Identificação de fatores de risco para morte por tétano em Pernambuco, Brasil: um estudo de caso-controle

A case-control study was conducted to identify risk factors for death from tetanus in the State of Pernambuco, Brazil. Information was obtained from medical records of 152 cases and 152 controls, admitted to the tetanus unit in the State University Hospital, in Recife, from 1990 to 1995. Variables were grouped in three different sets. Crude and adjusted odds ratios, p-values and 95% confidence intervals were estimated. Variables selected in the multivariate analysis in each set were controlled for the effect of those selected in the others. All factors related to the disease progression - incubation period, time elapsed between the occurrence of the first tetanus symptom and admission, and period of onset - showed a statistically significant association with death from tetanus. Similarly, signs and/or symptoms occurring on admission or in the following 24 hours (second set): reflex spasms, neck stiffness, respiratory signs/symptoms and respiratory failure requiring artificial ventilation (third set) were associated with death from tetanus even when adjusted for the effect of the others.Um estudo de caso-controle foi conduzido no Estado de Pernambuco, Brasil, para identificar fatores de risco para morte por tétano. As informações foram obtidas dos prontuários médicos de 152 casos e 152 controles, admitidos na Unidade de Tétano do Hospital Universitário Oswaldo Cruz, na cidade do Recife, de 1990 a 1995. As variáveis foram agrupadas em três diferentes conjuntos. Foram estimados os "odds ratios" brutos e ajustados, o intervalo de confiança de 95% e o valor de "p". As variáveis selecionadas na análise multivariada em cada conjunto, foram controladas para os efeitos daquelas selecionadas nos demais. Todos os fatores relacionados à progressão da doença - período de incubação, tempo decorrido entre o primeiro sintoma de tétano e a admissão no hospital, e período de progressão - mostraram uma associação estatisticamente significante com morte por tétano. De modo semelhante, o segundo conjunto de variáveis - sinais e/ou sintomas que ocorreram à admissão ou nas primeiras 24 horas: espasmos, rigidez de nuca, sinais e sintomas respiratórios - bem como as variáveis do terceiro conjunto - insuficiência respiratória que necessitou de respiração artificial foram associadas com morte por tétano, mesmo quando ajustadas com os efeitos das demais variáveis

Prognostic indicators in bacterial meningitis: a case–control study

AbstractThis was a case–control study to identify prognostic indicators of bacterial meningitis in a reference hospital in Pernambuco/Brazil. The data were collected from charts of 294 patients with bacterial meningitis between January 2000 and December 2004. Variables were grouped in biological, clinical, laboratory and etiologic agent/treatment. Variables selected in each step were grouped and adjusted for age. Two models were created: one containing clinical variables (clinical model) and other containing laboratory variables (laboratory model). In the clinical model the variables associated with death due to bacterial meningitis were dyspnea (p=0.006), evidence of shock (p=0.051), evidence of altered mental state (p=0.000), absence of headache (p=0.008), absence of vomiting (p=0.052), and age ≥40 years old (p=0.013). In the laboratory model, the variables associated with death due to bacterial meningitis were positive blood cultures (p=0.073) and thrombocytopenia (p=0.019). Identification of prognostic indicators soon after admission may allow early specific measures, like admission of patients with higher risk of death to Intensive Care Units

Diagnosticando co-infecção leishmaniose visceral e HIV/AIDS: uma série de casos em Pernambuco, Brasil

HIV/AIDS-associated visceral leishmaniasis may display the characteristics of an aggressive disease or without specific symptoms at all, thus making diagnosis difficult. The present study describes the results of diagnostic tests applied to a series of suspected VL cases in HIV-infected/AIDS patients admitted in referral hospitals in Pernambuco, Brazil. From a total of 14 eligible patients with cytopenias and/or fever of an unknown etiology, and indication of bone marrow aspirate, 10 patients were selected for inclusion in the study. Diagnosis was confirmed by the following examinations: Leishmania detection in bone marrow aspirate, direct agglutination test, indirect immunofluorescence, rK39 dipstick test, polymerase chain reaction and latex agglutination test. Five out of the ten patients were diagnosed with co-infection. A positive direct agglutination test was recorded for all five co-infected patients, the Leishmania detection and latex agglutination tests were positive in four patients, the rK39 dipstick test in three, the indirect immunofluorescence in two and a positive polymerase chain reaction was recorded for one patient. This series of cases was the first to be conducted in Brazil using this set of tests in order to detect co-infection. However, no consensus has thus far been reached regarding the most appropriate examination for the screening and monitoring of this group of patients.A associação da leishmaniose visceral com o HIV/AIDS pode se manifestar com características de doença agressiva ou sem sintomas específicos, dificultando o diagnóstico. Este artigo descreve o resultado de testes diagnósticos aplicados a uma série de casos suspeitos de leishmaniose visceral em pacientes com HIV/AIDS internados em hospitais de referência de Pernambuco, Brasil. De 14 pacientes elegíveis com citopenias e/ou febre de etiologia indefinida, com indicações de mielograma, foram incluídos dez. Para o diagnóstico, foram empregados os seguintes exames: pesquisa de Leishmania em aspirado de medula óssea, DAT, IFI, rK39, PCR e a KAtex. Cinco dos dez pacientes foram diagnosticados com co-infecção. Entre os cinco co-infectados, o DAT foi positivo em todos, a pesquisa de Leishmania foi positiva em quatro, assim como o KAtex, o rK39 em três, a IFI em dois e a PCR positiva em apenas um. Esta série de casos foi a primeira realizada no Brasil utilizando esse conjunto de exames para detecção de co-infecção, no entanto, ainda não há consenso quanto aos exames mais adequados a serem aplicados para screening e acompanhamento desse grupo de pacientes

Fatores preditivos de não-adesão à terapia antiretroviral

Cross-sectional study analyzed as case-control to identify risk factors for non-adherence to antiretroviral therapy. We studied 412 out-clinics HIV infected subjects of three public hospitals of Recife, Pernambuco. The objective was to examine the association between non-adherence to the antiretroviral therapy and biological, social-behavior and demographics and economic factors, factors related to the disease and/or treatment, factors related to life habits and depression symptoms. Variables significantly associated with non-adherence to antiretroviral therapy were: time elapsed since HIV diagnosis (p = 0.002), daily dose (p = 0.046), use of alcohol (p = 0.030) and past drug use (p = 0.048), and borderline p-values were found for educational level (p = 0.093) and family monthly income (p = 0.08). In the multivariable analysis, the factors that remained in the final model were family monthly income, time period with HIV infection and use of alcohol. No association was observed between non-adherence to antiretroviral therapy and gender, age, sexual orientation, marital status, educational level and place of residence. Based on our results and the local situation we suggest: assessment of social needs; training of partners and/or families on supporting adherence, creation of "adherence groups" to motivate and to reassure patients on the benefits of treatment; counseling and/or psychotherapy for alcohol drinkers.Estudo transversal com análise tipo caso-controle, que avaliou 412 pacientes de hospitais públicos do Recife - PE, com o objetivo de identificar fatores preditivos de não adesão à terapia antiretroviral. Verificou-se associação entre não adesão à terapia antiretroviral e aspectos biológicos, sócio-comportamentais e demográficos, econômicos, relacionados à doença e ao tratamento, aos hábitos de vida e aos distúrbios do humor. Variáveis com associação estatisticamente significante com não adesão na análise univariada foram: tempo de diagnóstico (p = 0,002), maior número diário de comprimidos (p = 0,046), uso de álcool (p = 0,030) e uso de drogas no passado (p = 0,048). Observou-se associação limítrofe com grau de instrução (p = 0,093) e renda mensal familiar (p = 0,08). Após análise multivariada, permaneceram no modelo final: renda mensal familiar, tempo de diagnóstico e uso de álcool. Não houve associação entre gênero, idade, comportamento sexual, estado civil, grau de instrução, município de residência e não adesão à terapia antiretroviral. Baseados nos nossos resultados e nas características da população estudada sugerimos: valorização das necessidades sociais, sensibilização de parceiros e/ou familiares para estimular a adesão, criação de grupos de adesão para motivar e persuadir os pacientes sobre os benefícios do tratamento, aconselhamento e/ou psicoterapia para alcoolistas

Cryptorchidism in Children with Zika-Related Microcephaly.

The genitourinary tract was recently identified as a potential site of complications related to the congenital Zika syndrome (CZS). We provide the first report of a series of cryptorchidism cases in 3-year-old children with Zika-related microcephaly who underwent consultations between October 2018 and April 2019 as part of the follow-up of the children cohort of the Microcephaly Epidemic Research Group, Pernambuco, Brazil. Of the 22 males examined, eight (36.4%) presented with cryptorchidism. Among 14 undescended testis cases, 11 (78.6%) could be palpated in the inguinal region. Seven of the eight children had severe microcephaly. Conventional risk factors for cryptorchidism were relatively infrequent in these children. We hypothesize that cryptorchidism is an additional manifestation of CZS present in children with severe microcephaly. As in our cases, for most of the children, the testes were located in the inguinal region, and the possible mechanisms for cryptorchidism were gubernaculum disturbance or cremasteric abnormality

The frequency and clinical presentation of Zika virus coinfections: a systematic review.

BACKGROUND: There is limited knowledge on the influence of concurrent coinfections on the clinical presentation of Zika virus (ZIKV) disease. METHODS: To better understand the types, frequencies and clinical manifestations of ZIKV coinfections, we did a systematic review of four databases (PubMed, Embase, Web of Science, LILACS) without restrictions for studies on ZIKV coinfections confirmed by nucleic acid (quantitative real-time-PCR) testing of ZIKV and coinfecting pathogens. The review aimed to identify cohort, cross-sectional, case series and case report studies that described frequencies and/or clinical signs and symptoms of ZIKV coinfections. Conference abstracts, reviews, commentaries and studies with imprecise pathogen diagnoses and/or no clinical evaluations were excluded. RESULTS: The search identified 34 articles from 10 countries, comprising 2 cohort, 10 cross-sectional, 8 case series and 14 case report studies. Coinfections were most frequently reported to have occurred with other arthropod-borne viruses (arboviruses); out of the 213 coinfections described, ZIKV infections co-occurred with chikungunya in 115 cases, with dengue in 68 cases and with both viruses in 19 cases. Other coinfecting agents included human immunodeficiency, Epstein-Barr, human herpes and Mayaro viruses, Leptospira spp, Toxoplasma gondii and Schistosoma mansoni. ZIKV-coinfected cases primarily presented with mild clinical features, typical of ZIKV monoinfection; however, 9% of cases in cohort and cross-sectional studies were reported to experience complications. CONCLUSION: Based on the evidence collated in this review, coinfections do not appear to strongly influence the clinical manifestations of uncomplicated ZIKV infections. Further research is needed to confirm whether risk of severe complications is altered when ZIKV infection co-occurs with other infections. PROSPERO REGISTRATION NUMBER: CRD42018111023

Incidence and risk factors for tuberculosis in people living with HIV: cohort from HIV referral health centers in Recife, Brazil.

OBJECTIVE: To identify the incidence of and risk factors for tuberculosis in people living with HIV (PLHIV). DESIGN: Observational, prospective cohort study. METHODS: A total of 2069 HIV-infected patients was observed between July 2007 and December 2010. The Kaplan-Meier method was used to estimate the probability of survival free of tuberculosis, and Cox regression analysis to identify risk factors associated with the development of tuberculosis. RESULTS: Survival free of tuberculosis (TB) was 91%. The incidence rate of tuberculosis was 2.8 per 100 persons/years. Incidence of tuberculosis was higher when subjects had CD4 cell count <200 cells/mm(3); were not on antiretroviral therapy; in those who had, a body mass index <18.5 kg/m(2), anemia (or were not tested for it), were illiterate or referred previous tuberculosis treatment at entry into the cohort. Those not treated for latent TB infection had a much higher risk (HR = 7.9) of tuberculosis than those with a negative tuberculin skin test (TST). Having a TST≥5 mm but not being treated for latent TB infection increased the risk of incident tuberculosis even in those with a history of previous tuberculosis. CONCLUSIONS: Preventive actions to reduce the risk of TB in people living with HIV should include an appropriate HAART and treatment for latent TB infection in those with TST≥5 mm. The actions towards enabling rigorous implementation of treatment of latent TB infection and targeting of PLHIV drug users both at the individual and in public health level can reduce substantially the incidence of TB in PLHIV

Validating a scoring system for the diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults.

BACKGROUND: The challenge of diagnosing smear-negative pulmonary TB (tuberculosis) in people living with HIV justifies the use of instruments other than the smear test for diagnosing the disease. Considering the clinical-radiological similarities of TB amongst HIV-infected adults and children, the proposal of this study was to assess the accuracy of a scoring system used to diagnose smear-negative pulmonary TB in children and adolescents, in HIV-infected adults suspected of having smear-negative pulmonary TB. METHODS: A Phase III validation study aiming to assess the diagnostic accuracy of a scoring system for diagnosing smear-negative pulmonary TB in HIV-infected adults. The study assessed sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values of the scoring system. Three versions of the scoring system were tested. RESULTS: From a cohort of 2,382 (HIV-infected adults), 1276 were investigated and 128 were diagnosed with pulmonary TB. Variables associated with the diagnosis of TB were: coughing, weight loss, fever, malnutrition, chest X-ray, and positive tuberculin test. The best diagnostic performance occurred with the scoring system with new scores, with sensitivity = 81.2% (95%-CI 74.5% -88%), specificity = 78% (75.6% -80.4%), PPV = 29.2% (24.5% -33.9%) and NPV = 97.4% (96.4% -98.4%), LR+ = 3.7 (3.4-4.0) and LR- = 0.24 (0.2-0.4). CONCLUSION: The proposed scoring system (with new scores) presented a good capacity for discriminating patients who did not have pulmonary TB, in the studied population. Further studies are necessary in order to validate it, thus permitting the assessment of its use in diagnosing smear-negative pulmonary TB in HIV-infected adults

Surgical findings in cryptorchidism in children with Zika-related microcephaly: a case series.

BACKGROUND: Complications in the urinary tract related to congenital Zika syndrome have recently been reported. One complication, cryptorchidism, has been reported by the Microcephaly Epidemic Research Group/MERG, in Pernambuco/Brazil. The present article describes for the first time the surgical findings in a case series of boys with Zika-related microcephaly and cryptorchidism, who underwent surgical testicular exploration as a contribution to better understand the possible mechanisms involved in gonads formation and descent. METHODS: A total of 7 children (11 testicular units), aged 3 to 4 years, were submitted to inguinal or scrotal orchidopexy for the treatment of palpable cryptorchidism between August 2019 and January 2020. Characteristics of the gonads and its annexes related to appendixes, testis-epididymis dissociation, gubernacular insertion, and associated hydroceles and/or hernias were described. Measures in centimetres were taken for volume calculate. RESULTS: We found a low prevalence of testicular and epididymal appendix (66.7%), a high prevalence of testis-epididymis dissociation (55.6%), low mean testicular volume for their ages (lower for older boys) and ectopic gubernacular insertion in all cases. There was no evidence of associated hydroceles and/or hernias in any case. No surgical complication was registered or reported, and all explored gonads were properly placed in the scrotal sac. CONCLUSIONS: We herein describe the surgical findings of these children's orchidopexies and discuss the possible mechanisms of viral action in embryogenesis and postnatal growth and development of the testes and annexes. These children need to be followed over time due to the higher risk of testicular atrophy and malignancy. Surgical timing seems to be relevant to avoid loss of testicular volume