Suporte avançado à vida: atendimento a vítimas de acidentes de trânsito

OBJETIVO: Analisar a atuação de um modelo de Suporte Avançado à Vida (SAV), a acidentados de trânsito por meio de indicadores, considerando a pontuação do Revised Trauma Score (RTS) na fase pré-hospitalar. MÉTODOS: Análise de 643 registros de atendimento de SAV a acidentados de trânsito, ocorridos em vias expressas da cidade de São Paulo, SP, no período de abril/1999 a abril/2000. Os intervalos de tempo avaliados foram: tempo resposta, de cena, de transporte e total. A análise da decisão de triagem considerou os registros de RTS<FONT FACE=Symbol>£FONT>11 como corretos para encaminhamento a hospitais terciários. As flutuações no RTS e parâmetros foram observadas através da equação: (RTSfinal <FONT FACE=Symbol>¾FONT> RTSinicial). RESULTADOS E CONCLUSÕES: Das 643 vítimas, 90,8% alcançaram RTS=12 e 5,2% obtiveram RTS<FONT FACE=Symbol>£FONT>10. O tempo resposta variou entre 8 e 9 min, sendo o tempo de cena e de transporte maior nos casos de RTS<FONT FACE=Symbol>£FONT>10. Das vítimas com RTS<FONT FACE=Symbol>£FONT>10, 45,5% foram corretamente encaminhadas para hospitais terciários. Identificaram-se incorreções na triagem de vítimas. A manutenção ou melhora nos valores de RTS ocorreu em 98,8% das vítimas. A freqüência respiratória foi o parâmetro que mais apresentou melhora, seguida da pressão arterial sistólica.

Infecção experimental pelo Encephalitozoon cuniculi em camundongos imunossuprimidos com dexametasona

OBJETIVO: O microsporídio Encephalitozoon cuniculi tem sido reconhecido como um patógeno oportunista em indivíduos imunossuprimidos, tais como pacientes com Aids. O objetivo do trabalho foi desenvolver animais farmacologicamente imunossuprimidos como modelo da infecção natural pelo E. cuniculi. MÉTODOS: Foram usados grupos distintos de camundongos Balb-C adultos, imunossuprimidos com diferentes doses de dexametasona (Dx, 3 ou 5 mg/kg/dia por via intraperitoneal <FONT FACE=Symbol>¾FONT> IP) e inoculados com esporos de E. cuniculi por via IP. Também foram usados grupos controle (animais inoculados, mas nãoimunossuprimidos, e animais imunossuprimidos, mas não inoculados). Os esporos de E. cuniculi foram previamente cultivados em células MDCK. Os animais foram sacrificados e submetidos à necropsia aos 7, 14, 21, 28 e 35 dias pós-inoculação. Fragmentos teciduais foram coletados e processados para análise por microscopia de luz, utilizando-se as técnicas de coloração de Gram -chromotrope e de hematoxilina-eosina. RESULTADOS: Em todos os animais imunossuprimidos e inoculados, porém especialmente naqueles que receberam 5 mg/kg/dia de Dx, os achados de necropsia mais proeminentes foram hepato e esplenomegalia. A inoculação experimental resultou em uma infecção disseminada e não-letal, caracterizada por lesões granulomatosas em diversos órgãos (fígado, pulmões, rins, intestino, encéfalo), porém mais notadamente no tecido hepático. Esporos de E. cuniculi foram observados em poucos animais tratados com 5 mg/kg/dia de Dx aos 35 dias pós-infecção. CONCLUSÕES: Microsporidiose em camundongos imunossuprimidos com Dx fornece um modelo útil para estudos da infecção por microsporídios, assemelhando-se àquela naturalmente observada em indivíduos imunodeficientes com Aids.

Perda auditiva induzida por ruído e hipertensão em condutores de ônibus

OBJETIVO: Estimar as prevalências de perda auditiva induzida por ruído e hipertensão arterial em condutores de ônibus urbanos. MÉTODOS: Executou-se estudo transversal em amostra probabilística de 108 motoristas da cidade de Campinas, SP. Aplicou-se questionário sobre história profissional, jornadas de trabalho e repouso, e realizou-se exame físico e laboratorial incluindo medida da pressão arterial, audiometria tonal limiar, logoaudiometria e dados antropométricos, após a obtenção de consentimento. RESULTADOS: A prevalência de perda auditiva induzida por ruído foi de 32,7% do total examinado. Segundo a classificação de Merluzzi, nos 31 casos classificados em primeiro e segundo graus, observou-se que a freqüência audiométrica com perda auditiva mais acentuada foi a de 6 kHz (61,3%), seguida pela de 4 kHz (38,7%), sem diferenças significantes quanto à lateralidade. A prevalência de hipertensão arterial diastólica (PAD<FONT FACE=Symbol>³FONT>90 mmHG; PAS<FONT FACE=Symbol>³FONT>140 mmHG) foi de 13,2% dos examinados. CONCLUSÕES: O risco de disacusia induzida por ruído foi maior para os motoristas com mais de seis anos de trabalho, após ajuste para a perda relacionada com a idade, com um odds ratio de 19,25 (1,59

Hipercolesterolemia em escolares e seus fatores de risco

OBJETIVO: Identificar os fatores de risco da hipercolesterolemia em escolares de sete a dez anos de idade. MÉTODOS: Estudo caso-controle, desenvolvido com 172 escolares do Município de Campinas, SP, pareados conforme sexo e trimestre de idade. Considerou-se caso a hipercolesterolemia, diagnosticada quando a criança apresentava colesterol <FONT FACE=Symbol>³FONT>200 mg/dL, e controle quando a criança apresentava colesterol entre 140 e 170 mg/dL. Além da coleta de sangue para a dosagem do nível de colesterol, foram levantados dados sobre pressão arterial, índice de massa corporal e história familiar de doenças cardiovasculares. Os dados foram analisados por correlação bivariada usando o teste t para as variáveis quantitativas e o qui-quadrado para a história familiar de doenças cardiovasculares. O odds-ratio foi usado para estimar o risco de hipercolesterolemia. RESULTADOS: A média do colesterol encontrada foi de 215 mg/dL nos casos e de 154 mg/dL nos controles. A média da pressão arterial sistólica foi de 107 mmHg nos casos e de 106 mmHg nos controles e da diastólica foi de 67 mmHg nos casos e 68 mmHg nos controles. O índice de massa corporal (Kg/m²) apresentou média de 18,2 nos casos e de 17,1 nos controles. A análise bivariada mostrou associação entre hipercolesterolemia e índice de massa corporal (p=0,048). O odds ratio apontou a obesidade como fator de risco para a hipercolesterolemia (OR=2,17; IC=1,05 a 4,45). CONCLUSÕES: Os resultados apontaram a obesidade como fator de risco da hipercolesterolemia.

Fatores de risco para nascimento de crianças pequenas para idade gestacional

OBJETIVO: Determinar os fatores de risco para o nascimento de crianças pequenas para a idade gestacional. MÉTODOS: Nos meses de outubro a dezembro de 1996, cinco maternidades de Pelotas, RS, foram visitadas diariamente para entrevistar puérperas. O peso ao nascer foi obtido do registro dos berçários. A idade gestacional foi calculada a partir da data da última menstruação. Considerou-se como pequena para a idade gestacional (PIG) aquelas crianças cujo peso ao nascer, de acordo com o sexo e a idade gestacional, estava abaixo do percentil 10 da população de referência de Williams. O teste qui-quadrado foi usado nas análises bivariadas e a regressão logística, não-condicional, na análise multivariada. RESULTADOS: Foram estudadas 1.082 puérperas e a prevalência de nascimento PIG foi de 13,1%. Mesmo após controle para possíveis fatores de confusão, as crianças cuja renda familiar era <1 salário-mínimo apresentaram uma maior chance de serem PIG (OR: 8,81 IC95% 1,12-69,46) do que aquelas com renda <FONT FACE=Symbol>³FONT>10 salários-mínimos. Um pré-natal de baixa qualidade também aumentou a chance de PIG (OR: 3,28 IC95% 1,09-9,91). Baixa estatura materna e exposição ao tabaco também estiveram associados com nascimentos PIG. CONCLUSÕES: O baixo nível socioeconômico, tabagismo materno, estatura materna e pré-natal de baixa qualidade foram os principais fatores de risco para PIG.

Impacto funcional da internação hospitalar de pacientes idosos

OBJETIVO: Descrever as alterações da capacidade funcional de idosos durante a internação hospitalar e o grau de associação dessas alterações na ocasião da alta hospitalar a variáveis sociodemográficas e clínicas. MÉTODOS: Foram estudados 94 pacientes internados em enfermaria geriátrico gerontológica de um hospital escola, com idades entre 65 e 94 anos. A primeira avaliação da capacidade funcional (número de atividades cotidianas comprometidas) dos idosos foi realizada em até 24 horas da entrada do paciente e a última, imediatamente após a alta. Os pacientes sofreram intervenções terapêuticas rotineiras por equipe interdisciplinar. Os dados foram analisados pelo teste qui-quadrado, tanto para a linha de base como em relação à análise dos resultados obtidos com a internação hospitalar (<FONT FACE=Symbol>a£FONT>0,05). RESULTADOS: Dos pacientes estudados, 25,6% obtiveram melhora na capacidade funcional, 34,0% não sofreram alterações funcionais, 19,1% pioraram funcionalmente e 21,3% faleceram durante o período. Houve correlação significante entre a piora funcional e a presença déficit cognitivo, delirium e baixa capacidade funcional na entrada no hospital. CONCLUSÕES: A capacidade funcional é um importante marcador de saúde em idosos hospitalizados. A melhora funcional durante a internação está associada a menores dificuldades nas atividades diárias referidas no momento da entrada no hospital e melhores condições clínicas.

Readability of medicinal package leaflets: a systematic review

OBJECTIVE To review studies on the readability of package leaflets of medicinal products for human use.METHODS We conducted a systematic literature review between 2008 and 2013 using the keywords “Readability and Package Leaflet” and “Readability and Package Insert” in the academic search engine Biblioteca do Conhecimento Online,comprising different bibliographic resources/databases. The preferred reporting items for systematic reviews and meta-analyses criteria were applied to prepare the draft of the report. Quantitative and qualitative original studies were included. Opinion or review studies not written in English, Portuguese, Italian, French, or Spanish were excluded.RESULTS We identified 202 studies, of which 180 were excluded and 22 were enrolled [two enrolling healthcare professionals, 10 enrolling other type of participants (including patients), three focused on adverse reactions, and 7 descriptive studies]. The package leaflets presented various readability problems, such as complex and difficult to understand texts, small font size, or few illustrations. The main methods to assess the readability of the package leaflet were usability tests or legibility formulae. Limitations with these methods included reduced number of participants; lack of readability formulas specifically validated for specific languages (e.g., Portuguese); and absence of an assessment on patients literacy, health knowledge, cognitive skills, levels of satisfaction, and opinions.CONCLUSIONS Overall, the package leaflets presented various readability problems. In this review, some methodological limitations were identified, including the participation of a limited number of patients and healthcare professionals, the absence of prior assessments of participant literacy, humor or sense of satisfaction, or the predominance of studies not based on role-plays about the use of medicines. These limitations should be avoided in future studies and be considered when interpreting the results.

Immune responses induced by a Leishmania (Leishmania) amazonensis recombinant antigen in mice and lymphocytes from vaccinated subjects

In the search for Leishmania recombinant antigens that can be used as a vaccine against American Cutaneous Leishmaniasis, we identified a Leishmania (Leishmania) amazonensis recombinant protein of 33 kD (Larp33) which is recognized by antibodies and peripheral blood leukocytes (PBL) from subjects vaccinated with Leishvacin ®, Larp33 was expressed in Escherichia coli after cloning of a 2,2 kb Sau3A digested genomic fragment of L. (L.) amazonensis into the pDS56-6 His vector. Immunoblotting analysis indicated that Larp33 corresponds to an approximately 40-kD native protein expressed in promastigotes of L.(L.) amazonensis and L. (Viannia) braziliensis. Northern blots of total RNA also demonstrated that the gene coding for this protein is expressed in promastigotes of the major lineages of Leishmania causing American Cutaneous Leishmaniasis. Larp33 induced partial protection in susceptible mouse strains (BALB/c and C57BL/10) against L. (L.) amazonensis after vaccination using Bacille Calmette-Guerin (BCG) as adjuvant. In vitro stimulation of splenocytes from BALB/c protected mice with Larp33 elicited the secretion of IL-2 and IFN-<FONT FACE="Symbol">gfont>, suggesting that a Th1 cell-mediated protective response is associated with the resistance observed in these mice. As revealed by its immunogenic and antigenic properties, this novel recombinant antigen is a suitable candidate to compose a vaccine against cutaneous leishmaniasis

Epidemiological and clinical aspects of snAkebite in Belo Horizonte, Southeast Brazil

Epidemiologic and clinical aspects of 310 hospitalized snakebite patients and 310 matched controls were described, over a seven years period, from an emergency hospital in Belo Horizonte, Southeast Brazil. The diagnosis was based upon clinical picture or actual snake identification. Fifty six percent of victims were bitten by the snakes of genus Bothrops, 32.0% by Crotalus, 1.0% by Lachesis and 10.0% undetermined. During the study period, stable number of cases and marked seasonal variation were noted. In comparing cases of snakebite and controls, those from a rural area or who were involved in agricultural labor activity were identified as a high risk group, with an odds ratio (OR) of 14.7 and 6.7, respectively, in favor of being bitten. Upon treatment, snakebite patients were 13.5 times more likely to have had early anaphylactic reactions than their controls, with a higher association in the age group <FONT FACE="Symbol">³font> 20 years (OR = 30.3). Increased risks were also detected for pyrexia (OR = 11.7), with a marked association in the group under 19 years old (OR = 16.6). Severe cases of snakebite are an important treatable cause of morbidity in Brazil but therapy may be potentially life threatening. The higher case-fatality ratio encountered, compared to national statistics may be due the representativeness of the more severe cases who sought hospitalization. Preventing snakebite and early referral of those who are bitten is proposed

Effect of b-Propiolactone treatment on the complement activation mediated by equine antisera

Reduction of complement activation through an alteration of the Fc fragment of immunoglobulins by <FONT FACE="Symbol">bfont>-propiolactone treatment was carried out in equine antisera raised against rabies virus, Bothrops venoms and diphtherial toxin. Results were evaluated by means of an anaphylactic test performed on guinea-pigs, and compared to the ones obtained with the same sera purified by saline precipitation (ammonium sulfate), followed or not by enzymatic digestion with pepsin. Protein purity levels for antibothropic serum were 184.5 mg/g and 488.5 mg/g in <FONT FACE="Symbol">bfont>-propiolactone treated and pepsin-digested sera, respectively. The recovery of specific activity was 100% and 62.5% when using antibothropic serum treated by<FONT FACE="Symbol"> bfont>-propiolactone and pepsin digestion, respectively. The antidiphtherial and anti-rabies sera treated with <FONT FACE="Symbol">bfont>-propiolactone and pepsin presented protein purity levels of 5,698 and 7,179 Lf/g, 16,233 and 6,784 IU/g, respectively. The recovery of specific activity for these antisera were 88.8%, 77.7%, 100% and 36,5%, respectively. <FONT FACE="Symbol">bfont>-propiolactone treatment induced a reduction in complement activation, tested "in vivo", without significant loss of biological activity. This treatment can be used in the preparation of heterologous immunoglobulins for human use.

Cryo-Microtome sections of coproculture larvae of Strongyloides stercoralis and Strongyloides ratti as antigen sources for the immunodiagnosis of human strongyloidiasis

Cryo-microtome sections of larvae of Strongyloides stercoralis and S. ratti respectively obtained from human and rat feces cultures, were used as antigens. Fluoresceinate conjugates against human IgG were employed at the ideal titer of 10 for S. stercoralis and 100 for S. ratti. The sensitivity of the indirect immunofluorescence reaction (IIF) was 94.4% and 92.5% and the specificity 94.2% and 97.1% for the two specific larval antigens, respectively. Sera from 123 persons (54 from carriers of S. stercoralis infections and 69 from controls) were submitted to the reaction. The titers of different sera varied from 20 to 2560. There was a significant linear correlation (r = 0.85 p <FONT FACE="Symbol">£font> 0.001) between the antibodies from the two species of larval antigens. We conclude that both antigens may be used in the IIF reaction for the diagnosis of human strongyloidiasis. Due to the feasibility of safe and low-cost mass production of S. ratti larvae in the laboratory with a considerable economy of conjugate, their utilization in the serum diagnosis of human strongyloidiasis is recommended

IgM and IgA Antibody Responses in 12 Cases of Human Acquired Toxoplasmosis

The persistence, in some subjects, of specific IgM antibodies to Toxoplasma gondii for several months after the acute phase of infection has complicated the interpretation of serological test results for toxoplasmosis. Several reports have emphasized the value of the detection of Toxoplasma-specific IgA antibodies for the diagnosis of acute toxoplasmosis. In this article, we report the follow-up profiles of Toxoplasma-specific IgM and IgA antibodies in serum samples obtained from 12 patients at various intervals after the onset of the clinical manifestations of infection. IgM antibodies were detected by the indirect immunofluorescence (IIF) test, antibody capture enzyme-linked immunosorbent assay (cELISA) and enzyme-mediated chemilluminescent technique (CmL). IgA antibodies were quantified by the direct ELISA (dELISA) and cELISA procedures. As defined by the manufacturer of the cELISA test for IgA used, most patients with acute toxoplasmosis have antibody levels > 40 arbritary units per ml (AU/ml). At values > 40 AU/ml, the cELISA for IgA detected significant antibody levels for a shorter time than the other techniques used for IgM and IgA detection. However, IgA levels <FONT FACE="Symbol">£font> 40 AU/ml do not exclude the possibility of acute toxoplasmosis since such levels can be reached very soon after infection with T. gondii. The results obtained in the present study show that the serological diagnosis of acute toxoplasmosis may not be such an easy task. Our data suggest that use of the IgA-cELISA concomitantly with IgM antibody screening could permit, in some circumstances, a more efficient diagnosis of acute acquired toxoplasmosis

Presence of Circulating Levels of Interferon-g, Interleukin-10 and Tumor Necrosis Factor-a in Patients with Visceral Leishmaniasis

Experimental murine L. major infection is characterized by the expansion of distinct CD4+ T cell subsets. The Th1 response is related to production of IFN-<FONT FACE="Symbol">gfont> and resolution of infection, whereas Th-2 response with production of IL-4 and IL-10 and dissemination of infection. The objective of this study was to measure the circulating levels of IFN-<FONT FACE="Symbol">gfont>, IL-10 and TNF-<FONT FACE="Symbol">afont> in patients with visceral leishmaniasis (VL) before, during and at the end of therapy and to examine the association between cytokine levels and activity of VL. Fifteen patients with VL were evaluated. The cytokine determinations were done by using the enzyme-linked immunoassay (ELISA) before, during and at the end of therapy. At baseline, we detected circulating levels of IFN-<FONT FACE="Symbol">gfont> in 13 of 15 patients (median = 60 pg/ml); IL-10 in 14 of 15 patients (median = 141.4 pg/ml); and TNF-<FONT FACE="Symbol">afont> in 13 of 14 patients (median = 38.9 pg/ml). As patients improved, following antimonial therapy, circulating levels of IL-10 showed an exponential decay (y = 82.34 e–0,10367x, r = –0.659; p < 0.001). IFN-<FONT FACE="Symbol">gfont> was no longer detected after 7/14 days of therapy. On the other hand, circulating levels of TNF-<FONT FACE="Symbol">afont> had a less pronounced decay with time on therapy, remaining detectable in most patients during the first seven days of therapy (y = 36.99-0.933x, r = –0.31; p = 0.05). Part of the expression of a successful response to therapy may, therefore, include reduction in secretion of inflammatory as well as suppressive cytokines. Since IL-10 and IFN-<FONT FACE="Symbol">gfont> are both detected prior to therapy, the recognized cellular immune depression seen in these patients may be due to biological predominance of IL-10 (type 2 cytokine), rather than lack of IFN-<FONT FACE="Symbol">g font>(type 1 cytokine) production.

Involvement of the central nervous system in dengue fever: three serologically confirmed cases from Fortaleza, Ceará, Brazil

Three cases of dengue fever involving the central nervous system (CNS) are reported. All occurred in 1994 during a dengue (DEN) epidemic caused by serotypes DEN-1 and DEN-2. The first case examined was a 17-year-old girl who complained of fever, nuchal rigidity and genital bleeding. Three blood samples were positive by anti-dengue IgM ELISA and showed hemagglutination-inhibition (HI) test titers <FONT FACE="Symbol">³font> 1,280. The second case concerned a 86-year-old woman with fever, muscle and joint pains, altered consciousness, syncope, nuchal rigidity and meningismus. Her blood sample showed an HI titer of 1:320 for flaviviruses, and an IgM ELISA positive for dengue. The third case was a 67-year-old woman with fever, abnormal behaviour, seizures, tremor of extremities, thrombocytopenia, increased hematocrit and leukopenia. The patient suffered a typical case of dengue hemorrhagic fever with ensuing shock and a fatal outcome. A single blood sample showed HI antibodies of <FONT FACE="Symbol">³font> 1,280 and an IgM ELISA positive for dengue. No virus could be isolated from any patient by inoculation of blood into C6/36 cells and suckling mice. No other agent of disease was encountered in the patient.

IL-2 AND IFN-g, BUT NOT IL-4 SECRETION BY PERIPHERAL BLOOD MONONUCLEAR CELLS (PBMC) ARE RELATED TO CD4+ T CELLS AND CLINICAL STATUS IN BRAZILIAN HIV-1-INFECTED SUBJECTS

It has been reported that production of IL-2 and IFN-<FONT FACE="Symbol">gFONT>, known as T-helper type 1 cytokines, by peripheral mononuclear cells (PBMC) decreases with progression of HIV infection. In contrast, IL-4 and IL-10 production, Th2 cytokine profile, increases with HIV disease progression. PBMC were evaluated from 55 HIV-infected subjects from Divisão de Imunologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, to "in vitro" cytokines production after 24 hours of stimulation with PHA. Low levels of IL-4 production in both HIV- infected patients and normal subjects, were detected. The patients with CD4+ T cell counts <200 showed a significant decrease of IL-2 and IFN-<FONT FACE="Symbol">gFONT> production compared to controls. Patients with higher counts of CD4+ T cells (either between 200-500 or >500 cells/mm3) also showed decreased production of IL-2 that was not statistically significant. There was a correlation between IL-2 and IFN-<FONT FACE="Symbol">gFONT> release with CD4+ T cells counts. HIV-1-infected individuals with CD4+ T cells >500 cells/mm3 showed increased levels of IL-2 and IFN-<FONT FACE="Symbol">gFONT>, than individuals with CD4+ T cells <500 cells/mm3. In conclusion, we observed a decline of IL-2 and IFN-<FONT FACE="Symbol">gFONT> production at advanced HIV disease. IL-4 production was not affected during HIV infection. Taken together, these findings suggest that the cytokine profile might be influenced by the HIV infection rather than the cause of disease progression.