The II Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19 Joint Guidelines of the Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia and Sociedade Brasileira de Reumatologia

OBJECTIVE

To update the recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil.

METHODS

Experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method.

RESULTS

Twenty-one recommendations were generated, including strong recommendations for the use of corticosteroids in patients using supplemental oxygen and conditional recommendations for the use of tocilizumab and baricitinib for patients on supplemental oxygen or on noninvasive ventilation and anticoagulants to prevent thromboembolism. Due to suspension of use authorization, it was not possible to make recommendations regarding the use of casirivimab + imdevimab. Strong recommendations against the use of azithromycin in patients without suspected bacterial infection, hydroxychloroquine, convalescent plasma, colchicine, and lopinavir + ritonavir and conditional recommendations against the use of ivermectin and remdesivir were made.

CONCLUSION

New recommendations for the treatment of hospitalized patients with COVID-19 were generated, such as those for tocilizumab and baricitinib. Corticosteroids and prophylaxis for thromboembolism are still recommended, the latter with conditional recommendation. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and to promote resource economy.

Sociodemographic risk factors for gestational syphilis in a maternity hospital in Santa Catarina, Brazil

Objective: to identify risk factors for the acquisition of gestational syphilis. Methods: Coorte study. The participants will perform rapid tests to detect syphilis during pregnancy and hospitalization. Data referring to age, ethnicity, education, and family income were collected in the interview. To investigate factors associated with syphilis infection in the gestational period, binary logistic regression models were run to analyze the crude and adjusted odds ratios for sociodemographic and economic variables. The statistical significance level of 5% was adopted. Results: There was a statistically significant association between syphilis infection and the social class of the patient [χ2 9.821 (4 df); p = 0.05]. The logistic regression model showed that black women had a higher chance of syphilis infection (OR = 2.582; 95% CI 1.068 – 6.243). Conclusion: Low social class and black ethnicity are risk factors for acquiring syphilis during pregnancy.

Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19

Objective

Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil.

Methods

A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method.

Results

Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made.

Conclusion

To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.

Brazilian Guidelines for the pharmacological treatment of patients hospitalized with COVID-19: Joint guideline of Associação Brasileira de Medicina de Emergência, Associação de Medicina Intensiva Brasileira, Associação Médica Brasileira, Sociedade Brasileira de Angiologia e Cirurgia Vascular, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Pneumologia e Tisiologia, Sociedade Brasileira de Reumatologia

OBJECTIVE

Several therapies are being used or proposed for COVID-19, and many lack appropriate evaluations of their effectiveness and safety. The purpose of this document is to develop recommendations to support decisions regarding the pharmacological treatment of patients hospitalized with COVID-19 in Brazil.

METHODS

A group of 27 experts, including representatives of the Ministry of Health and methodologists, created this guideline. The method used for the rapid development of guidelines was based on the adoption and/or adaptation of existing international guidelines (GRADE ADOLOPMENT) and supported by the e-COVID-19 RecMap platform. The quality of the evidence and the preparation of the recommendations followed the GRADE method.

RESULTS

Sixteen recommendations were generated. They include strong recommendations for the use of corticosteroids in patients using supplemental oxygen, the use of anticoagulants at prophylactic doses to prevent thromboembolism and the nonuse of antibiotics in patients without suspected bacterial infection. It was not possible to make a recommendation regarding the use of tocilizumab in patients hospitalized with COVID-19 using oxygen due to uncertainties regarding the availability of and access to the drug. Strong recommendations against the use of hydroxychloroquine, convalescent plasma, colchicine, lopinavir + ritonavir and antibiotics in patients without suspected bacterial infection and also conditional recommendations against the use of casirivimab + imdevimab, ivermectin and rendesivir were made.

CONCLUSION

To date, few therapies have proven effective in the treatment of hospitalized patients with COVID-19, and only corticosteroids and prophylaxis for thromboembolism are recommended. Several drugs were considered ineffective and should not be used to provide the best treatment according to the principles of evidence-based medicine and promote economical resource use.

Early Rehabilitation Index: translation and cross-cultural adaptation to Brazilian Portuguese; and Early Rehabilitation Barthel Index: validation for use in the intensive care unit

Objetivo

Traduzir, adaptar transculturalmente para o português do Brasil o instrumento Early Rehabilitation Index e validar para uso na unidade de terapia intensiva o instrumento Early Rehabilitation Barthel Index, para avaliação do estado funcional.

Métodos

Foram executadas as seguintes etapas: preparação, tradução, reconciliação, tradução reversa, revisão, harmonização, pré-teste e avaliação psicométrica. Após esse processo inicial, a versão em português foi aplicada por dois avaliadores em pacientes que permaneciam pelo menos 48 horas internados na unidade de terapia intensiva. Verificou-se a confiabilidade da escala por meio da consistência interna, da confiabilidade entre avaliadores e do efeito piso e teto. Para a validade de constructo, correlacionou-se o Early Rehabilitation Barthel Index com instrumentos que usualmente são utilizados para avaliação do estado funcional na unidade de terapia intensiva.

Resultados

Participaram 122 pacientes com mediana de idade de 56 [46,8 - 66] anos. O Early Rehabilitation Barthel Index teve confiabilidade adequada com coeficiente alfa de Cronbach de 0,65. A confiabilidade entre avaliadores foi excelente, com coeficiente de correlação intraclasse de 0,94 (IC95% 0,92 - 0,96) e moderado a excelente com índice de concordância de kappa de 0,54 a 1,0. Os efeitos piso e teto foram mínimos. Observou-se a validade do Early Rehabilitation Barthel Index por meio das correlações com o escore total do Perme Escore (rô = 0,72), da Escala de Estado Funcional em UTI (rô = 0,77), do Physical Function in Intensive Care Test-score (rô = 0,69), do Medical Research Council sum score (rô = 0,58), além das dinamometrias de preensão palmar (rô = 0,58) e manual de coxa (rô = 0,55), todos com p < 0,001.

Conclusão

A versão adaptada do Early Rehabilitation Index para o português brasileiro e na sua totalidade, Early Rehabilitation Barthel Index é confiável e válida para avaliação do estado funcional dos pacientes na alta da unidade de terapia intensiva.

2018 recommendations for the management of community acquired pneumonia

Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.

Diagnostic yield of real-time polymerase chain reaction in the diagnosis of intrapartum maternal rectovaginal colonization by group B Streptococcus: a systematic review with meta-analysis

Group B Streptococcus is the leading etiologic factor of neonatal sepsis. Intrapartum real-time polymerase chain reaction (RT-PCR) may allow faster and more accurate detection of maternal colonization. The aim of this study was to determine the sensitivity and specificity of RT-PCR when compared to the reference standard culture in selective broth media collected from rectovaginal tract from laboring women. We selected 15 studies that included 6368 women. Papers selection, data extraction, and quality assessment were carried out by two independent researchers. The prevalence of maternal colonization was 23.8% by RT-PCR and 22.1% by culture. The meta-analysis demonstrated an RT-PCR sensitivity of 93.7% (CI 92.1-95.3), and specificity of 97.6% (CI 97.0-98.1). This result is above the cutoff point defined by the Centers for Disease Control and Prevention for clinical usefulness. In conclusion, RT-PCR for GBS screening in labor ward is a promising tool; however, further well-designed studies to justify its use are needed.

Nosocomial infections in a neonatal intensive care unit in South Brazil

Objective

The aim of this study was to describe the incidence and epidemiology of nosocomial infection in newborns who were admitted to a neonatal intensive care unit in a hospital in south Santa Catarina, Brazil.

Methods

A prospective cohort study was conducted for 1 year among 239 neonates who remained as in-patients 48 hours after admission. The criteria that were used to diagnose infection were in accordance with the Centers for Disease Control and Prevention and the National Health Surveillance Agency.

Results

The incidence of nosocomial infection was 45.8%. The primary reasons for admission were primary bloodstream infection (80.7%) and pneumonia (6.7%). Coagulase-negative Staphylococcus was the most commonly identified agent in the blood cultures and in the hospital unit. Prematurity was the most prevalent reason for admission. The general mortality rate was 12.1%, and mortality from nosocomial infection was 33.8%.

Conclusions

The incidence of nosocomial infection in the hospital unit was higher than rates that have been reported in other national studies. The major types of nosocomial infection were primary bloodstream infection and pneumonia.

The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil

OBJECTIVE

To estimate the burden of disease due to tuberculosis in the state of Santa Catarina, Brazil, in 2009.

METHODS

This was an epidemiological study with an ecological design. Data on tuberculosis incidence and mortality were collected from specific Brazilian National Ministry of Health databases. The burden of disease due to tuberculosis was based on the calculation of disability-adjusted life years (DALYs). The DALYs were estimated by adding the years of life lost (YLLs) and years lived with disability (YLDs). Absolute values were transformed into rates per 100,000 population. The rates were calculated by gender, age group, and health care macroregion.

RESULTS

The burden of disease due to tuberculosis was 5,644.27 DALYs (92.25 DALYs/100,000 population), YLLs and YLDs respectively accounting for 78.77% and 21.23% of that total. The highest rates were found in males in the 30-44 and 45-59 year age brackets, although that was not true in every health care macroregion. Overall, the highest estimated burden was in the Planalto Norte macroregion (179.56 DALYs/100,000 population), followed by the Nordeste macroregion (167.07 DALYs/100,000 population).

CONCLUSIONS

In the majority of the health care macroregions of Santa Catarina, the burden of disease due to tuberculosis was concentrated in adult males, the level of that concentration varying among the various macroregions.

Exacerbations of COPD and symptoms of gastroesophageal reflux: a systematic review and meta-analysis

OBJECTIVE:

To examine the relationship between gastroesophageal reflux (GER) and COPD exacerbations.

METHODS:

We conducted a systematic search of various electronic databases for articles published up through December of 2012. Studies considered eligible for inclusion were those dealing with COPD, COPD exacerbations, and GER; comparing at least two groups (COPD vs. controls or GER vs. controls); and describing relative risks (RRs) and prevalence ratios-or ORs and their respective 95% CIs (or presenting enough data to allow further calculations) for the association between GER and COPD-as well as exacerbation rates. Using a standardized form, we extracted data related to the study design; criteria for GER diagnosis; age, gender, and number of participants; randomization method; severity scores; methods of evaluating GER symptoms; criteria for defining exacerbations; exacerbation rates (hospitalizations, ER visits, unscheduled clinic visits, prednisone use, and antibiotic use); GER symptoms in COPD group vs. controls; mean number of COPD exacerbations (with symptoms vs. without symptoms); annual frequency of exacerbations; GER treatment; and severity of airflow obstruction.

RESULTS:

Overall, GER was clearly identified as a risk factor for COPD exacerbations (RR = 7.57; 95% CI: 3.84-14.94), with an increased mean number of exacerbations per year (mean difference: 0.79; 95% CI: 0.22-1.36). The prevalence of GER was significantly higher in patients with COPD than in those without (RR = 13.06; 95% CI: 3.64-46.87; p < 0.001).

CONCLUSIONS:

GER is a risk factor for COPD exacerbations. The role of GER in COPD management should be studied in greater detail.

Depressive Symptoms and Associated Factors among People Living with HIV/AIDS

The purpose of this study was to evaluate the prevalence of depressive symptoms and associated variables among people living with HIV/AIDS (PLWHA) in a specialized treatment center in a city located in southern Brazil. A cross-sectional study was conducted using the Beck Depression Inventory to assess the presence of depressive symptoms. The prevalence of depressive symptoms was 53.5% among the surveyed population, which supports the idea that depressive symptoms are more common among PLWHA, mainly if compared with the general population. It was observed that 57.7% of the study participants were with depressive symptoms and did not take any psychiatric medication and 100% did not undergo psychotherapy, which indicates undertreatment. There was no statistically significant difference in the mean CD4 count between patients with depressive symptoms (484.1  ±  353) and patients without depressive symptoms (528.4  ±  263). Further actions should be taken to improve the care for PLWHA. The interface between psychology, psychiatry, and internal medicine is of utmost importance to provide a more humanized care, in which the psychosocial, psychological, and psychiatric aspects are not neglected.

Cartilaginous choristoma of the tongue with an immunohistochemical study

By definition, choristomas are normal tissues found in anomalous topography. The cartilaginous features of these lesions are rare in the soft tissues of the oral cavity. The majority of cartilaginous choristomas of the tongue--the primary site of emergence of the oropharynx--are associated with adipose, fibrous or bone tissues--apart from that, only a few of these were confirmed by an immunohistochemical study. The neoplasm exclusively composed of chondromatous tissue is extremely rare in the tongue. This paper reports the clinical, surgical and pathological characteristics of a cartilaginous choristoma of the tongue diagnosed in a 64-year-old woman.

Tendência temporal da morbidade e mortalidade por tuberculose no estado de Santa Catarina, Brasil, no período entre 2002 e 2009

O objetivo deste estudo foi descrever a tendência temporal da morbidade e mortalidade por tuberculose no estado de Santa Catarina no período entre 2002 e 2009. Os dados de mortalidade e incidência foram obtidos, respectivamente, do Sistema de Informação de Mortalidade e do Sistema Nacional de Informação de Agravos de Notificação. As taxas brutas foram calculadas e padronizadas por idade pelo método direto. Estimou-se a variação anual por intermédio de regressão linear segmentada e identificaram-se pontos em que houve modificação da tendência. Observou-se uma redução significativa na taxa de mortalidade de 3,7% ao ano. No período estudado, houve duas tendências distintas: a primeira, entre 2002 e 2007, com redução significativa na taxa de mortalidade de 5,9% ao ano; a segunda, com incremento não significativo dessa taxa de 2,0% ao ano entre 2007 e 2009. Em relação à incidência, observou-se uma redução significativa de 0,9% ao ano.

The Anabolic Steroid Nandrolone Enhances Motor and Sensory Functional Recovery in Rat Median Nerve Repair With Long Interpositional Nerve Grafts

Background. Recovery from peripheral nerve repair is frequently incomplete. Hence drugs that enhance nerve regeneration are needed clinically. Objectives. To study the effects of nandrolone decanoate in a model of deficient reinnervation in the rat. Methods. In 40 rats, a 40-mm segment of the left median nerve was removed and interposed between the stumps of a sectioned right median nerve. Starting 7 days after nerve grafting and continuing over a 6-month period, we administered nandrolone at a dose of 5 mg/kg/wk to half the rats (n = 20). All rats were assessed behaviorally for grasp function and nociceptive recovery for up to 6 months. At final assessment, reinnervated muscles were tested electrophysiologically and weighed. Results were compared between rats that had received versus not received nandrolone and versus 20 nongrafted controls. Results. Rats in the nandrolone group recovered finger flexion faster. At 90 days postsurgery, they had recovered 42% of normal grasp strength versus just 11% in rats grafted but not treated with nandrolone. At 180 days, the average values for grasp strength recovery in the nandrolone and no-nandrolone groups were 40% and 33% of normal values for controls, respectively. At 180 days, finger flexor muscle twitch strength was 16% higher in treated versus nontreated rats. Thresholds for nociception were not detected in either group 90 days after nerve grafting. At 180 days, nociceptive thresholds were significantly lower in the nandrolone group. Conclusions. Nandrolone decanoate improved functional recovery in a model of deficient reinnervation.

Diagnosis of the pulmonary tuberculosis by polymerase chain reaction: a comparative study between HIV-positive and -negative individuals

This study was performed to assess the efficiency of polymerase chain reaction (PCR) directly from sputum for the diagnosis of pulmonary tuberculosis by comparison between HIV-positive and HIV-negative individuals. Sputum samples were collected from hospitalized patients admitted with a clinical diagnosis of pulmonary tuberculosis, and subjected to smear microscopy, culture on LJ medium and detection of M. tuberculosis by PCR. Sensitivity, specificity, and predictive values (positive and negative) were calculated using smear and/or culture at day 42 as the gold standard, by comparing the yield in HIV-positive and HIV-negative individuals. Regardless of serostatus, the technique’s yield had 62% sensitivity, 70% specificity, 79% positive predictive value, 50% negative predictive value, and 65% accuracy. HIV-negative had 64% sensitivity, 74% specificity, 75% positive predictive value, 63% negative predictive value, and 68% accuracy. HIV-positive had 59% sensitivity, 33% specificity, 87% positive predictive value, 10% negative predictive value, and 56% accuracy. The PCR showed a higher yield in HIV-negative individuals compared to HIV-positive individuals.

Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae: a review of epidemiological and clinical aspects

INTRODUCTION

The indiscriminate use of antibiotics associated with other situations has revealed a considerable increase in outbreaks caused by microorganisms resistant to antimicrobial drugs. Among these is the Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae.

AREAS COVERED

This review provides an overview of the KPC-producing K. pneumoniae with emphasis on the epidemiological and clinical aspects.

EXPERT OPINION

The KPC-producing K. pneumoniae was first described in the US. Most cases were reported between 2007 and 2009. It is widespread in almost all continents. The presence of severe comorbidities, previous use of fluoroquinolones and broad-spectrum cephalosporin are independent factors for this type of infection. Besides the increasing number of resistant strains that greatly complicates the therapeutic management of patients, the clinical characteristics of infection make the diagnosis difficult, resulting in high morbidity and mortality rates. The spread of KPC-producing K. pneumoniae shows how we are prone to pandemics. Transport systems, the exchange of healthcare professionals, the transfer of patients between hospitals and, mainly, the lack of preventive measures such as hand washing are related to the spread of KPC-producing Klebsiella pneumoniae in virtually all continents.

Manifestações clínicas, radiológicas e laboratoriais em indivíduos com tuberculose pulmonar: estudo comparativo entre indivíduos HIV positivos e HIV negativos internados em um hospital de referência

OBJETIVO: Comparar as manifestações clínicas, radiológicas e laboratoriais de indivíduos com tuberculose pulmonar coinfectados com HIV com aqueles sem a coinfecção. MÉTODOS: Estudo transversal, no qual sinais e sintomas foram analisados por meio de anamnese e exame físico em pacientes internados com tuberculose pulmonar. A baciloscopia, a cultura para Mycobacterium tuberculosis, a dosagem de hemoglobina e a contagem de células T CD4+ foram obtidas de registros dos prontuários, assim como os laudos das radiografias de tórax. RESULTADOS: Foram incluídos 50 pacientes com tuberculose pulmonar, que foram divididos em dois grupos (HIV positivo e HIV negativo; n = 25 por grupo). A média de idade dos participantes foi de 38,4 ± 10,5 anos, 46 (92%) eram do sexo masculino, e 27 (54%) eram caucasianos. Apresentaram expectoração 21 (84%) e 13 (52%) dos pacientes nos grupos HIV negativo e HIV positivo, respectivamente (p = 0,016). Achados radiológicos de cavitação estavam presentes em 10 (43%) e 2 (10%) dos pacientes nos grupos HIV negativo e HIV positivo, respectivamente (p = 0,016), ao passo que padrão intersticial estava presente em 18 (78%) e 8 (40%) dos pacientes nesses grupos (p = 0,012). O nível médio de hemoglobina foi de 11,1 ± 2,9 g/dL e 9,3 ± 2,2 g/dL nos grupos HIV negativo e HIV positivo, respectivamente (p = 0,015). CONCLUSÕES: Entre pacientes coinfectados com tuberculose e HIV desta amostra, houve menor prevalência de expectoração, foram menos frequentes os achados radiológicos de cavitação e de padrão intersticial, e os níveis de hemoglobina foram mais baixos do que naqueles sem essa coinfecção.

O PROCESSO DE VIVER E DE SER CUIDADO DE IDOSOS E A PERCEPÇÃO DOS CUIDADORES

Estudo exploratório descritivo com abordagem qualitativa objetivou conhecer como o idoso percebe o cuidado em saúde e a significação deste em sua vida, e identificar a percepção dos cuidadores leigos e trabalhadores de saúde acerca do cuidado oferecido. Para a coleta de dados utilizou-se entrevista e questionário. A amostra foi constituída de dez idosos institucionalizados e sete domiciliados; seis cuidadores e quatorze trabalhadores. Os dados, analisados pelo referencial da análise de conteúdo, resultaram em quatro categorias centrais e identificou-se que o processo de viver e de ser cuidado é percebido de diferentes maneiras e tem relação com a história de vida, individual e familiar de cada ser. Cuidar do idoso requer preparo e valorização cultural em função das peculiaridades que envolvem o processo de envelhecimento humano.

Quality of sputum in the performance of polymerase chain reaction for diagnosis of pulmonary tuberculosis

SETTING

faster alternative techniques are required to improve the diagnosis and control of pulmonary tuberculosis.

OBJECTIVE

To evaluate the sample quality in the performance of PCR for diagnosis of pulmonary tuberculosis.

METHOD

during one year, sputum samples were collected from 72 pulmonary tuberculosis patients and 12 non-tuberculosis controls, which were admitted to the Nereu Ramos hospital, Florianópolis city, Brazil. The samples were subjected to Ziehl-Neelsen-stained sputum smear microscopy and Lowestein-Jensen medium culture, which were defined as gold standard tests for mycobacteria, and polymerase chain reaction (PCR). Those samples that presented more than 40% of viable cells and less than 25% of epithelial cells were defined as high quality samples.

RESULTS

PCR showed sensitivity of 55.6%, specificity of 41.7%, positive predictive value of 85.1%, negative predictive value of 13.5%, and accuracy of 53.6%. High quality samples showed sensitivity of 72.4%, specificity of 50%, positive predictive value of 91.3%, negative predictive value of 20%, and accuracy of 69.7%. Low quality samples showed sensitivity of 44.2%, specificity of 37.5%, positive predictive value of 79.2%, negative predictive value of 11.1%, and accuracy of 43.1%.

CONCLUSION

use of high quality samples improved significantly the PCR performance, especially on their sensitivity and positive predictive values.

The clinical utility of induced sputum for the diagnosis of bacterial community-acquired pneumonia in HIV-infected patients: a prospective cross-sectional study

BACKGROUND

Bacterial pneumonias have been overcoming pneumocytosis in frequency. Controversy still remains about how to manage immunocompromised patients and those with lung diseases. Sputum analysis is a noninvasive and simple method, and when interpreted according to specific criteria it may help with diagnosis. We conducted a study to evaluate sensitivity, specificity, positive and negative predicted values, and the accuracy of induced sputum (IS) for bacterial community-acquired pneumonia diagnosis in HIV-positive patients.

MATERIAL AND METHODS

This cross sectional study evaluated a diagnostic procedure in a reference hospital for HIV patients in Florianópolis, SC, Brazil. From January 1, 2001 to September 30, 2002, 547 HIV-positive patients were analyzed and 54 inpatients with pulmonary infection were selected. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were considered the gold standards. Gram stains and quantitative cultures of IS and BAL were obtained. The cut-offs for quantitative cultures were 10(6) CFU/mL for IS and 10(4) CFU/mL for BAL.

RESULTS

The mean age was 35.7 years, 79.6% were males and 85.2% were caucasians. The mean lymphocyte count was 124.8/mm(3). Bacterial pneumonia was diagnosed in 20 patients. The most prevalent bacteria was Streptococcus pneumoniae. Considering IS for the diagnosis of bacterial pneumonia, sensitivity was 60%, specificity 40%, the positive predictive value was 80%, negative predictive value 20% and accuracy 56%.

CONCLUSION

IS with quantitative culture can be helpful for the diagnosis of bacterial pneumonia in HIV-positive patients.

Alterações radiográficas em pacientes com a co-infecção vírus da imunodeficiência humana/tuberculose: relação com a contagem de células TCD4+

OBJETIVO: Correlacionar os padrões radiológicos com a contagem de células TCD4+ em pacientes co-infectados por tuberculose e vírus da imunodeficiência humana. MÉTODO: Foram avaliados os pacientes admitidos no Hospital Nereu Ramos, Florianópolis (SC), co-infectados por tuberculose e vírus da imunodeficiência humana, no período de janeiro de 2000 a dezembro de 2003. RESULTADOS: Foram incluídos no estudo 87 pacientes, com média de idade de 34 ± 8 anos, sendo 6,8% não caucasianos. A média de linfócitos TCD4+ foi de 220,2 células/mm³ e a mediana foi de 144 células/mm³, sendo que 56,4% dos pacientes possuíam menos de 200 células/mm³. Os padrões radiográficos isolados foram relacionados com a contagem de células TCD4+. O padrão de consolidação alveolar estava presente em 50,6% dos casos (56,8% TCD4+ < 200); o intersticial em 32,2% (53,6% TCD4+ < 200); derrame pleural em 24,1% (47,6% TCD4+ < 200); cavitação em 24,1% (57,1% TCD4+ < 200); linfonodomegalia mediastinal e/ou hilar em 11,5% (90% TCD4+ < 200); e sem alterações radiológicas em 11,5% deles (60% TCD4+ < 200). A média dos linfócitos para cada padrão radiológico foi de 235,2/mm³ (consolidação alveolar); 208,8/mm³ (intersticial); 243,3/mm³ (derrame pleural); 265/mm³ (cavitação); 115,1/mm³ (linfonodomegalia mediastinal e/ou hilar) (p < 0,05); e 205,5/mm³ (sem alteração radiológica). A linfonodomegalia mediastinal e/ou hilar foi o único padrão que se correlacionou de forma estatisticamente significativa com o grau de imunidade celular. CONCLUSÃO: Com exceção da linfonodomegalia mediastinal e/ou hilar, as alterações radiológicas distribuíram-se aleatoriamente em relação à contagem de células TCD4+.

Radiographic alterations in patients presenting human immunodeficiency virus/tuberculosis coinfection: correlation with CD4+ T cell counts

OBJECTIVE

To look for correlations between radiological patterns and CD4+ T cell counts in patients coinfected with tuberculosis and human immunodeficiency virus.

METHODS

Patients included were selected from among those presenting human immunodeficiency virus/tuberculosis coinfection and admitted to the Nereu Ramos Hospital, located in Florianópolis, Brazil, between January of 2000 and December of 2003.

RESULTS

A total of 87 patients were included. The mean age was 34 +/- 8 years, and 6.8% were non-Caucasian. The mean CD4+ T cell count was 220.2 cells/mm(3) (median, 144 cells/mm(3)), and 56.4% of the patients presented less than 200 cells/mm(3). We identified the following radiographic patterns and related them to the CD4+ T cell counts: the alveolar pattern in 50.6% of the cases (56.8% CD4+ T cells < 200); the interstitial pattern in 32.2% (53.6% CD4+ T cells < 200); pleural effusion in 24.1% (47.6% CD4+ T cells < 200); cavitation in 24.1% (57.1% CD4+ T cells < 200); enlarged mediastinal or hilar lymph nodes in 11.5% (90% CD4+ T cells < 200); and a normal pattern in 11.5% (60% CD4+ T cells < 200). The mean CD4+ T cell counts for the radiologic patterns isolated were as follows: 235.2/mm(3) (alveolar consolidation); 208.8/mm(3) (interstitial); 243.3/mm(3) (pleural effusion); 265/mm(3) (cavitation); 115.1/mm(3) (enlarged mediastinal or hilar lymph nodes) (p < 0.05); and 205.5/mm(3) (presenting no radiological alterations). As noted, mediastinal/hilar lymph node enlargement was the only pattern that correlated with the degree of cell-mediated immunity in a statistically significant way.

CONCLUSION

With the exception of mediastinal/hilar lymph node enlargement, the radiographic patterns were randomly distributed in relation to the CD4+ T cell counts.

O escarro induzido no diagnóstico das doenças pulmonares em pacientes positivos ao vírus da imunodeficiência humana

INTRODUÇÃO: O escarro induzido é utilizado para monitorar a inflamação de vias aéreas, porém seu papel como ferramenta diagnóstica de doenças pulmonares em pacientes imunocomprometidos ainda necessita de melhor definição. OBJETIVOS: Determinar o rendimento do escarro induzido no diagnóstico das doenças pulmonares em pacientes positivos ao virus da imunodeficiência humana (HIV). MÉTODO: No período de janeiro de 2001 a setembro de 2002, foram avaliados todos os pacientes com idade superior a 14 anos, infectados com o HIV, admitidos em Hospital de Referência. Foram incluídos aqueles indivíduos que apresentavam manifestações clínicas do aparelho respiratório há pelo menos 7 dias, associadas, ou não, a alterações radiológicas, bem como indivíduos assintomáticos do ponto de vista respiratório, com alterações no radiograma de tórax. Os pacientes foram submetidos à avaliação clínica, radiológica e laboratorial e realizaram a indução de escarro, seguida pela broncofibroscopia, lavado broncoalveolar e biópsia pulmonar transbrônquica. As amostras foram processadas para bacterioscopia pelo método de Gram e Ziehl-Neelsen, cultura quantitativa para bactérias, exame micológico direto, cultura para micobactérias e fungos, pesquisa de citomegalovírus e Pneumocystis jiroveci, bem como celularidade total e diferencial. RESULTADOS: 54 pacientes foram incluídos no estudo. A pesquisa de agente etiológico resultou negativa em 7 pacientes, sendo que nos casos restantes foram isolados 60 agentes. Dentre os agentes isolados, 46,7% foram P. jiroveci; 33,5% bactérias piogênicas e 16,7% Mycobacterium tuberculosis. O escarro induzido apresentou sensibilidade de 57,5%, especificidade de 42,9%, valor preditivo positivo de 87,1%, valor preditivo negativo de 13% e acurácia de 55,6%. CONCLUSÕES: Nesta população, a análise do escarro induzido é um procedimento simples, seguro e com bom rendimento diagnóstico.