Detection of psychiatric morbidity in the primary medical care setting in Brazil

The aims of this study were a) to assess the ability of primary care doctors to make accurate ratings of psychiatric disturbance and b) to evaluate the use of a case-finding questionnaire in the detection of psychiatric morbidity. The estudy took place in three primary care clinics in the city of São Paulo, Brazil, during a six-month survey. A time sample of consecutive adult attenders were asked to complete a case-finding questionnaire for psychiatric disorders (the Self Report Questionnaire - SRQ) and a subsample were selected for a semi-structured psychiatric interview (the Clinical Interview Schedule - CIS). At the end of the consultation the primary care doctors were asked to assess, in a standardized way, the presence or absence of psychiatric disorder; these assessments were then compared with that ratings obtained in the psychiatric interview. A considerable proportion of minor psychiatric morbidity remained undetected by the three primary care doctors: the hidden morbidity ranged from 22% to 79%. When these were compared to those of the case-finding questionnaire, they were consistently lower, indicating that the use of these instruments can enhance the recognition of psychiatric disorders in primary care settings. Four strategies for adopting the questionnaire are described, and some of the clinical consequences of its use are discussed.

Child-care attendance and common morbidity: evidence of association in the literature and questions of design

Papers on child-care attendance as a risk factor for acute respiratory infections and diarrhea were reviewed. There was great variety among the studies with regard to the design, definition of exposure and definition of outcomes. All the traditional epidemiological study designs have been used. The studies varied in terms of how child-care attendance in general was defined, and for different settings. These definitions differed especially in relation to the minimum time of attendance required. The outcomes were also defined and measured in several different ways. The analyses performed were not always appropriate, leading to sets of results of uneven quality, and composed of different measures of association relating different exposures and outcomes, that made summarizing difficult. Despite that, the results reported were remarkably consistent. Only two of the papers reviewed failed to show some association between child-care attendance and increased acute respiratory infections, or diarrhea. On the other hand, the magnitude of the associations reported varied widely, especially for lower respiratory infections. Taken together, the studies so far published provide evidence that children attending child-care centers, especially those under three years of age, are at a higher risk of upper respiratory infections, lower respiratory infections, and diarrhea. The studies were not consistent, however, in relation to attendance at child-care homes. Children in such settings were sometimes similar to those in child-care centers, sometimes similar to those cared for at home, and sometimes presented an intermediate risk.

Epidemiological methods for research with drug misusers: review of methods for studying prevalence and morbidity

Epidemiological studies of drug misusers have until recently relied on two main forms of sampling: probability and convenience. The former has been used when the aim was simply to estimate the prevalence of the condition and the latter when in depth studies of the characteristics, profiles and behaviour of drug users were required, but each method has its limitations. Probability samples become impracticable when the prevalence of the condition is very low, less than 0.5% for example, or when the condition being studied is a clandestine activity such as illicit drug use. When stratified random samples are used, it may be difficult to obtain a truly representative sample, depending on the quality of the information used to develop the stratification strategy. The main limitation of studies using convenience samples is that the results cannot be generalised to the whole population of drug users due to selection bias and a lack of information concerning the sampling frame. New methods have been developed which aim to overcome some of these difficulties, for example, social network analysis, snowball sampling, capture-recapture techniques, privileged access interviewer method and contact tracing. All these methods have been applied to the study of drug misuse. The various methods are described and examples of their use given, drawn from both the Brazilian and international drug misuse literature.

Assessing morbidity in the paediatric community

INTRODUCTION: Morbidity information is easily available from medical records but its scope is limited to the population attended by the health services. Information on the prevalence of diseases requires community surveys, which are not always feasible. These two sources of information represent two alternative assessments of disease occurrence, namely demand morbidity and perceived morbidity. The present study was conceived so as to elicit a potential relationship between them so that the former could be used in the absence of the latter. METHODS: A community of 13,365 families on the outskirts of S. Paulo, Brazil, was studied during the period from 15/Nov/1994 to 15/Jan/1995. Data regarding children less than 5 years old were collected from a household survey and from the 2 basic health units in the area. Prevalence of diseases was ascertained from perceived morbidity and compared to estimates computed from demand morbidity. RESULTS: Data analysis distinguished 2 age groups, infants less than 1 year old and children 1 to less than 5. The most important groups of diseases were respiratory diseases, diarrhoea, skin problems and infectious & parasitical diseases. Basic health units presented a better coverage for infants. Though disease frequencies were not different within or outside these units, a better coverage was found for diarrhoea and infectious & parasitical diseases in the infant group, and for diarrhoea in the older age group. Equivalence between the two types of morbidity was found to be limited to the infant group and concerned only the best covered diseases. The odds of a disease being seen at the health service should be of at least 4:10 to ensure this equivalence. CONCLUSION: It was concluded that, provided that health service coverage is good, demand morbidity can be taken as a reliable estimate of community morbidity.

The effect of Schistosoma mansoni infection on child morbidity in the State in Bahia, Brazil: II — Analysis at the individual level

The present investigation was carried out on a sample of 840 children (5 to 16 years old) from ten small towns of the State of Bahia in northeastern Brazil. The objetive was to study, by using a cross sectional methodology, the evolution of schistosomiasis morbidity (hepatic and splenic enlargement) in children, and the role of the intensity of S. mansoni infection in this process. The children were analised in three age groups (5 to 8, to 12 and 13 to 16 years old) and classified as uninfected, mildly infected, moderately infected and heavily infected according to the number of eggs in the stool. In children aged 5 to 8 years, increasing egg counts were not associated with increasing frequencies of hepatic or splenic enlargement. In the 9 to 12 years old group and association was observed with the prevalence of hepatic enlargement, but not with the prevalence of spleen enlargement. In the oldest group, 13 to 16 years old, an association was observed with the prevalence of enlargement of both organs. It was evident that in this population schistosomiasis morbidity develops in the early period of life as a gradual process starting with liver enlargement and followed by spleen enlargement some years later. It was found that the intensity of infection has a fundamental role in this process, although there is a latent period of some years before clinical splenomegaly appears in moderate-heavily infected children. The Authors suggest that the prevalence of splenomegaly in the 13 to 16 years old group is a good measure of the community level of schistosomiasis morbidity and could be used to measure the impact of control programs.

Effect of skin colour and selected physical characteristics on Schistosoma mansoni dependent morbidity

The effect of the colour group on the morbidity due to Schistosoma mansoni was examined in two endemic areas situated in the State of Minas Gerais, Brazil. Of the 2773 eligible inhabitants, 1971 (71.1%) participated in the study: 545 (27.6%) were classified as white, 719 (36.5%) as intermediate and 707 (35.9%) as black. For each colour group, signs and symptoms of individuals who eliminated S.mansoni eggs (cases) were compared to those who did not present eggs in the faeces (controls). The odds ratios were adjusted by age, gender, previous treatment for schistosomiasis, endemic area and quality of the household. There was no evidence of a modifier effect of colour on diarrhea, bloody faeces or abdominal pain. A modifier effect of colour on hepatomegaly was evident among those heaviest infected (> 400 epg): the adjusted odds ratios for palpable liver at the middle clavicular and the middle sternal lines were smaller among blacks (5.4 and 6.5, respectively) and higher among whites (10.6 and 12.9) and intermediates (10.4 and 10.1, respectively). These results point out the existence of some degree of protection against hepatomegaly among blacks heaviest infected in the studied areas.

Morbidity and survival in advanced AIDS in Rio de Janeiro, Brazil

Opportunistic diseases (OD) are the most common cause of death in AIDS patients. To access the incidence of OD and survival in advanced immunodeficiency, we included 79 patients with AIDS treated at Hospital Evandro Chagas (FIOCRUZ) from September 1997 to December 1999 with at least one CD4 count <=100 cells/mm³. The incidence of OD was analyzed by Poisson's regression, and survival by Kaplan Meier and Cox analysis, considering a retrospective (before CD4 <=100 cells/mm³) and a prospective (after CD4 <=100 cells/mm³) period, and controlling for demographic, clinical and laboratory characteristics. The confidence interval estipulated was 95%. Mean follow-up period was 733 days (CI = 683-782). During the study 9 (11.4%) patients died. Survival from AIDS diagnosis was a mean of 2589 days (CI = 2363-2816) and from the date of the CD4 count CD4 <=100 cells/mm³ was a mean of 1376 (CI = 1181-1572) days. Incidence of OD was 0.51 pp/y before CD4 <= 100 cells/mm³ and 0.29 pp/y after CD4 <= 100 cells/mm³. A lower number of ODs before CD4 < 100 cells/mm³ was associated with lower incidence rates after CD4 <= 100 cells/mm³. AIDS diagnosis based on CD4+ counts <= 200 cells/mm³ was associated with lower incidence rates after CD4 <= 100 cells/mm³. Baseline CD4 counts above 50 cells/mm³ (HR = 0.13) and restoration of baseline CD4+ counts above 100 cells/mm³ (HR = 0.16) were associated with a lower risk of death. Controling both variables, only restoration of baseline counts was statistically significant (HR = 0.22, p = 0.04). We found a very low incidence of OD and long survival after CD4 < 100 cells/mm³. Survival was significantly associated with restoration of baseline CD4 counts above 100 cells/mm³.

Susceptibility and morbidity between male and female Swiss mice infected with Angiostrongylus costaricensis: Susceptibilidade e morbidade entre camundongos Swiss machos e fêmeas infectados com Angiostrongylus costaricensis

The gender of vertebrate hosts may affect the outcome of parasitic infections. An experimental murine infection with Angiostrongylus costaricensis was followed with determinations of body weight, fecal larval elimination, number and length of adult worms, number of macroscopic intestinal lesions, and mortality. Groups of male and female Swiss mice were infected with 10 3rd-stage A. costaricensis larvae per animal. The results indicate there are no significant differences related to gender of the host, except for higher length of worms developed in male mice.

MORBIDITY AND MORTALITY DUE TO AIDS: A STUDY OF BURDEN OF DISEASE AT A MUNICIPAL LEVEL

Introduction: The purpose of measuring the burden of disease involves aggregating morbidity and mortality components into a single indicator, the disability-adjusted life year (DALY), to measure how much and how people live and suffer the impact of a disease. Objective: To estimate the global burden of disease due to AIDS in a municipality of southern Brazil. Methods: An ecological study was conducted in 2009 to examine the incidence and AIDS-related deaths among the population residing in the city of Tubarao, Santa Catarina State, Brazil. Data from the Mortality Information System in the National Health System was used to calculate the years of life lost (YLL) due to premature mortality. The calculation was based on the difference between a standardized life expectancy and age at death, with a discount rate of 3% per year. Data from the Information System for Notifiable Diseases were used to calculate the years lived with disability (YLD). The DALY was estimated by the sum of YLL and YLD. Indicator rates were estimated per 100,000 inhabitants, distributed by age and gender. Results: A total of 131 records were examined, and a 572.5 DALYs were estimated, which generated a rate of 593.1 DALYs/100,000 inhabitants. The rate among men amounted to 780.7 DALYs/100,000, whereas among women the rate was 417.1 DALYs/100,000. The most affected age groups were 30-44 years for men and 60-69 years for women. Conclusion: The burden of disease due to AIDS in the city of Tubarao was relatively high when considering the global trend. The mortality component accounted for more than 90% of the burden of disease.

Reduction of morbidity in hepatosplenic Schistosomiasis mansoni after treatment with praziquantel: a long term study

Forty-two with hepatosplenic patients treated with praziquantel and followed up for 5 years. One half of the patients received a single 30 mg/kg dose and the other half, two doses of 25 mg/kg given 4 hrs apart. According to Hoffman and Kato-Katz stool exams, an 83.3% cure rate, was observed after twelve months. Stool egg counts in cases of incomplete cure were greatly reduced. Liver function, as assessed by serum levels of aspartate aminotransferase, alanine aminotransferase, gamma glutamyltransferase and alkaline phosphatase activities as well as albumin and gamma globulin showed marked improvement after one year. Hepatomegaly was reduced in 81.0% of patients and splenomegaly in 78.8%. Spleen regression was complete in 15.1% of the total, and in 18.5% of those with compensated hepatosplenic disease. As a result of these observations, the authors recomend early treatment with anti-schistosomal medication, either oxamniquine or praziquantel, to halt progression of disease and reduce splenomegaly.

Comparative clinical and ultrasound study of egg-negative and egg-positive individuals from Schistosoma mansoni low morbidity endemic areas, and hospitalized patients with hepatosplenic disease

Two hundred and twenty three subjects from a Schistosoma mansoni low morbidity endemic area and nine hospitalized hepatosplenic patients were submitted to stool test and clinical examination and abdomen ultrasound assessments. According to stool examination and ultrasound results, they were grouped as follows: G1 - 63 Schistosoma mansoni egg-negative individuals; G2 - 141 egg-positive patients and without evidence of periportal fibrosis; G3 - 19 egg-positive patients with periportal echogenicity (3-6mm); and G4 - 9 hepatosplenic patients with periportal echogenicity (> 6mm). Hepatomegaly detected by physical examination of the abdomen evaluated in the midclavicular line was verified in G1, G2 and G3, respectively, in 11.1, 12.1 and 26.3%. In G1, G2 and G3, periportal thickening occurred only in schistosomal patients (8.5%). Mild pathological alterations in patients that cannot yet be detected by clinical examination were detectable in the liver by ultrasound and can be due to fibrosis. The degree of mild periportal fibrosis was diminished in 57.9% of patients 12 months after treatment of schistosomiasis with oxamniquine. At ultrasonography, the mean liver left lobe measurement of G3 was larger than that of G1, and that of G4 larger than that of G1 and G2. The mean size of the spleen of G4 was significantly larger than that of the other three groups, and that of G3 larger than that of G1 and G2.

Morbidity due to Schistosoma mansoni - Entamoeba histolytica coinfection in hamsters (Mesocricetus auratus)

Data on Schistosoma mansoni-Entamoeba histolytica coinfection are scarce in the literature. In the present study, hamsters that had been infected for 70 days with Schistosoma mansoni (LE strain) were inoculated via the portal vein with two strains of trophozoites of Entamoeba histolytica: ICB-EGG (highly virulent) and ICB-RPS (non-virulent). The most evident result of coinfection was increased morbidity and mortality, in comparison with either of the infections alone. Histologically, there were no evident signs of interaction between these two infections. The morphological findings of schistosomal granuloma and amoebic abscesses in the liver were similar to those seen in the respective single-infection controls. However, there was severe wasting of the animals with both infections and greater numbers of amoebic lesions in their livers. The results obtained indicated that schistosomiasis aggravates the course of amoebiasis in hamsters.

In-house ELISA method to analyze anti-Trypanosoma cruzi IgG reactivity for differential diagnosis and evaluation of Chagas disease morbidity

INTRODUCTION: The goal was to develop an in-house serological method with high specificity and sensitivity for diagnosis and monitoring of Chagas disease morbidity. METHODS: With this purpose, the reactivities of anti-T. cruzi IgG and subclasses were tested in successive serum dilutions of patients from Berilo municipality, Jequitinhonha Valley, Minas Gerais, Brazil. The performance of the in-house ELISA was also evaluated in samples from other relevant infectious diseases, including HIV, hepatitis C (HCV), syphilis (SYP), visceral leishmaniasis (VL), and American tegumentary leishmaniasis (ATL), and noninfected controls (NI). Further analysis was performed to evaluate the applicability of this in-house methodology for monitoring Chagas disease morbidity into three groups of patients: indeterminate (IND), cardiac (CARD), and digestive/mixed (DIG/Mix), based on their clinical status. RESULTS: The analysis of total IgG reactivity at serum dilution 1:40 was an excellent approach to Chagas disease diagnosis (100% sensitivity and specificity). The analysis of IgG subclasses showed cross-reactivity, mainly with NI, VL, and ATL, at all selected serum dilutions. Based on the data analysis, the IND group displayed higher IgG3 levels and the DIG/Mix group presented higher levels of total IgG as compared with the IND and CARD groups. CONCLUSIONS: These findings demonstrated that methodology presents promising applicability in the analysis of anti-T. cruzi IgG reactivity for the differential diagnosis and evaluation of Chagas disease morbidity.