Surveillance of hemorrhagic fever and/or neuroinvasive disease: challenges of diagnosis

  OBJECTIVE To evaluate the performance of post mortem laboratory analysis in identifying the causes of hemorrhagic fever and/or neuroinvasive disease in deaths by arbovirus infection. METHODS Retrospective cross-sectional study based on the differential analysis and final outcome obtained in patients whose samples underwent laboratory testing for arboviruses at the Pathology Center of the Adolfo Lutz Institute, in São Paulo, Brazil. RESULTS Of the 1355 adults clinically diagnosed with hemorrhagic fever and/or neuroinvasive disease, the most commonly attributed cause of death and the most common final outcome was dengue fever. Almost half of the samples tested negative on all laboratory tests conducted. CONCLUSION The failure to identify the causative agent in a great number of cases highlights a gap in the diagnosis of deaths of unknown etiology. Additional immunohistochemical and molecular assessments need to be added to the post-mortem protocol if all laboratory evaluations performed fail to identify a causative agent. While part of our findings may be due to technical issues related to sample fixation, better information availability when making the initial diagnosis is crucial. Including molecular approaches might lead to a significant advancement in diagnostic accuracy

Clinical features and natural history of the first 2073 suspected COVID-19 cases in the Corona São Caetano primary care programme: a prospective cohort study.

BACKGROUND: Despite most cases not requiring hospital care, there are limited community-based clinical data on COVID-19. METHODS: The Corona São Caetano programme is a primary care initiative providing care to all residents with COVID-19 in São Caetano do Sul, Brazil. It was designed to capture standardised clinical data on community COVID-19 cases. After triage of potentially severe cases, consecutive patients presenting to a multimedia screening platform between 13 April and 13 May 2020 were tested at home with SARS-CoV-2 reverse transcriptase (RT) PCR; positive patients were followed up for 14 days with phone calls every 2 days. RT-PCR-negative patients were offered additional SARS-CoV-2 serology testing to establish their infection status. We describe the clinical, virological and natural history features of this prospective population-based cohort. FINDINGS: Of 2073 suspected COVID-19 cases, 1583 (76.4%) were tested by RT-PCR, of whom 444 (28.0%, 95% CI 25.9 to 30.3) were positive; 604/1136 (53%) RT-PCR-negative patients underwent serology, of whom 52 (8.6%) tested SARS-CoV-2 seropositive. The most common symptoms of confirmed COVID-19 were cough, fatigue, myalgia and headache; whereas self-reported fever (OR 3.0, 95% CI 2.4 to 3.9), anosmia (OR 3.3, 95% CI 2.6 to 4.4) and ageusia (OR 2.9, 95% CI 2.3 to 3.8) were most strongly associated with a positive COVID-19 diagnosis by RT-PCR or serology. RT-PCR cycle thresholds were lower in men, older patients, those with fever and arthralgia and closer to symptom onset. The rates of hospitalisation and death among 444 RT-PCR-positive cases were 6.7% and 0.7%, respectively, with older age and obesity more frequent in the hospitalised group. CONCLUSION: COVID-19 presents in a similar way to other mild community-acquired respiratory diseases, but the presence of fever, anosmia and ageusia can assist the specific diagnosis. Most patients recovered without requiring hospitalisation with a low fatality rate compared with other hospital-based studies

Access to diagnostic colposcopy among women with abnormal cervical screening tests in the state of São Paulo, Brazil

Investigar a taxa de aderência à colposcopia, e fatores associados com a mesma, em mulheres com lesões do colo uterino identificadas por rastreamento em serviços de atenção primária no estado de São Paulo. MÉTODOS: Nós analisamos duas fontes de dados. Primeiro, analisamos uma coorte prospectiva de mulheres com infeção do colo uterino pelo papilomavírus humano de alto risco (hr-HPV). A coorte foi formada em um estudo piloto da implementação de rastreamento por testagem de hr-HPV. Nós determinamos a taxa de comparecimento para colposcopia e investigamos covariáveis associadas usando regressão logística. Segundo, analisamos dados administrativos, provenientes do estado de São Paulo no Sistema de Informação do Câncer do Colo do Útero (SISCOLO) que contém os resultados de citolgia, e no Sistema de Informação Ambulatorial (SIA-SUS) em que há registros de colposcopias. Nós desenvolvemos uma rotina de linkage probabilístico para combinar os dois bancos de dados e determinar a taxa de acesso à colposcopia. RESULTADOS: Entre 1537 mulheres que testaram positivas para hr-HPV, 1235 (80,4%) compareceram para colposcopia, com uma defasagem mediana entre exame de rastreamento e colposcopia de 132 dias. Idade mais jovem (0<0,001) e resultado citológico negativo (P=0,025) foram associados com taxa menor de colposcopia. Mulheres cadastradas em unidades de saúde que ofereceram ambos o exame de hr-HPV e colposcopia tinham uma taxa de colposcopia maior comparado com aquelas que foram encaminhadas para serviços externos (788/862 [91,4%] versus 447/675 [66,2%], P<0.001). Usando os dados administrativos do SISCOLO e SIA-SUS, 1761 mulheres com citologia alterada foram identificadas entre 1 maio 2014 e 30 de junho 2014. 700 (39,8%) delas com um registro de colposcopia no tempo de seguimento. A taxa de colposcopia foi ligeiramente mais alta entre mulheres residentes na região metropolitana de São Paulo comparado com o interior. CONCLUSÃO: Perda de seguimento de mulheres com indicação de colposcopia pode comprometer o sucesso tanto do programa atual de rastreamento por Papanicolaou quanto de programas no futuro usando testagem de hr-HPV no BrasilOBJECTIVE: To investigate the rate of, and factors associated with, colposcopy attendance among women with screen-detected cervical lesions in primary care services in the state of São Paulo. METHODS: Firstly, we analyzed a prospective cohort of women positive for high risk HPV (hr-HPV) undergoing cervical cancer screening in primary care services in the municipality of São Paulo, as part of a pilot study of this screening technology. We determined the rate of attendance for colposcopy and examined co-variates associated with attendance within a logistic regression framework. Second, we analyzed state-level screening data recorded in the Sistema de Informação do Câncer do Colo do Útero, SISCOLO, which contains all cytology results performed within the public health system, and the Sistema de Informação Ambulatorial, SIA-SUS, which contains all the colposcopies. We developed a probabilistic linkage algorithm to combine these two data sources and determine the rate of colposcopy attendance among women with a cytological indication. RESULTS: Of 1537 hrHPV-positive women, 1235 (80.4%) attended for colposcopy, with a median time from primary test to colposcopy of 132 days. Younger age (P<0.001) and concurrent negative cytology results (P=0.025) were associated with lower attendance. Women registered at units providing both the primary test and colposcopy were more likely to attend than those at units making external referrals (788/862 [91.4%] versus 447/675 [66.2%], P<0.001). Using the linked administrative datasets, we found 1761 women with abnormal cytology results between 1st May 2014 and 30th June 2014. 700 (39.8%) linked to a colposcopy record within the follow-up period. Slightly higher attendance was seen in women living in the metropolitan region of greater São Paulo compared to residents of the rest of the state. CONCLUSIONS: Non-attendance for colposcopy may limit the success of screening of current screening programs based on Papanicolaou cytology or future programs using hr-HPV testing in Brazi

Effects of Self-Generated Noise on Estimates of Detection Threshold in Quiet for School-Age Children and Adults

OBJECTIVES: Detection thresholds in quiet become adult-like earlier in childhood for high than low frequencies. When adults listen for sounds near threshold, they tend to engage in behaviors that reduce physiologic noise (e.g., quiet breathing), which is predominantly low frequency. Children may not suppress self-generated noise to the same extent as adults, such that low-frequency self-generated noise elevates thresholds in the associated frequency regions. This possibility was evaluated by measuring noise levels in the ear canal simultaneous with adaptive threshold estimation. DESIGN: Listeners were normal-hearing children (4.3-16.0 yrs) and adults. Detection thresholds were measured adaptively for 250-, 1000- and 4000-Hz pure tones using a three-alternative forced-choice procedure. Recordings of noise in the ear canal were made while the listeners performed this task, with the earphone and microphone routed through a single foam insert. Levels of self-generated noise were computed in octave-wide bands. Age effects were evaluated for four groups: 4- to 6-year-olds, 7- to 10-year-olds, 11- to 16-year-olds, and adults. RESULTS: Consistent with previous data, the effect of child age on thresholds was robust at 250 Hz and fell off at higher frequencies; thresholds of even the youngest listeners were similar to adults’ at 4000 Hz. Self-generated noise had a similar low-pass spectral shape for all age groups, although the magnitude of self-generated noise was higher in younger listeners. If self-generated noise impairs detection, then noise levels should be higher for trials associated with the wrong answer than the right answer. This association was observed for all listener groups at the 250-Hz signal frequency. For adults and older children, this association was limited to the noise band centered on the 250-Hz signal. For the two younger groups of children, this association was strongest at the signal frequency, but extended to bands spectrally remote from the 250-Hz signal. For the 1000-Hz signal frequency, there was a broadly tuned association between noise and response only for the two younger groups of children. For the 4000-Hz signal frequency, only the youngest group of children demonstrated an association between responses and noise levels, and this association was particularly pronounced for bands below the signal frequency. CONCLUSIONS: These results provide evidence that self-generated noise plays a role in the prolonged development of low-frequency detection thresholds in quiet. Some aspects of the results are consistent with the possibility that self-generated noise elevates thresholds via energetic masking, particularly at 250 Hz. The association between behavioral responses and noise spectrally remote from the signal frequency is also consistent with the idea that self-generated noise may also reflect contributions of more central factors (e.g., inattention to the task). Evaluation of self-generated noise could improve diagnosis of minimal or mild hearing loss