through a questionnaire that defines the knowledge, attitudes and skills that future doctors should acquire. The Cronbach's Alpha and Principal Components Analysis (PCA) were used to evaluate the reliability of the questionnaire. In order to remove possible confounding effect, individual scores were standardized by country.</p> <p>Results</p> <p>The order of the domain's scores was similar between countries. After standardization, Personal Attitudes and Professional Behavior showed median scores above the country global median and Knowledge alone showed median score below the country global median. In Portugal, Clinical Skills showed score below the global median. In Angola, Clinical Skills and General Skills showed a similar result. There were only significant differences between countries in Personal Attitudes (p < 0.001) and Professional Behavior (p = 0.043).</p> <p>Conclusions</p> <p>The reliability of the instrument in Portuguese and Portuguese-speaking African medical schools was confirmed. Students have perceived their level of competence in personal attitudes in a high level and in opposite, knowledge and clinical skills with some weaknesses.</p

Validity of a Minimally Invasive Autopsy for Cause of Death Determination in Adults in Mozambique: An Observational Study

Background There is an urgent need to identify tools able to provide reliable information on the cause of death in low-income regions, since current methods (verbal autopsy, clinical records, and complete autopsies) are either inaccurate, not feasible, or poorly accepted. We aimed to compare the performance of a standardized minimally invasive autopsy (MIA) approach with that of the gold standard, the complete diagnostic autopsy (CDA), in a series of adults who died at Maputo Central Hospital in Mozambique. Methods and Findings In this observational study, coupled MIAs and CDAs were performed in 112 deceased patients. The MIA analyses were done blindly, without knowledge of the clinical data or the results of the CDA. We compared the MIA diagnosis with the CDA diagnosis of cause of death. CDA diagnoses comprised infectious diseases (80; 71.4%), malignant tumors (16; 14.3%), and other diseases, including non-infectious cardiovascular, gastrointestinal, kidney, and lung diseases (16; 14.3%). A MIA diagnosis was obtained in 100/112 (89.2%) cases. The overall concordance between the MIA diagnosis and CDA diagnosis was 75.9% (85/112). The concordance was higher for infectious diseases and malignant tumors (63/80 [78.8%] and 13/16 [81.3%], respectively) than for other diseases (9/16; 56.2%). The specific microorganisms causing death were identified in the MIA in 62/74 (83.8%) of the infectious disease deaths with a recognized cause. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation. Conclusions A simple MIA procedure can identify the cause of death in many adult deaths in Mozambique. This tool could have a major role in improving the understanding and surveillance of causes of death in areas where infectious diseases are a common cause of mortality

The pathology of eclampsia: An autopsy series

Objective: We describe the main lesions in the liver, brain, and kidney from autopsies of women who died of eclampsia and characterize the endothelial injury. Methods: Cases were identified from a study involving 317 maternal deaths (2003–2006) conducted at the Maputo Central Hospital (Maputo, Mozambique) in association with ISGlobal (Barcelona, Spain). Histology slides along with stains for endothelial, histiocyte, and platelet markers (CD31, CD34, CD68, CD42B) were reviewed to identify the relevant lesions. Malondialdehyde stain was performed to demonstrate free radical generation. Results: Brain lesions were characterized by perivascular “edema” (68.4%), hemorrhage (36.8%), hemosiderin (31.6%), small vessel thrombosis (10.5%), and parenchymal necrosis (15.8%). Liver sections showed periportal/portal necrosis and sinusoidal fibrin (72.2%) with associated hepatic arterial medial necrosis (44.4%). Kidneys showed glomerular endotheliosis. Endothelial, histiocytic, and platelet markers highlighted capillary injury in the otherwise intact brain parenchyma. Stains for free radical formation were positive predominantly in the areas of tissue injury, but intact glial/neuronal elements were focally positive as evidence of widespread oxidative stress. Conclusion: Pathological changes in cases of eclampsia include widespread endothelial/vascular injury in vulnerable organ beds

Trends in cancer incidence in Maputo, Mozambique, 1991-2008

PMID: 26110774 WOS:000356933800051Background: Very limited information is available regarding the incidence of cancer in sub-Saharan Africa. We analyzed changes in cancer patterns from 1991 to 2008 in Maputo (Mozambique). Methods: We calculated the rates of incidence of different cancer sites by sex in the 5-year age-group of the population of Maputo city as well as age-standardized rates (ASRs) and average annual percentage changes (AAPC). Results: Over the 18-year study period a total of 12,674 cases of cancer (56.9% females) were registered with an overall increase in the risk of cancer in both sexes. In males, the most common cancers were those of the prostate, Kaposi sarcoma (KS) and the liver. Prostate cancer showed the most dramatic increase over the whole study period (AAPC +11.3%; 95% CI: 9.7-13.0), with an ASR of 61.7 per 105 in 2003-2008. In females, the most frequent cancers were of the uterine cervix, the breast and KS, with the former increasing along the whole study period (AAPC + 4.7%; 95% CI: 3.4-6) with an ASR of 62.0 per 105 in 2003-2008 as well as breast cancer (AAPC +6.5%; 95%CI: 4.3-8.7). Conclusions: Overall, the risk of cancer rose in both sexes during the study period, particularly among cancers associated with westernization of lifestyles (prostate, breast), combined with increasingly rising incidences or limited changes in cancers associated with infection and poverty (uterine cervix, liver). Moreover, the burden of AIDS-associated cancers has shown a marked increase.publishersversionpublishe

Weak surveillance and policy attention to cancer in global health: the example of Mozambique

Cancer is an emerging public health problem in sub-Saharan Africa due to population growth, ageing and westernisation of lifestyles. The increasing burden of cancer calls for urgent policy attention to develop cancer prevention and control programmes. Cancer surveillance is an essential prerequisite. Only one in five low-income and middle-income countries have the necessary data to drive policy and reduce the cancer burden. In this piece, we use data from Mozambique over a 50-year period to illustrate cancer epidemiological trends in low-income and middle-income countries to hypothesise potential circumstances and factors that could explain changes in cancer burden and to discuss surveillance weaknesses and potential improvements. Like many low-income and middle-income countries, Mozambique faces the dual challenge of a still high morbidity and mortality due to infectious diseases in rural areas and increased incidence of cancers associated with westernisation of lifestyles in urban areas, as well as a rise of cancers related to the HIV epidemic. An increase in cancer burden and changes in the cancer profile should be expected in coming years. The Mozambican healthcare and health-information systems, like in many other low-income and middle-income countries, are not prepared to face this epidemiological transition, which deserves increasing policy attention

Clinico-Pathological discrepancies in the Diagnosis of Causes of Maternal Death in Sub-Saharan Africa: Retrospective Analysis

Background Maternal mortality is a major public-health problem in developing countries. Extreme differences in maternal mortality rates between developed and developing countries indicate that most of these deaths are preventable. Most information on the causes of maternal death in these areas is based on clinical records and verbal autopsies. Clinical diagnostic errors may play a significant role in this problem and might also have major implications for the evaluation of current estimations of causes of maternal death. Methods and Findings A retrospective analysis of clinico-pathologic correlation was carried out, using necropsy as the gold standard for diagnosis. All maternal autopsies (n ¼ 139) during the period from October 2002 to December 2004 at the Maputo Central Hospital, Mozambique were included and major diagnostic discrepancies were analyzed (i.e., those involving the cause of death). Major diagnostic errors were detected in 56 (40.3%) maternal deaths. A high rate of false negative diagnoses was observed for infectious diseases, which showed sensitivities under 50%: HIV/AIDS-related conditions (33.3%), pyogenic bronchopneumonia (35.3%), pyogenic meningitis (40.0%), and puerperal septicemia (50.0%). Eclampsia, was the main source of false positive diagnoses, showing a low predictive positive value (42.9%). Conclusions Clinico-pathological discrepancies may have a significant impact on maternal mortality in sub-Saharan Africa and question the validity of reports based on clinical data or verbal autopsies. Increasing clinical awareness of the impact of obstetric and nonobstetric infections with their inclusion in the differential diagnosis, together with a thorough evaluation of cases clinically thought to be eclampsia, could have a significant impact on the reduction of maternal mortality