Selection bias: neighbourhood controls and controls selected from those presenting to a Health Unit in a case control study of efficacy of BCG revaccination.

BACKGROUND: In most case control studies the hardest decision is the choice of the control group, as in the ideal control group the proportion exposed is the same as in the population that produced the cases. METHODS: A comparison of two control groups in a case control study of the efficacy of BCG revaccination. One group was selected from subjects presenting to the heath unit the case attended for routine prevention and care; the second group was selected from the neighbourhood of cases. All Health Units from which controls were selected offered BCG revaccination. Efficacy estimated in a randomized control trial of BCG revaccination was used to establish that the neighbourhood control group was the one that gave unbiased results. RESULTS: The proportion of controls with scars indicating BCG revaccination was higher among the control group selected from Health Unit attenders than among neighbourhood controls. This excess was not removed after control for social variables and history of exposure to tuberculosis, and appears to have resulted from the fact that people attending the Health Unit were more likely to have been revaccinated than neighbourhood controls, although we can not exclude an effect of other unmeasured variables. CONCLUSION: In this study, controls selected from people presenting to a Health Unit overrepresented exposure to BCG revaccination. Had the results from the HU attenders control group been accepted this would have resulted in overestimation of vaccine efficacy. When the exposure of interest is offered in a health facility, selection of controls from attenders at the facility may result in over representation of exposure in controls and selection bias

Fatores associados ao controle glicêmico em pessoas com diabetes na Estratégia Saúde da Família em Pernambuco

OBJETIVO Identificar los factores asociados con el control glucémico en personas con Diabetes Mellitus (DM) tipo 2 registradas en la Estrategia Salud de la Familia (ESF) en Pernambuco, Brasil. MÉTODO Fueron investigadas, por regresión múltiple, las asociaciones entre el control glucémico (hemoglobina A glicosilada menor o mayor o igual al 7%) presentado por las personas con DM y variables relacionadas con condiciones sociodemográficas, hábitos de vida, características de la diabetes, de su tratamiento y seguimiento de los pacientes por los servicios sanitarios. RESULTADOS Más del 65% de los participantes presentaron control glucémico inadecuado, especialmente aquellos de menos edad, duración de la enfermedad más larga, más contactos anuales con la ESF y régimen terapéutico complejo. Personas con DM sin derivaciones a especialistas presentaron un mayor descontrol glucémico. Asociaciones con escolaridad y obesidad no permanecieron significativas en el modelo multivariado. CONCLUSIÓN La evolución de la diabetes dificulta el control adecuado. Sin embargo, la atención a las personas con DM más jóvenes y las derivaciones a especialistas son factores susceptibles de mejora del control glucémico.OBJETIVO Identificar fatores associados ao controle glicêmico em pessoas com Diabetes Mellitus (DM) tipo 2 cadastradas na Estratégia Saúde da Família (ESF) em Pernambuco, Brasil. MÉTODO Foram investigadas, por regressão múltipla, as associações entre o controle glicêmico (hemoglobina A glicosilada menor ou maior ou igual a 7%) apresentado pelas pessoas com DM e variáveis relacionadas com condições sociodemográficas, hábitos de vida, características do diabetes, de seu tratamento e acompanhamento dos pacientes pelos serviços de saúde. RESULTADOS Mais de 65% dos participantes apresentaram controle glicêmico inadequado, principalmente aqueles com idade menor, duração da doença mais longa, mais contatos anuais com a ESF e regime terapêutico complexo. Pessoas com DM sem encaminhamentos para especialistas apresentaram um maior descontrole glicêmico. Associações com escolaridade e obesidade não permaneceram significativas no modelo multivariado. CONCLUSÃO A evolução do diabetes dificulta o controle adequado, todavia, a atenção às pessoas com DM mais jovens e os encaminhamentos para especialistas são fatores suscetíveis de melhora do controle glicêmico.OBJECTIVE Identifying factors associated with glycemic control in people with type 2 Diabetes Mellitus (DM) registered in the Family Health Strategy (FHS) in Pernambuco, Brazil. METHOD Associations between glycemic control (glycosylated hemoglobin A lower or equal to 7%) presented by people with DM and variables related to sociodemographic conditions, lifestyle, characteristics of diabetes, treatment and follow-up of patients by health services were investigated by multiple regression. RESULTS More than 65% of the participants presented inadequate glycemic control, especially those with lower age, longer illness duration, more annual contacts with FHS and complex therapeutic regimen. People with DM without referrals to specialists presented greater glycemic control. Associations with education level and obesity did not remain significant in the multivariate model. CONCLUSION The evolution of diabetes hinders adequate control, however, attention to younger people with DM and referrals to specialists are factors that can improve glycemic control

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

Prevalence of hepatitis A in the capitals of the States of North, Southeast and South regions of Brazil: decrease in prevalence and some consequences

Hepatitis A virus (HAV) infection has been considered one of the leading causes of acute hepatitis. The aim of the present study was to estimate the prevalence of HAV among children and adolescents in a population-based study in the capitals of the States of the North, Southeast and South of Brazil and identify predictive factors for the infection. A multi-stage sampling was used to select subjects aged between 5-9 and 10-19 years. Individual and household levels aside from the level of variables in the areas were collected. The outcome was the total IgG antibodies to HAV levels detected using a commercial Enzyme Immuno Assay (EIA). The associations between HAV and the independent variables were assessed using the odds ratio. A multilevel analysis was performed by GLLAMM using the Stata software. The prevalence of HAV infection in the 5-9 and 10-19 age groups was 28.7% and 67.5%, respectively for the North, 20.6% and 37.7%, for the Southeast and 18.9% and 34.5% for the South Region. The prevalence of HAV increased according to age in all sites. Variables related to education at the individual level (North and South), family and area level (South and Southeast) and family income level (Southeast and South) were independently associated with HAV infection. This emphasizes the need for individualized strategies to prevent the infection

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

Non Electrocardiographic alterations in exercise testing in asymptomatic women. Associations with cardiovascular risk factors

OBJECTIVES: To estimate the prevalence of exercise testing alterations in middle-aged women without symptoms of heart disease and to verify the associations of functional capacity and heart rate behavior during and after exercise with cardiovascular risk factors. METHODS: A cross-sectional study was conducted with 509 asymptomatic women aged between 46 and 65 years who underwent clinical evaluations and exercise testing (Bruce protocol). The heart rate behavior was evaluated by the maximal predicted heart rate achieved, chronotropic index and recovery heart rate. RESULTS: The mean age was 56.4±4.8 years, and 13.4% of the patients had a Framingham risk score above 10%. In the exercise treadmill testing, 58.0% presented one or more of the following alterations (listed in order of ascending prevalence): symptoms (angina, dyspnea, and dizziness), ST-segment depression, arrhythmia, reduction in recovery heart rate of p12 bpm at 1 minute, altered maximal predicted heart rate achieved, abnormal blood pressure, functional capacity deficiency, and altered chronotropic index. In the multivariate analysis, the following associations (odds ratio) were observed for these alterations: chronotropic index was associated with obesity (2.08) and smoking (4.47); maximal predicted heart rate achieved was associated with smoking (6.45); reduction in the recovery heart rate at 1 minute was associated with age (1.09) and obesity (2.78); functional capacity was associated with age (0.92), an overweight status (2.29) and obesity (6.51). CONCLUSIONS: More than half of middle-aged women without cardiovascular symptoms present alterations in one or more exercise testing parameters. Alterations in the functional capacity or heart rate behavior, as verified by exercise testing, are associated with age, smoking, an overweight status and obesity

Evaluation hematological and biochemical parameters of rats in the second thirds of the gestation submitted to the action of the extract methanol of Cereus jamacaru DC., Cactaceae

The effects of oral administration of methanol extract (ME) prepared from stems of Cereus jamacaru DC., Cactaceae were investigated on the biochemical and hematological parameters in pregnant adult Wistar rats. Twenty rats (n = 5 per group) have been treated orally for four consecutive days with ME in doses of 100, 250 and 500 mg/kg weight, and then, it was determined the biochemical and hematological profiles. The results showed that during the period of treatment there was no signs of toxicity or death. The hematological and biochemical parameters were not modified by oral administration of ME, except for a significant increase of 45.7% and 41.9% for alanine transaminase (ALT) in doses of 250 and 500 mg/kg in addition to the significant increase, of to 48.2%, 39.8% and 41.8% for aspartate transaminase (AST). In hematology, it was registered a fluctuation within the reference values of hemoglobin in the differential count of neutrophil and lymphocyte. In this way the administration of methanol extract of C. jamacaru does not produce toxic effects or alters the majority of biochemical and hematological studies in pregnant adult Wistar rats. However, the increase of serum ALT and AST in high doses suggests a liver overload, which must be investigated in more detail.Os efeitos da administração oral do extrato metanólico (EM) de Cereus jamacaru DC., Cactaceae, foram investigados sobre os parâmetros hematológicos e bioquímicos em ratas Wistar adultas grávidas. Vinte ratas (n = 5 por grupo) foram tratadas durante quatro dias consecutivos com EM por via oral nas doses de 100, 250 e 500 mg/kg de peso e, em seguida, determinados os perfis bioquímico e hematológico. Os resultados mostraram que durante o período do tratamento não foi observado efeitos nocivos ou óbitos. Os parâmetros hematológicos e bioquímicos não foram modificados pela administração oral do EM, excetuando-se o aumento significativo de 45,7% e de 41,9% para alanina transferase (ALT) nas doses de 250 e 500 mg/kg além do aumento significativo, respectivo de 48,2%, 39,8% e 41,8% para aspartato aminotransferase (AST). Em relação aos valores hematológicos, registrou-se flutuação dentro dos valores de referência na contagem diferencial de hemoglobina, de neutrófilo e de linfócito. Dessa forma, a administração do extrato metanólico de C. jamacaru não apresentou reações tóxicas sobre a maioria dos parâmetros hematológicos e bioquímicos estudados em ratas Wistar adultas grávidas. Entretanto, o aumento dos níveis séricos de AST e ALT em doses elevadas sugere uma sobrecargas hepática, as quais devem ser investigadas em maiores detalhes

Comparison between potential risk factors for cardiovascular disease in people living with HIV/AIDS in areas of Brazil

Introduction: Coronary heart disease and its risk factors depend on genetic characteristics, behaviors, and habits, all of which vary in different regions. The use of antiretroviral therapy (ARV) has increased the survival of people living with HIV/AIDS (PLWHA), who begin to present mortality indicators similar to the general population. This study aimed to compare the prevalence of factors potentially associated with coronary heart disease in three cohorts of PLWHA from three different regions of Brazil. Methodology: The study population was composed of participants of the cohorts of Pernambuco, Goiás, and Rio Grande do Sul states. In these sites, adult patients attending reference centers for treatment of HIV/AIDS were consecutively enrolled. Results: Pernambuco and Goiás had a higher proportion of males and of individuals with high-risk high-density lipoprotein (HDL). Pernambuco also had a greater proportion of individuals with hypertension, elevated triglycerides, and CD4 counts below 200 cells/mm3. Lower education was more frequent in Rio Grande do Sul, and the use of cocaine was higher in this state. Conclusions: The results confirm the importance of risk factors for coronary heart disease in PLHIV and highlight differences in the three cohorts. Specific measures against smoking and sedentary lifestyle, avoidance of advanced stages of immunosuppression, and appropriate treatment of dyslipidemia and dysglicemia are urgently needed to cope with the disease in Brazil