Assessment of integration of the leprosy program into primary health care in Aracaju, state of Sergipe, Brazil

INTRODUCTION: The aim of this study was to assess the epidemiological and operational characteristics of the Leprosy Program before and after its integration into the Primary healthcare Services of the municipality of Aracaju-Sergipe, Brazil. METHODS: Data were drawn from the national database. The study periods were divided into preintegration (1996-2000) and postintegration (2001-2007). Annual rates of epidemiological detection were calculated. Frequency data on clinico-epidemiological variables of cases detected and treated for the two periods were compared using the Chi-squared (χ2) test adopting a 5% level of significance. RESULTS: Rates of detection overall, and in subjects younger than 15 years, were greater for the postintegration period and were higher than rates recorded for Brazil as a whole during the same periods. A total of 780 and 1,469 cases were registered during the preintegration and postintegration periods, respectively. Observations for the postintegration period were as follows: I) a higher proportion of cases with disability grade assessed at diagnosis, with increase of 60.9% to 78.8% (p < 0.001), and at end of treatment, from 41.4% to 44.4% (p < 0.023); II) an increase in proportion of cases detected by contact examination, from 2.1% to 4.1% (p < 0.001); and III) a lower level of treatment default with a decrease from 5.64 to 3.35 (p < 0.008). Only 34% of cases registered from 2001 to 2007 were examined. CONCLUSIONS: The shift observed in rates of detection overall, and in subjects younger than 15 years, during the postintegration period indicate an increased level of health care access. The fall in number of patients abandoning treatment indicates greater adherence to treatment. However, previous shortcomings in key actions, pivotal to attaining the outcomes and impact envisaged for the program, persisted in the postintegration period.

Plasmodium falciparum infection in pregnant women attending antenatal care in Luanda, Angola

INTRODUCTION: Malaria during pregnancy remains a serious public health problem. The aim of this study was to establish the prevalence and possible risk factors for malaria in pregnant women attending antenatal care at Augusto Ngangula Specialized General Hospital in Luanda, Angola. METHODS: Pregnant women (679 total) who attended antenatal care from April to September 2008 were included in the study after signing informed consent. For each participant, the social-demographic profile and malaria and obstetric histories were investigated via a questionnaire. Diagnosis was made by optic microscopy, and hemoglobin concentration measured. The associations between age, parity, gestational age, residence, schooling, malaria during gravity, anemia and treatment with incidence of Plasmodium falciparum infection were analyzed through logistic regression. RESULTS: During the period of study, 74 (10.9%) out of 679 women were infected by P. falciparum. The average concentration of hemoglobin was 11.1 ± 0.07g/dL, and there were significant associations between the history of malaria during pregnancy, P. falciparum infection (p<0.01) and anemia at the time of observation (p<0.001). CONCLUSIONS: Previous history of malaria during pregnancy represents a risk factor for current infection and anemia was an important complication associated with malaria, even in women who were treated with sulfadoxine-pyrimethamine during pregnancy.

Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance

INTRODUCTION: This study aimed to determine the epidemiology of the three most common nosocomial infections (NI), namely, sepsis, pneumonia, and urinary tract infection (UTI), in a pediatric intensive care unit (PICU) in a developing country and to define the risk factors associated with NI. METHODS: We performed a prospective study on the incidence of NI in a single PICU, between August 2009 and August 2010. Active surveillance by National Healthcare Safety Network (NHSN) was conducted in the unit and children with NI (cases) were compared with a group (matched controls) in a case-control fashion. RESULTS: We analyzed 172 patients; 22.1% had NI, 71.1% of whom acquired it in the unit. The incidence densities of sepsis, pneumonia, and UTI per 1,000 patients/day were 17.9, 11.4, and 4.3, respectively. The most common agents in sepsis were Enterococcus faecalis and Escherichia coli (18% each); Staphylococcus epidermidis was isolated in 13% of cases. In pneumonias Staphylococcus aureus was the most common cause (3.2%), and in UTI the most frequent agents were yeasts (33.3%). The presence of NI was associated with a long period of hospitalization, use of invasive devices (central venous catheter, nasogastric tube), and use of antibiotics. The last two were independent factors for NI. CONCLUSIONS: The incidence of NI acquired in this unit was high and was associated with extrinsic factors.

Assessing the community needs of mental health residential care service users in Republic of Moldova

RESUMO: Background: Problemas de saúde mental são um grande problema clínico e social na República da Moldávia, representando uma quota significante de deficiência, sendo classificada no top cinco das dez linhas na hierarquia das condições. A taxa de incidência tem sido crescente na República da Moldávia, atingindo cerca de 15.000 por ano (14,655 em 2011), ou seja, 411,4 por 100 mil habitantes, e uma taxa de prevalência de 97.525 pessoas em 2011, ou seja, 2,737.9 por 100 mil habitantes. Sistema de atendimento psiquiátrico fornece serviços de saúde mental escassos a nível da comunidade, visando principalmente terapia hospitalar, centralizada, através de uma rede de três hospitais psiquiátricos, com 1.860 camas e 4 sanatórios psico- neurológicos com 1890 camas, assim alimentando-se a estigmatização do paciente. Objetivos: O objetivo deste estudo foi a avaliação das necessidades individuais dos beneficiários e do seu nível de autonomia dentro de cuidados residenciais, para o planeamento de reformas de saúde mental e desinstitucionalização na República da Moldávia. Este estudo foi encomendado pelo Ministério do Trabalho, Proteção Social e da Família e pelo Ministério da Saúde, com o apoio da Organização Mundial da Saúde, para determinar o cumprimento eficaz do artigo 19 da Convenção da ONU. O estudo tem os seguintes objetivos: Avaliar o nível de autonomia dos residentes nos hospitais psiquiátricos e sanatórios psico-neurológico, usando uma amostra representativa de 10 por ce nto do número total de pacientes/residentes e comparação cruzada; Para avaliar quatro sanatórios psico-neurológicos para adultos e três hospitais psiquiátricos; Para desenvolver recomendações para o planeamento da desinstitucionalização das pessoas com problemas de saúde mental e colocação na comunidade com base nos resultados do estudo. Metodologia e resultados: O estudo fez uso de duas ferramentas globais: questionário para a avaliação individual dos residentes do estabelecimento de saúde mental, e questionário de avaliação institucional. Todos os entrevistados foram divididos em quatro categorias conforme com o grau de dependência e preparação de viver de forma independente na comunidade. Apenas 1,2% dos entrevistados de PNHB eram totalmente dependentes de terceiros ou serviços especializados, tornando-se a categoria 4, que necessitam de cuidados e apoio contínuo. No PH esta categoria de pessoas é ausente. Conclusões: A condição dos entrevistados foi pior em PNBH que em PH. No entanto, ainda, aqueles que estão prontos para ser desinstitucionalizados correspondem com a maior parte dos entrevistados. Todos os hospitais tinham o consentimento do utente para admissão e tratamento, enquanto não houve consentimento qualquer em PNBH. É bastante óbvio que tanto os hospitais como também a sistema de assistência residencial não atingem a sua finalidade, o que significa que a maioria dos utentes pode ser desinstitucionalizados, sem qualquer terapia de suporte.------------------ABSTRACT: Background: Mental health problems are a major clinical and social issue in the Republic of Moldova,accounting for a significant share of disability and ranking in top five of the ten lines in the hierarchy of conditions. The incidence rate has been growing in the Republic of Moldova to reach approximately 15 thousand a year (14,655 in 2011), i.e. 411.4 per 100 thousand population, and a prevalence rate of 97,525 thousand people in 2011, i.e. 2,737.9 per 100 thousand population. Psychiatric care system provides for scanty mental health services at community level, aiming mainly at centralized hospital-based therapy through a network of three psychiatric hospitals tallying up 1,860 beds and 4 psycho-neurological boarding houses with 1,890 beds, thus fuelling up patient stigmatization. Objectives: The purpose of this study was to assess the individual needs of beneficiaries and their level of autonomy within residential care for the planning of mental health system reforms and deinstitutionalization in the Republic of Moldova. This study was commissioned by the Ministry of Labour, Social Protection and Family and by the Ministry of Health, with the World Health Organization support, to provide for effective enforcement of article 19 of the UN CRPD. The study pursued the following goals: To evaluate the level of autonomy of the psychiatric hospital and psycho-neurological boarding house residents by using a representative sample of 10 per cent of the total number of patients / residents and cross-comparison; To evaluate four psycho-neurological boarding houses for adults and three psychiatric hospitals; To develop recommendations for planning the deinstitutionalization of people with mental health problems and community placement based on the study findings.Methodology and results: The study made use of two global tools: questionnaire for individual assessment of mental health facility residents, and institutional assessment questionnaire. All interviewees were divided into four categories by one’s degree of dependence and readiness to live independently in the community. Only 1.2% of respondents from PNHB were fully dependent on a third party or specialized services, making up category 4, requiring continuous care and support. In PH this category of people is absent.Conclusions: The condition of respondents was worse in PNBH than in PH. However, yet, those ready to be deinstitutionalized accounted for most of respondents there. All hospitals had the resident’s consent to admission and treatment, whereas there was no consent in PNBH whatsoever. It is quite obvious that both the hospitals and residential care system do not achieve their intended purpose, meaning that the majority of residents may be deinstitutionalized without any support therapy.

Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Antimicrobial use, incidence, etiology and resistance patterns in bacteria causing ventilator-associated pneumonia in a clinical-surgical intensive care unit

INTRODUCTION : Antimicrobial resistance is an increasing threat in hospitalized patients, and inappropriate empirical antimicrobial therapy is known to adversely affect outcomes in ventilator-associated pneumonia (VAP). The aim of this study was to evaluate antimicrobial usage, incidence, etiology, and antimicrobial resistance trends for prominent nosocomial pathogens causing ventilator-associated pneumonia in a clinical-surgical intensive care unit (ICU). METHODS : Gram-negative bacilli and Staphylococcus aureus causing VAP, as well as their antimicrobial resistance patterns and data on consumption (defined daily dose [DDD] per 1,000 patient days) of glycopeptides, extended-spectrum cephalosporins, and carbapenems in the unit were evaluated in two different periods (A and B). RESULTS: Antimicrobial use was high, mainly of broad-spectrum cephalosporins, with a significant increase in the consumption of glycopeptides (p < 0.0001) and carbapenems (p < 0.007) in period B. For Acinetobacter baumannii and members of the Enterobacteriaceae family, 5.27- and 3.06-fold increases in VAPs, respectively, were noted, and a significant increase in resistance rates was found for imipenem-resistant A. baumannii (p = 0.003) and third-generation cephalosporins-resistant Enterobacteriaceae (p = 0.01) isolates in this same period. CONCLUSIONS: Our results suggest that there is a link between antibiotics usage at institutional levels and resistant bacteria. The use of carbapenems was related to the high rate of resistance in A. baumannii and therefore a high consumption of imipenem/meropenem could play a major role in selective pressure exerted by antibiotics in A. baumannii strains.

Invasive candidosis: contrasting the perceptions of infectious disease physicians and intensive care physicians

Introduction We analyze how infectious disease physicians perceive and manage invasive candidosis in Brazil, in comparison to intensive care unit specialists. Methods A 38-question survey was administered to 56 participants. Questions involved clinicians' perceptions of the epidemiology, diagnosis, treatment and prophylaxis of invasive candidosis. P < 0.05 was considered statistically significant. Results The perception that candidemia not caused by Candida albicans occurs in less than 10% of patients is more commonly held by intensive care unit specialists (p=0.018). Infectious disease physicians almost always use antifungal drugs in the treatment of patients with candidemia, and antifungal drugs are not as frequently prescribed by intensive care unit specialists (p=0.006). Infectious disease physicians often do not use voriconazole when a patient's antifungal treatment has failed with fluconazole, which also differs from the behavior of intensive care unit specialists (p=0.019). Many intensive care unit specialists use fluconazole to treat candidemia in neutropenic patients previously exposed to fluconazole, in contrast to infectious disease physicians (p=0.024). Infectious disease physicians prefer echinocandins as a first choice in the treatment of unstable neutropenic patients more frequently than intensive care unit specialists (p=0.013). When candidemia is diagnosed, most infectious disease physicians perform fundoscopy (p=0.015), whereas intensive care unit specialists usually perform echocardiograms on all patients (p=0.054). Conclusions This study reveals a need to better educate physicians in Brazil regarding invasive candidosis. The appropriate management of this disease depends on more drug options being available in our country in addition to global coverage in private and public hospitals, thereby improving health care.

Late diagnosis and HIV infection in children attending a service of specialized care for pediatric AIDS in Brazil

Introduction: This study describes the frequency of late diagnosis and HIV among children attending a pediatric AIDS clinic. Methods: Cross-sectional study in children exposed to HIV from 2005-2008. A questionnaire was given that included questions on demographics and clinical information. Results: Two-hundred twenty-one (97.8%) children were exposed to HIV during pregnancy/childbirth. A total of 193 (87.3%) children had late enrolment in the service and late access to HIV serology. The frequency of HIV was 21.3% (95% confidence interval [CI] 15.9%-26.7%). Protective factors were earlier diagnosis [odds ratio (OR)=0.17 (0.08-0.37)] and receiving complete prophylaxis [OR=0.29 (0.09-0.97)]; being born by vaginal delivery was a risk factor [OR=4.45 (1.47-13.47)]. Conclusions: There was a high frequency of late diagnosis in this patient cohort. Earlier diagnosis is an important measure for controlling HIV among children.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Nosocomial infections in a neonatal intensive care unit during 16 years: 1997-2012

Introduction Surveillance of nosocomial infections (NIs) is an essential part of quality patient care; however, there are few reports of National Healthcare Safety Network (NHSN) surveillance in neonatal intensive care units (NICUs) and none in developing countries. The purpose of this study was to report the incidence of NIs, causative organisms, and antimicrobial susceptibility patterns in a large cohort of neonates admitted to the NICU during a 16-year period. Methods The patients were followed 5 times per week from birth to discharge or death, and epidemiological surveillance was conducted according to the NHSN. Results From January 1997 to December 2012, 4,615 neonates, representing 62,412 patient-days, were admitted to the NICU. The device-associated infection rates were as follows: 17.3 primary bloodstream infections per 1,000 central line-days and 3.2 pneumonia infections per 1,000 ventilator-days. A total of 1,182 microorganisms were isolated from sterile body site cultures in 902 neonates. Coagulase-negative staphylococci (CoNS) (34.3%) and Staphylococcus aureus (15.6%) were the most common etiologic agents isolated from cultures. The incidences of oxacillin-resistant CoNS and Staphylococcus aureus were 86.4% and 28.3%, respectively. Conclusions The most important NI remains bloodstream infection with staphylococci as the predominant pathogens, observed at much higher rates than those reported in the literature. Multiresistant microorganisms, especially oxacillin-resistant staphylococci and gram-negative bacilli resistant to cephalosporin were frequently found. Furthermore, by promoting strict hygiene measures and meticulous care of the infected infants, the process itself of evaluating the causative organisms was valuable.

Illness perception, knowledge and self-care about cervical cancer

Prevention plays a central role in early detection of cervical cancer. Common Sense Model proposes that the nature and organization of illness representations can guide actions related to health and how self-care is exercised. The aim of this study was to describe and compare illness perception, knowledge and self-care in women with and without cancer precursor lesions. Participants were 92 women (aged 18-59) from primary care unity divided into two groups: women with and without premalignant lesion. Measures for illness perception, knowledge and self-care were used. There was no statistically signifi cant difference (t test e chi-square test) between groups in the variables analyzed. Despite the risk for cervical cancer, women with precursor lesions do not adjust their illness perceptions, knowledge and self-care to the situation. These data show the need to warn women against the cervical cancer risks, because their distorted perceptions and lack of knowledge about the disease may hamper the screening and control of cervical cancer.

Evaluation of the predictive indices for candidemia in an adult intensive care unit

INTRODUCTION: To evaluate predictive indices for candidemia in an adult intensive care unit (ICU) and to propose a new index. METHODS: A prospective cohort study was conducted between January 2011 and December 2012. This study was performed in an ICU in a tertiary care hospital at a public university and included 114 patients staying in the adult ICU for at least 48 hours. The association of patient variables with candidemia was analyzed. RESULTS: There were 18 (15.8%) proven cases of candidemia and 96 (84.2%) cases without candidemia. Univariate analysis revealed the following risk factors: parenteral nutrition, severe sepsis, surgical procedure, dialysis, pancreatitis, acute renal failure, and an APACHE II score higher than 20. For the Candida score index, the odds ratio was 8.50 (95% CI, 2.57 to 28.09); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.78, 0.71, 0.33, and 0.94, respectively. With respect to the clinical predictor index, the odds ratio was 9.45 (95%CI, 2.06 to 43.39); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.89, 0.54, 0.27, and 0.96, respectively. The proposed candidemia index cutoff was 8.5; the sensitivity, specificity, positive predictive value, and negative predictive value were 0.77, 0.70, 0.33, and 0.94, respectively. CONCLUSIONS: The Candida score and clinical predictor index excluded candidemia satisfactorily. The effectiveness of the candidemia index was comparable to that of the Candida score.

Opportunistic infections among individuals with HIV-1/AIDS in the highly active antiretroviral therapy era at a Quaternary Level Care Teaching Hospital

INTRODUCTION : In this study, clinical-laboratory and epidemiological characteristics are described for a group of 700 individuals with HIV (human immunodeficiency virus)/AIDS (acquired immunodeficiency syndrome) in the ART (antiretroviral therapy) era at a teaching hospital that provides a quaternary level of care, with an emphasis on opportunistic infections (OIs), co-infections and immune profile. METHODS : A retrospective cross-sectional study of AIDS cases was conducted from 1998 to 2008 by reviewing medical records from the Base Hospital/FUNFARME (Fundação Faculdade Regional de Medicina), São José do Rio Preto, São Paulo, Brazil. RESULTS: The individuals were 14 to 75 years of age, and 458 were males. Heterosexuals accounted for 31.1% of all patients. Eighty-three percent were on ART, and 33.8% of those presented difficulties with treatment adherence. OIs were analyzed from medical records, and Pneumocystis jiroveci pneumonia was the most prevalent, regardless of the LTCD4+ (TCD4+ Lymphocytes) levels. Individuals whose viral loads were ≥10,000 showed a 90% greater chance of neurotoxoplasmosis. For P. jiroveci pneumonia, neurotoxoplasmosis, esophageal candidiasis, pulmonary tuberculosis and neurocryptococcosis, the chances of infection were higher among patients with LTCD4+ levels below 200 cells/mm3. HIV/hepatitis C virus (HCV) and HIV/hepatitis B virus (HBV) co-infections were significantly associated with death. CONCLUSIONS : OIs remain frequent in the ART era even in populations where the access to medical care is considered satisfactory.

Estimating demand for primary health care services

Primary health services exist with the purpose of providing basic health care to every person at a cost they can afford. But is it fully available to everyone? The objective of this work project is to estimate the demand for primary health care services having into account that in some regions the citizens are not using as much health care as they would like due to supply side constraints. Using the number of consultations as proxy for demand, and applying an econometric tool called switching regression, the demand for primary health care services will be estimated.

Secular trends in Klebsiella pneumoniae isolated in a tertiary-care hospital: increasing prevalence and accelerated decline in antimicrobial susceptibility

Abstract: INTRODUCTION Klebsiella pneumoniae has become an increasingly important etiologic agent of nosocomial infections in recent years. This is mainly due to the expression of virulence factors and development of resistance to several antimicrobial drugs. METHODS This retrospective study examines data obtained from the microbiology laboratory of a Brazilian tertiary-care hospital. To assess temporal trends in prevalence and antimicrobial susceptibility, K. pneumoniae isolates were analyzed from 2000 to 2013. The relative frequencies of K. pneumoniae isolation were calculated among all Gram-negative bacilli isolated in each period analyzed. Susceptibility tests were performed using automated systems. RESULTS: From 2000-2006, K. pneumonia isolates comprised 10.7% of isolated Gram-negative bacilli (455/4260). From 2007-2013, this percentage was 18.1% (965/5331). Strictly considering isolates from bloodstream infections, the relative annual prevalence of K. pneumoniae increased from 14-17% to 27-32% during the same periods. A progressive decrease in K. pneumoniae susceptibility to all antimicrobial agents assessed was detected. Partial resistance was also observed to antimicrobial drugs that have been used more recently, such as colistin and tigecycline. CONCLUSIONS Our study indicates that K. pneumoniae has become a major pathogen among hospitalized patients and confirms its recent trend of increasing antimicrobial resistance.