Quimioprofilaxia para prevenção de hanseníase e sua implantação no Brasil: uma explicação introdutória para não epidemiologistas

The occurrence of leprosy has decreased in the world but the perspective of its elimination has been questioned. A proposed control measure is the use of post-exposure chemoprophylaxis (PEP) among contacts, but there are still questions about its operational aspects. In this text we discuss the evidence available in literature, explain some concepts in epidemiology commonly used in the research on this topic, analyze the appropriateness of implementing PEP in the context of Brazil, and answer a set of key questions. We argue some points: (1) the number of contacts that need to receive PEP in order to prevent one additional case of disease is not easy to be generalized from the studies; (2) areas covered by the family health program are the priority settings where PEP could be implemented; (3) there is no need for a second dose; (4) risk for drug resistance seems to be very small; (5) the usefulness of a serological test to identify a higher risk group of individuals among contacts is questionable. Given that, we recommend that, if it is decided to start PEP in Brazil, it should start on a small scale and, as new evidence can be generated in terms of feasibility, sustainability and impact, it could move up a scale, or not, for a wider intervention.A ocorrência de hanseníase tem diminuído no mundo apesar de que a perspectiva de sua eliminação tem sido questionada. Uma proposta para o controle da endemia é a quimioprofilaxia pós-exposição entre contatos (post-exposure chemoprophylaxis, PEP), embora ainda existam dúvidas quanto aos seus aspectos operacionais e generalização de resultados. Nesse texto nós discutimos as evidências disponíveis na literatura, explicamos alguns conceitos epidemiológicos comumente encontrados em pesquisa sobre PEP e a implantação da PEP no contexto brasileiro. Nós argumentamos que: (1) a estimativa em diferentes estudos do numero de contatos necessário para receber PEP para prevenir um novo caso de hanseníase (number needed to treat, NNT) não é facilmente generalizável; (2) áreas cobertas pelo programa de saúde da família são as áreas prioritárias onde PEP poderia ser implantado; (3) não existe necessidade de segunda dose da quimioprofilaxia; (4) o risco de resistência à droga usada na PEP parece ser muito pequeno; (5) questionamos a necessidade de teste sorológico para identificar indivíduos entre os contatos que tenham maior risco de doença. Nós opinamos que, se houver uma decisão para se iniciar PEP no Brasil, essa intervenção deveria ser iniciada em pequena escala e, à proporção que novas evidências são geradas sobre a factibilidade, sustentabilidade e impacto da intervenção, a intervenção com PEP poderia ou não ser usada em larga escala

Comportamento de violência e fatores associados entre estudantes de Barra do Garças, MT

OBJECTIVE: To estimate the prevalence of violence among adolescents and young adults and to identify associated factors. METHODS: Cross-sectional study carried out in 2008 with systematic random sampling of 699 elementary and high school students enrolled in urban state schools of Barra do Garças, Central-Western Brazil. A self-administered questionnaire was applied in the classrooms without the presence of the teacher. The outcome "violent behavior" was defined as (1) use of firearm or sharp instrument, and/or (2) aggressions against oneself and/or others, and/or (3) suicide attempt. The analyzed independent variables were age, gender, socioeconomic status, use of alcohol, use of psychoactive drugs, sexual activity, and relationship between parents. Univariate analysis was conducted, as well as multiple regression adjusted for effect of clustering. RESULTS: Violence prevalence was of 18.6%, varying with age: 10.1% in the group aged 10 and 11 years; 20.2% for those aged 12-19 years; and 4.5% in the group aged 20-21 years. The factors associated with violent behavior were use of alcohol (RP = 2.51, 95%CI 1.22;5.15), use of psychoactive drugs (RP = 2.10, 95%CI 1.61;2.75), male gender (RP = 1.63, 95%CI 1.13;2.35) and unsatisfactory relationship between parents (RP = 1.64, 95%CI 1.25;2.15). CONCLUSIONS: Results indicate high prevalence of violence among adolescents in the age group 12-19 years, mainly among users of alcohol and drugs, of the male sex, from families whose parents do not have satisfactory relationships. Although without statistical significance in the final regression model, school result discrepancy and socioeconomic level should be considered in educational actions for prevention of violence behavior among students.OBJETIVO: Estimar la prevalencia de violencia entre adolescentes y jóvenes adultos e identificar factores asociados. MÉTODOS: Estudio transversal con muestreo aleatorio sistemático de 699 estudiantes de primaria y bachillerato de la red publica urbana de Barra do Garças, Centro-Oeste de Brasil, en 2008. Cuestionario de autocompletación fue aplicado en el salón de clases sin la presencia del profesor. El resultado "comportamiento violento" fue definido como (1) uso de arma de fuego o blanca, y/o (2) agresiones contra si y o terceros, y/o (3) intento de suicidio. Las variables independientes analizadas fueron edad, género, condición socioeconómica, uso de alcohol, uso de drogas psicoactivas, actividad sexual, y relacionamiento con los padres. Se realizaron análisis univariado y regresión múltiple ajustado para efecto de agregado. RESULTADOS: La prevalencia de violencia fue de 18,6%, variando según la edad: de 10,1% en el grupo de diez y 11 años; 20,2% de los 12 a 19 años; y 4,5% de los 20 y 21 años. Los factores asociados al comportamiento de violencia fueron uso de alcohol (RP=2,51, IC95% 1,22;5,15), uso de drogas psicoactivas (RP = 2,10, IC95%1,61;2,75), género masculino (RP = 1,63, IC95% 1,13;2,35) y relaciones insatisfactorias entre los padres (RP = 1,64, IC95% 1,25;2,15). CONCLUSIONES: Los resultados indican alta prevalencia de violencia entre los adolescentes en el grupo de edad de 12 a 19 años, sobretodo entre los usuarios de alcohol y drogas, del sexo masculino, de familia cuyos padres no poseen relaciones satisfactorias. A pesar de no haber significancia estadística en el modelo final de regresión, el desfase escolar y nivel socioeconómicos deben ser considerados en acciones educativas de prevención del comportamiento de violencia entre estudiantes.OBJETIVO: Estimar a prevalência de violência entre adolescentes e jovens adultos e identificar fatores associados. MÉTODOS: Estudo transversal com amostragem aleatória sistemática de 699 estudantes do ensino fundamental e médio da rede pública urbana de Barra do Garças, MT, em 2008. Questionário autopreenchível foi aplicado em sala de aula sem a presença do professor. O desfecho "comportamento violento" foi definido como (1) uso de arma de fogo ou branca, e/ou (2) agressões contra si e ou terceiros, e/ou (3) tentativa de suicídio. As variáveis independentes analisadas foram idade, gênero, condição socioeconômica, uso de álcool, uso de drogas psicoativas, atividade sexual e relacionamento com os pais. Foram realizadas análises univariadas e regressão múltipla ajustada para efeito de agregado. RESULTADOS: A prevalência de violência foi de 18,6%, variando segundo a idade: de 10,1% no grupo de dez e 11 anos; 20,2% dos 12 aos 19 anos; e 4,5% dos 20 e 21 anos. Os fatores associados ao comportamento de violência foram uso de álcool (RP = 2,51, IC95% 1,22;5,15), uso de drogas psicoativas (RP = 2,10, IC95%1,61;2,75), gênero masculino (RP = 1,63, IC95% 1,13;2,35) e relações insatisfatórias entre os pais (RP = 1,64, IC95% 1,25;2,15). CONCLUSÕES: Os resultados indicam alta prevalência de violência entre os adolescentes na faixa etária de 12 a 19 anos, sobretudo entre os usuários de álcool e drogas, do sexo masculino, de família cujos pais não possuem relações satisfatórias. Embora sem significância estatística no modelo final de regressão, a defasagem escolar e nível socioeconômico devem ser considerados em ações educativas de prevenção ao comportamento de violência entre estudantes

Evidence for causal associations between prenatal and postnatal antibiotic exposure and asthma in children, England.

BACKGROUND: Higher risks of asthma have been observed in children with prenatal exposure to antibiotics and during early life compared with those who have not. However, the causality of such associations is unclear. OBJECTIVE: To assess whether exposure to antibiotics in early life had a causal effect in increasing the risk of asthma in children diagnosed at 5-8 years of life, and the impact in the target population. METHODS: Data were from electronic health records and questionnaires for children and their mothers in the Born in Bradford birth cohort. Exposure variables were prescriptions of systemic antibiotics to the mother during pregnancy (prenatal) and to the children at 0-24 months of life (postnatal). We assessed the association in 12,476 children with several approaches to deal with different sources of bias (triangulation): the interactions with mother's ethnicity, mode of delivery, and between prenatal and postnatal exposures; dose-response; and estimated the population attributable risk. RESULTS: There was an association between prenatal exposure at 7-27 days before the child's birth and asthma (adjusted OR = 1.40; 1.05, 1.87), but no association with the negative control exposure (before pregnancy) (adjusted OR = 0.99 (0.88, 1.12)). For postnatal exposure, the adjusted OR was 2.00 (1.71, 2.34), and for sibling analysis, it was 1.99 (1.00, 3.93). For postnatal exposure, the risk of asthma increased with the number of prescriptions. The observed effect of both exposures was lower among children with mothers of Pakistani ethnicity, but inconclusive (p > .25). The interaction between prenatal and postnatal exposures was also inconclusive (p = .287). The population attributable risk of postnatal exposure for asthma was 4.6% (0.1% for prenatal). CONCLUSIONS: We conclude that the associations between both late-pregnancy prenatal exposure to antibiotics and postnatal exposure to antibiotics and an increased risk of asthma are plausible and consistent with a causal effect

Determination of maximum water infiltration areas in Vacacaí-Mirim Basin in southern Brazil

Determining the rates of water infiltration into the soil is of extreme importance, because it does not only determine the recharge of aquifers, but also estimates the vulnerability to soil contamination. Considering this, the present study aims to determine the rate of water infiltration into the soil using the DRASTIC method in the Vacacaí-Mirim basin in Rio Grande do Sul state, Brazil. To determine these rates, the analysis of physical parameters was obtained in the soil physics laboratory at the Federal University of Santa Maria, campus of Frederico Westphalen, in the state of Rio Grande do Sul. The ease infiltration rates in the years 2010 and 2011 ranged from 10 (slightly cracked areas) to 30 (areas with high drilling). Regarding the areas of maximum infiltration in 2010, 24% of the basin area showed this condition, and in 2011, the percentage decreased to 18.55%. According to the results, the methodology is proven to be significant to determine the infiltration rates of water in the Vacacaí-Mirim basin. The areas that stood out with the highest infiltration rates are in the floodplains of the river basin, where rice cultivation prevails. Therefore, it is incredibly important to preserve these areas to maintain the local quality and quantity of the groundwaterA determinação das taxas de infiltração de água no solo é de fundamental importância, pois além de determinar a recarga de aquíferos, estima a vulnerabilidade à contaminação do solo. Com base nisso, o presente trabalho tem por objetivo determinar o índice de infiltração de água no solo pelo método DRASTIC na bacia hidrográfica do rio Vacacaí-Mirim, no estado do Rio Grande do Sul. Para a determinação desses índices, as análises dos parâmetros físicos foram obtidas no laboratório de física do solo da Universidade Federal de Santa Maria, campus de Frederico Westphalen-RS. Os índices de facilidade a infiltração nos anos de 2010 e 2011 variaram de 10 (áreas pouco fissuradas) a 30 (áreas com altas perfurações). Com relação as áreas de infiltração máxima, no ano de 2010, 24% da área da bacia apresentou tal condição, já para o ano de 2011, esse percentual caiu para 18,55%. Com base nisso, a metodologia se mostra interessante para a determinação das taxas de infiltração de água na bacia hidrográfica do rio Vacacaí-Mirim. As áreas que mais se destacaram com as taxas de infiltração máxima localizam-se nas várzeas da bacia hidrográfica, onde predominam o cultivo de arroz, sendo assim é de fundamental importância a preservação de tais áreas com vista a manutenção da quali/quantidade da água subterrânea no local

Analysis of natural vulnerability to groundwater contamination : comparison between the GOD and DRASTIC methodologies

A água é um recurso natural imprescindível para todas as formas de vida, porém, atividades antrópicas, aumento populacional e urbanização estão alterando a qualidade dos mananciais superficiais, tornando indisponível para determinados usos. Surge como alternativa para complementar ou até mesmo substituir o uso da água superficial a água subterrânea, porém, e necessita-se de um controle para que atividades antrópicas não venham a contaminar o aquífero. Nesse sentido, esse estudo tem por objetivo comparar os métodos DRASTIC e GOD na bacia hidrográfica do Rio Vacacaí-Mirim, no estado do Rio Grande do Sul. Ambos os métodos tiveram suas classes de vulnerabilidade entre insignificante e extrema, com maior predominâncias da vulnerabilidade média (DRASTIC) e alta (GOD). O método GOD concentrou 89,91 % da vulnerabilidade em 2 classes (Média e alta), já o DRASTIC apresentou 66,15 % nessas mesmas classes. Assim, o DRASTIC, na área de estudo apresentou, uma maior variabilidade das classes, indicando resultados mais consistentes, e com parâmetros obtidos a campo. Porém, o GOD é mais simplificado pelo número de variáveis necessárias para sua aplicação. Assim, destaca-se a importância da aplicação dessas metodologias para fornecer subsídios para tomadas de decisões para gestores dos recursos hídricos.Water is an essential natural resource to all forms of life; however, antropic activity, population increase and urbanization are changing the quality of shallow springs and making them unavailable for certain uses. Groundwater emerges as alternative to complete or even replace surface water; however, it is essential to have control over antropic activities so they would not contaminate aquifers. Thus, the aim of the present study is to compare the DRASTIC and GOD methods applied to the Vacacaí-Mirim River basin, in Rio Grande do Sul State. Both methods recorded vulnerability classes between insignificant an external, with higher prevalence of moderate (DRASTIC) and high (GOD) vulnerability. The GOD method held 89.91% of the vulnerability in 2 classes (moderate and high), whereas the DRASTIC one recorded 66.15% in these same classes. The DRASTIC method presented the highest class vulnerabilities in the study site. This outcome regards more consistent results and similar to parameters recorded in the field. Nevertheless, GOD is simpler due to the number of variables necessary for its application. It is important highlighting the importance of applying these methodologies to provide subsidies for decision-making by water resource managers

Stroke outcome measurements from electronic medical records : cross-sectional study on the effectiveness of neural and nonneural classifiers

Background: With the rapid adoption of electronic medical records (EMRs), there is an ever-increasing opportunity to collect data and extract knowledge from EMRs to support patient-centered stroke management. Objective: This study aims to compare the effectiveness of state-of-the-art automatic text classification methods in classifying data to support the prediction of clinical patient outcomes and the extraction of patient characteristics from EMRs. Methods: Our study addressed the computational problems of information extraction and automatic text classification. We identified essential tasks to be considered in an ischemic stroke value-based program. The 30 selected tasks were classified (manually labeled by specialists) according to the following value agenda: tier 1 (achieved health care status), tier 2 (recovery process), care related (clinical management and risk scores), and baseline characteristics. The analyzed data set was retrospectively extracted from the EMRs of patients with stroke from a private Brazilian hospital between 2018 and 2019. A total of 44,206 sentences from free-text medical records in Portuguese were used to train and develop 10 supervised computational machine learning methods, including state-of-the-art neural and nonneural methods, along with ontological rules. As an experimental protocol, we used a 5-fold cross-validation procedure repeated 6 times, along with subject-wise sampling. A heatmap was used to display comparative result analyses according to the best algorithmic effectiveness (F1 score), supported by statistical significance tests. A feature importance analysis was conducted to provide insights into the results. Results: The top-performing models were support vector machines trained with lexical and semantic textual features, showing the importance of dealing with noise in EMR textual representations. The support vector machine models produced statistically superior results in 71% (17/24) of tasks, with an F1 score >80% regarding care-related tasks (patient treatment location, fall risk, thrombolytic therapy, and pressure ulcer risk), the process of recovery (ability to feed orally or ambulate and communicate), health care status achieved (mortality), and baseline characteristics (diabetes, obesity, dyslipidemia, and smoking status). Neural methods were largely outperformed by more traditional nonneural methods, given the characteristics of the data set. Ontological rules were also effective in tasks such as baseline characteristics (alcoholism, atrial fibrillation, and coronary artery disease) and the Rankin scale. The complementarity in effectiveness among models suggests that a combination of models could enhance the results and cover more tasks in the future. Conclusions: Advances in information technology capacity are essential for scalability and agility in measuring health status outcomes. This study allowed us to measure effectiveness and identify opportunities for automating the classification of outcomes of specific tasks related to clinical conditions of stroke victims, and thus ultimately assess the possibility of proactively using these machine learning techniques in real-world situations

Pré-eclâmpsia : rastreamento universal ou prevenção universal para países de baixa e média-renda?

Pre-eclampsia (PE) is a severe disorder that affects up to 8% of all pregnancies and represents an important cause of maternal and perinatal morbidity and mortality. The screening of the disease is a subject of studies, but the complexity and uncertainties regarding its etiology make this objective a difficult task. In addition, the costs related to screening protocols, the heterogeneity of the most affected populations and the lack of highly effective prevention methods reduce the potential of current available algorithms for screening. Thus, the National Specialized Commission of Hypertension in Pregnancy of the Brazilian Association of Gynecology and Obstetrics Federation (Febrasgo, in the Portuguese acronym) (NSC Hypertension in Pregnancy of the Febrasgo) considers that there are no screening algorithms to be implemented in the country to date and advocates that Aspirin and calcium should be widely used.A Pré-eclâmpsia (PE) é uma doença grave que acomete ~8% das gestações e representa importante causa de morbimortalidade, tanto materna quanto perinatal. O rastreamento da doença émotivo de estudos, porém a complexidade e as incertezas quanto a sua etiologia tornam esse objetivo bastante difícil. Além disso, os custos relacionados com o rastreamento, a heterogeneidade das populações mais afetadas e ainda a falta de métodos de prevenção de grande eficácia reduzem o potencial dos algoritmos de rastreamento. Assim, a Comissão Nacional Especializada sobre Hipertensão na Gravidez da Federação Brasileira das Associações de Ginecologia e Obstetrícia (CNE Hipertensão na Gravidez da FEBRASGO) considera que não há algoritmos de rastreamento que possam ser aplicados no país nesse momento e defende a utilização dos métodos de prevenção como ácido acetilsalicílico e cálcio de maneira ampla

Pré-eclâmpsia/Eclâmpsia

Pre-eclampsia is a multifactorial and multisystemic disease specific to gestation. It is classically diagnosed by the presence of hypertension associated with proteinuria manifested in a previously normotensive pregnant woman after the 20th week of gestation. Pre-eclampsia is also considered in the absence of proteinuria if there is target organ damage. The present review takes a general approach focused on aspects of practical interest in the clinical and obstetric care of these women. Thus, it explores the still unknown etiology, current aspects of pathophysiology and of the diagnosis, the approach to disease prediction, its adverse outcomes and prevention. Management is based on general principles, on nonpharmacological and on pharmacological clinical treatment of severe or nonsevere situations with emphasis on the hypertensive crisis and eclampsia. Obstetric management is based on preeclampsia without or with signs of clinical and/or laboratory deterioration, stratification of gestational age in < 24 weeks, between 24 and less than 34 weeks, and ≥ 34 weeks of gestation, and guidance on route of delivery. An immediate puerperium approach and repercussions in the future life of pregnant women who develop preeclampsia is also presented.A pré-eclâmpsia é uma doença multifatorial e multissistêmica específica da gestação. É classicamente diagnosticada pela presença de hipertensão arterial associada à proteinúria em gestante previamente normotensa após a 20a semana de gestação. A pré-eclâmpsia também é considerada na ausência de proteinúria se houver lesão de órgão-alvo. A presente revisão tem uma abordagem geral focada em aspectos de interesse prático na assistência clínica e obstétrica dessas mulheres. Assim, explora a etiologia ainda desconhecida, aspectos atuais da fisiopatologia e do diagnóstico e diagnóstico diferencial de convulsões, a abordagem da predição da doença, seus resultados adversos e prevenção. A conduta baseia-se em princípios gerais, tratamento clínico não farmacológico e farmacológico de situações graves ou não graves, com ênfase na crise hipertensiva e eclâmpsia. O controle obstétrico se fundamenta na pré-eclâmpsia sem ou com sinais de deterioração clínica e/ou laboratorial, estratificação da idade gestacional abaixo de 24 semanas, entre 24 e menos de 34 semanas e 34 ou mais semanas de gestação e orientação na via de parto. Uma abordagem imediata do puerpério e repercussões na vida futura de gestantes que desenvolvem pré-eclâmpsia também foram apresentadas