Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches

Objective The Brazilian National Hansens Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters. Method The study area included 373 municipalities in the four Brazilian states Maranha o, Para ', Tocantins and Piaui '. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases / 100 000 population, (ii) rate of cases < 15 years / 100 000 population, (iii) new cases with grade-2 disability / 100 000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic. Results A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates > 40 cases / 100 000 inhabitants). There was a concentration of municipalities with higher detection rates in Para ' and in the center of Maranha o. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate < 15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2 / population overlap with those of new cases detection and detection of children < 15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters. Conclusions Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.

The impact of late diagnosis on the survival of patients following their first AIDS-related hospitalization in Belo Horizonte, Brazil

The purpose of this study is to estimate the survival probability of patients following their first admission for the treatment of AIDS to an infectious disease reference hospital in Belo Horizonte, Brazil, during 2005. Study subjects were monitored during a 12-month period to identify factors associated with survival probability. Late diagnosis was recorded among many of the 250 study subjects: almost half (44.8%) were diagnosed less than 30 days prior to or during their hospitalization. A high mortality rate was also detected: 39.6% of the subjects died during the 12 months of monitoring. The cumulative survival probability of the cohort group was estimated at 68.0% after 3 months and at 61.2% after 12 months. However, certain patient subgroups analyzed had even lower cumulative survival probabilities after 12 months of monitoring: if diagnosed during hospitalization, it was estimated at only 48.0% and those with no record of antiretroviral treatment had a 48.5% cumulative survival probability. Patients with severe anemia had the lowest survival probability, similar among the two lymphocyte count groups (<1000 mm(3) and >= 1000 mm(3)), the former with a 45.5% survival probability and the latter with a 46.7% one. The proportional death risk was 2.5-fold higher for men residing in other area than the capital city of the State of Minas Gerais and greater metropolitan region when compared with women residing there. The findings of this study highlight the importance of early diagnosis for predicting patient survival and reinforce the necessity off acilitating HIV diagnosis.

Delay in the search for health services for the diagnosis of tuberculosis in Ribeirao Preto, Sao Paulo

The scope of this paper is to analyze delays in locating health services for the diagnosis of tuberculosis in Ribeirao Preto in 2009. An epidemiological and cross-sectional study was conducted with 94 TB patients undergoing treatment. A structured questionnaire, based on the Primary Care Assessment Tool adapted for TB care was used. A median (15 days or more) was established to characterize delay in health attendance. Using the Prevalence Ratio, the variables associated with longer delay were identified. The first healthcare services sought were the Emergency Services (ES) (57.5%). The longest period between seeking assistance occurred among males, aged between 50 and 59, who earned less than five minimum wages, had pulmonary TB, were new cases, were not co-infected with TB/HIV, did not consume alcohol, had satisfactory knowledge about TB before diagnosis (with a statistically significant association with delay) and who did not seek healthcare close to home before developing TB. There is a perceived need for training healthcare professionals about the signs and symptoms of the disease, reducing barriers of access to timely diagnosis of TB and widely disseminating it to the community in general.

Why Are Women With Cervical Cancer Not Being Diagnosed in Preinvasive Phase? An Analysis of Risk Factors Using a Hierarchical Model

Objective: To assess the risk factors for delayed diagnosis of uterine cervical lesions. Materials and Methods: This is a case-control study that recruited 178 women at 2 Brazilian hospitals. The cases (n = 74) were composed of women with a late diagnosis of a lesion in the uterine cervix (invasive carcinoma in any stage). The controls (n = 104) were composed of women with cervical lesions diagnosed early on (low-or high-grade intraepithelial lesions). The analysis was performed by means of logistic regression model using a hierarchical model. The socioeconomic and demographic variables were included at level I (distal). Level II (intermediate) included the personal and family antecedents and knowledge about the Papanicolaou test and human papillomavirus. Level III (proximal) encompassed the variables relating to individuals' care for their own health, gynecologic symptoms, and variables relating to access to the health care system. Results: The risk factors for late diagnosis of uterine cervical lesions were age older than 40 years (odds ratio [OR] = 10.4; 95% confidence interval [CI], 2.3-48.4), not knowing the difference between the Papanicolaou test and gynecological pelvic examinations (OR, = 2.5; 95% CI, 1.3-4.9), not thinking that the Papanicolaou test was important (odds ratio [OR], 4.2; 95% CI, 1.3-13.4), and abnormal vaginal bleeding (OR, 15.0; 95% CI, 6.5-35.0). Previous treatment for sexually transmissible disease was a protective factor (OR, 0.3; 95% CI, 0.1-0.8) for delayed diagnosis. Conclusions: Deficiencies in cervical cancer prevention programs in developing countries are not simply a matter of better provision and coverage of Papanicolaou tests. The misconception about the Papanicolaou test is a serious educational problem, as demonstrated by the present study.

Missed opportunities for prevention of mother-to-child transmission of HIV-1 in the NISDI Perinatal and LILAC cohorts

Objective: To evaluate cases of mother-to-child transmission of HIV-1 at multiple sites in Latin America and the Caribbean in terms of missed opportunities for prevention. Methods: Pregnant women infected with HIV-1 were eligible for inclusion if they were enrolled in either the NISDI Perinatal or LILAC protocols by October 20, 2009, and had delivered a live infant with known HIV-1 infection status after March 1, 2006. Results: Of 711 eligible mothers, 10 delivered infants infected with HIV-1. The transmission rate was 1.4% (95% CI, 0.7-2.6). Timing of transmission was in utero or intrapartum (n = 5), intrapartum (n = 2), intrapartum or early postnatal (n = 1), and unknown (n = 2). Possible missed opportunities for prevention included poor control of maternal viral load during pregnancy; late initiation of antiretrovirals during pregnancy; lack of cesarean delivery before labor and before rupture of membranes; late diagnosis of HIV-1 infection; lack of intrapartum antiretrovirals; and incomplete avoidance of breastfeeding. Conclusion: Early knowledge of HIV-1 infection status (ideally before or in early pregnancy) would aid timely initiation of antiretroviral treatment and strategies designed to prevent mother-to-child transmission. Use of antiretrovirals must be appropriately monitored in terms of adherence and drug resistance. If feasible, breastfeeding should be completely avoided. Presented in part at the XIX International AIDS Conference (Washington, DC; July 22-27, 2012); abstract WEPE163. (c) 2012 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

Atraso na busca por serviço de saúde para o diagnóstico da tuberculose em Ribeirão Preto (SP)

Foi analisado o atraso na busca por serviço de saúde para o diagnóstico da Tuberculose (TB) em Ribeirão Preto, 2009, em um estudo epidemiológico, transversal, realizado com 94 doentes. Utilizou-se questionário baseado no Primary Care Assessment Tool, adaptado para avaliar a atenção à TB. Estabeleceu-se a mediana (15 dias ou mais) para caracterizar atraso na busca pelo primeiro atendimento. Através da Razão de Prevalência, identificaram-se as variáveis relacionadas ao maior atraso. O primeiro serviço de saúde procurado foi o de pronto atendimento (57,4%). Verificou-se um maior tempo na procura pelos serviços de saúde entre os doentes: do sexo masculino; com idade entre 50 a 59 anos; com renda familiar inferior a cinco salários mínimos; forma pulmonar; casos novos; não coinfecção TB/HIV; não consumiam bebida alcoólica, conhecimento satisfatório sobre TB (apresentou significância estatística na associação com o atraso) e que não procuravam o serviço de saúde próximo do domicílio antes de ter TB. Verificou-se a necessidade de capacitação para os profissionais de saúde quanto aos sinais e sintomas da doença, reduzindo as barreiras de acesso ao diagnóstico oportuno da TB e divulgação ampla para a comunidade em geral.

Evaluation of Long-Term Outcomes, Cytogenetic and Molecular Responses with Imatinib Mesylate in Early and Late Chronic-Phase Chronic Myeloid Leukemia: A Report from a Single Institute

Here we compare the management and survival outcomes of chronic myeloid leukemia (CML) patients who had early or late imatinib mesylate (IM) therapy. The cytogenetic and molecular responses of 189 CML patients were analyzed. Of this group, 121 patients were classified as the early chronic phase (ECP) group and started IM within 12 months of diagnosis. The other 68 patients were classified as the late chronic phase (LCP) group who had been treated with interferon (IFN)-alpha-2 and crossed over to IM more than 12 months after diagnosis. The overall rates of complete cytogenetic response (CCyR) and major molecular response (MMR) at last follow-up were 83.6 and 78.1% in the ECP and LCP groups, respectively. The CCyR rates were 89.3 (for ECP patients) versus 73.5% (for LCP patients; p < 0.0001). At last follow-up, 82.4% ECP and 64.2% LCP patients had achieved an MMR (p < 0.0001). No significant differences were noted between the two groups with regard to survival outcomes. Our experience reveals that IM is an effective rescue therapy in most CML LCP patients who are intolerant or in whom IFN-alpha therapy fails. Such therapeutic options should be considered in LCP patients, particularly in countries where IM may not be available. Copyright (C) 2012 S. Karger AG, Basel

Circulating Glial-derived neurotrophic factor is reduced in late-life depression

Background: The Glial Cell-line derived neurotrophic factor (GDNF) is part of the TGF-beta superfamily and is abundantly expressed in the central nervous system. Changes in GDNF homeostasis have been reported in affective disorders. Aim: To assess serum GDNF concentration in elderly subjects with late-life depression, before antidepressant treatment, as compared to healthy elderly controls. Methods: Thirty-four elderly subjects with major depression and 37 age and gender-matched healthy elderly controls were included in this study. Diagnosis of major depression was ascertained by the SCID interview for DSM-IV and the severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HDRS-21). Serum GDNF concentration were determined by sandwich ELISA. Results: Patients with major depression showed a significant reduction in GDNF levels as compared to healthy elderly controls (p < 0.001). Also, GDNF level was negatively correlated with HDRS-21 scores (r = -0.343, p = 0.003). Discussion: Our data provide evidence that GDNF may be a state marker of depressive episode in older adults. Changes in the homeostatic control of GDNF production may be a target to development of new antidepressant strategies. (C) 2011 Elsevier Ltd. All rights reserved.

Late entry into HIV care: lessons from Brazil, 2003 to 2006

Background: To ascertain the population rates and proportion of late entry into HIV care, as well as to determine whether such late entry correlates with individual and contextual factors. Methods: Data for the 2003-2006 period in Brazil were obtained from public health records. A case of late entry into HIV care was defined as one in which HIV infection was diagnosed at death, one in which HIV infection was diagnosed after the condition of the patient had already been aggravated by AIDS-related diseases, or one in which the CD4(+) T-cell count was <= 200 cells/mm(3) at the time of diagnosis. We also considered extended and stricter sets of criteria (in which the final criterion was <= 350 cells/mm(3) and <= 100 cells/mm(3), respectively). The estimated risk ratio was used in assessing the effects of correlates, and the population rates (per 100,000 population) were calculated on an annual basis. Results: Records of 115,369 HIV-infected adults were retrieved, and 43.6% (50,358) met the standard criteria for late entry into care. Diagnosis at death accounted for 29% (14,457) of these cases. Late entry into HIV care (standard criterion) was associated with certain individual factors (sex, age, and transmission category) and contextual factors (region with less economic development/increasing incidence of AIDS, lower local HIV testing rate, and smaller municipal population). Use of the extended criteria increased the proportion of late entry by 34% but did not substantially alter the correlations analyzed. The overall population rate of late entry was 9.9/100,000 population, specific rates being highest for individuals in the 30-59 year age bracket, for men, and for individuals living in regions with greater economic development/higher HIV testing rates, collectively accounting for more than half of the cases observed. Conclusions: Although the high proportion of late entry might contribute to spreading the AIDS epidemic in less developed regions, most cases occurred in large cities, with broader availability of HIV testing, and in economically developed regions.

Expanding the differential diagnosis of inherited neuropathies with non-uniform conduction: Andermann syndrome

Uniform conduction slowing has been considered a characteristic of inherited demyelinating neuropathies. We present an 18-year-old girl, born from first cousins, that presented a late motor and psychological development, cerebellar ataxia, facial diplegia, abnormal eye movement, scoliosis, and corpus callosum agenesis, whose compound muscle action potentials were slowed and dispersed. A mutation was found on KCC3 gene, confirming Andermann syndrome, a disease that must be included in the differential diagnosis of inherited neuropathies with non-uniform conduction slowing.