Predictors of Lethality in Severe Leptospirosis in Urban Brazil

To ascertain prognostic factors associated with fatal outcomes in severe leptospirosis, a retrospective case-control study was done using population-based surveillance data. Centralized death certificate reporting of leptospirosis mortality was combined with details of patients` hospitalizations, which were obtained from hospitals representing all sectors of Sao Paulo city. Among identified leptospirosis cases, 89 lethal cases and 281 survivor cases were analyzed. Predictors of death included age > 40 years, development of oliguria, platelet count < 70,000/mu L, creatinine > 3 mg/dL. and pulmonary involvement. The latter was the strongest risk Factor with all estimated odds ratio of 6.0 (95% confidence interval: 3.0-12.0). Serologic findings with highest titer against Leptospira interrogans serovar Copenhageni did not show significant differences between survivors and non-survivors. Lung involvement was an important predictor of death in leptospirosis in Sao Paulo, of relevance in leptospirosis-endemic regions where this complication is common.

Long-Term Prospective, Randomized, Controlled Study Using Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure Outpatients The REMADHE Trial

Background-The effectiveness of heart failure disease management proarams in patients under cardiologists` care over long-term follow-up is not established. Methods and Results-We investigated the effects of a disease management program with repetitive education and telephone monitoring on primary (combined death or unplanned first hospitalization and quality-of-life changes) and secondary end points (hospitalization, death, and adherence). The REMADHE [Repetitive Education and Monitoring for ADherence for Heart Failure] trial is a long-term randomized, prospective, parallel trial designed to compare intervention with control. One hundred seventeen patients were randomized to usual care, and 233 to additional intervention. The mean follow-up was 2.47 +/- 1.75 years, with 54% adherence to the program. In the intervention group, the primary end point composite of death or unplanned hospitalization was reduced (hazard ratio, 0.64; confidence interval, 0.43 to 0.88; P=0.008), driven by reduction in hospitalization. The quality-of-life questionnaire score improved only in the intervention group (P<0.003). Mortality was similar in both groups. Number of hospitalizations (1.3 +/- 1.7 versus 0.8 +/- 1.3, P<0.0001), total hospital days during the follow-up (19.9 +/- 51 versus 11.1 +/- 24 days, P<0.0001), and the need for emergency visits (4.5 +/- 10.6 versus 1.6 +/- 2.4, P<0.0001) were lower in the intervention group. Beneficial effects were homogeneous for sex, race, diabetes and no diabetes, age, functional class, and etiology. Conclusions-For a longer follow-up period than in previous studies, this heart failure disease management program model of patients under the supervision of a cardiologist is associated with a reduction in unplanned hospitalization, a reduction of total hospital days, and a reduced need for emergency care, as well as improved quality of life, despite modest program adherence over time. (Circ Heart Fail. 2008;1:115-124.)

Depression: a predictor of smoking relapse in a 6-month follow-up after hospitalization for acute coronary syndrome

Objective The objective of the study was to investigate whether depression is a predictor of postdischarge smoking relapse among patients hospitalized for myocardial infarction (MI) or unstable angina (ILIA), in a smoke-free hospital. Methods Current smokers with MI or UA were interviewed while hospitalized; patients classified with major depression (MD) or no humor disorder were reinterviewed 6 months post discharge to ascertain smoking status. Potential predictors of relapse (depression; stress; anxiety; heart disease risk perception; coffee and alcohol consumption; sociodemographic, clinical, and smoking habit characteristics) were compared between those with MD (n = 268) and no humor disorder (n = 135). Results Relapsers (40.4%) were more frequently and more severely depressed, had higher anxiety and lower self-efficacy scale scores, diagnosis of UA, shorter hospitalizations, started smoking younger, made fewer attempts to quit, had a consort less often, and were more frequently at the `precontemplation` stage of change. Multivariate analysis showed relapse-positive predictors to be MD [odds ratio (OR): 2.549; 95% confidence interval (CI): 1.519-4.275] (P<0.001); `precontemplation` stage of change (OR: 7.798; 95% CI: 2.442-24.898) (P<0.001); previous coronary bypass graft surgery (OR: 4.062; 95% CI: 1.356-12.169) (P=0.012); and previous anxiolytic use (OR: 2.365; 95% CI: 1.095-5.107) (P=0.028). Negative predictors were diagnosis of MI (OR: 0.575; 95% CI: 0.361-0.916) (P=0.019); duration of hospitalization (OR: 0.935; 95% CI: 0.898-0.973) (P=0.001); smoking onset age (OR: 0.952; 95% CI: 0.910-0.994) (P=0.028); number of attempts to quit smoking (OR: 0.808; 95% CI: 0.678-0.964) (P=0.018); and `action` stage of change (OR: 0.065; 95% CI: 0.008-0.532) (P= 0.010). Conclusion Depression, no motivation, shorter hospitalization, and severity of illness contributed to postdischarge resumption of smoking by patients with acute coronary syndrome, who underwent hospital-initiated smoking cessation.

Rotavirus morbidity and mortality in children in Brazil

Objective. To study the epidemiology of rotavirus and estimate rotavirus- associated morbidity and mortality in children <= 5 years of age in Brazil in 2004 before introducing the rotavirus vaccine in Brazil`s National Immunization Program ( Programa Nacional de Imunizacoes, PNI). Methods. To estimate rotavirus morbidity, published studies ( 1999 - 2006) addressing incidence of acute diarrhea among children <= 5 years of age and frequency of rotavirus infection among children with diarrhea in Brazil were reviewed. Diarrhea episodes were divided into three categories of severity by level of care: mild cases requiring only home- based care; moderate cases requiring a visit to an outpatient healthcare facility; and severe cases requiring hospitalization. To estimate rotavirus mortality, information on the number of registered deaths from diarrhea in children <= 5 years of age was obtained from the Mortality Information System ( Sistema de Informacao, sobre Mortalidade, SIM) of Brazil`s public healthcare system ( Sistema Unico de Sa de, SUS) and the proportion of deaths due to rotavirus was calculated. Results. Rotavirus infections were estimated to cause 3 525 053 episodes of diarrhea, 655 853 visits to outpatient healthcare facilities, 92 453 hospitalizations, and 850 deaths of children <= 5 years of age each year in Brazil. Conclusion. Rotavirus infections are an important cause of child morbidity and mortality in Brazil.

Adverse Drug Reactions and Drug Interactions as Causes of Hospital Admission in Oncology

Context. Although several studies have evaluated the frequency of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) in general medicine, few studies have looked at the epidemiology of adverse drug events (ADEs) in oncology. Objectives. We sought to investigate how many hospital admissions in oncology are related to a DDI or an ADR. Methods. All cancer patients admitted to an oncology ward during an eight-month period had their charts retrospectively evaluated for reasons of hospitalization, using a 4-point scale (definitely, probably, possibly, or unlikely associated) to classify admissions by their probability of being associated with either a DDI or an ADR. Results. From September 2007 to May 2008, there were 550 hospital admissions and 458 were eligible. Among unplanned admissions (n = 298), 39 (13.0%, 95% confidence interval [CI] 9.4%-17.4%) were considered to be associated with an ADE, 33 (11.0%, 95% CI 7.7%-15.2%) with an ADR, and six (2.0%, 95% CI 0.7%-4.3%) with a DDI. The most common DDIs involved warfarin, captopril, and anti-inflammatory agents, and the most frequent ADR was neutropenic fever post-chemotherapy. Most patients were discharged completely recovered, but two patients died. Conclusion. Approximately one in 10 unplanned hospitalizations of cancer patients is associated with an ADE. Prospective and population-based studies are warranted to evaluate their magnitude in oncology. J Pain Symptom Manage 2011;42:342-353. (C) 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Lower respiratory tract infections among human immunodeficiency virus-exposed, uninfected infants

Objectives: To evaluate whether maternal HIV disease severity during pregnancy is associated with an increased likelihood of lower respiratory tract infections (LRTIs) in HIV-exposed, uninfected infants. Methods: HIV-exposed, uninfected, singleton, term infants enrolled in the NISDI Perinatal Study, with birth weight >2500 g were followed from birth until 6 months of age. LRTI diagnoses, hospitalizations, and associated factors were assessed. Results: Of 547 infants, 103 (18.8%) experienced 116 episodes of LRTI (incidence = 0.84 LRTIs/100 child-weeks). Most (81%) episodes were bronchiolitis. Forty-nine (9.0%) infants were hospitalized at least once with an LRTI. There were 53 hospitalizations (45.7%) for 116 LRTI episodes. None of these infants were breastfed. The odds of LRTI in infants whose mothers had CD4% <14 at enrollment were 4.4 times those of infants whose mothers had CD4% >= 29 (p = 0.003). The odds of LRTI in infants with a CD4+ count (cells/ mm(3)) <750 at hospital discharge were 16.0 times those of infants with CD4+ >= 750 (p = 0.002). Maternal CD4+ decline and infant hemoglobin at the 6-12 week visit were associated with infant LRTIs after 6-12 weeks and before 6 months of age. Conclusions: Acute bronchiolitis is common and frequently severe among HIV-exposed, uninfected infants aged 6 months or less. Lower maternal and infant CD4+ values were associated with a higher risk of infant LRTIs. Further understanding of the immunological mechanisms of severe LRTIs is needed. (C) 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Detection of human respiratory syncytial virus in respiratory samples by LightCycler reverse transcriptase PCR

Laboratory diagnosis of human respiratory syncytial virus (hRSV) infections has traditionally been performed by virus isolation in cell culture and the direct fluorescent-antibody assay (DFA). Reverse transcriptase PCR (RT-PCR) is now recognized as a sensitive and specific alternative for detection of hRSV in respiratory samples. Using the LightCycler instrument, we developed a rapid RT-PCR assay for the detection of hRSV (the LC-RT-PCR) with a pair of hybridization probes that target the hRSV L gene. In the present study, 190 nasopharyngeal aspirate samples from patients with clinically recognized respiratory tract infections were examined for hRSV. The results were then compared to the results obtained with a testing algorithm that combined DFA and a culture-augmented DFA (CA-DFA) assay developed in our laboratory. hRSV was detected in 77 (41%) specimens by LC-RT-PCR and in 75 (39%) specimens by the combination of DFA and CA-DFA. All specimens that were positive by the DFA and CA-DFA testing algorithm were positive by the LC-RT-PCR. The presence of hRSV RNA in the two additional LC-RT-PCR-positive specimens was confirmed by a conventional RT-PCR method that targets the hRSV N gene. The sensitivity of LC-RT-PCR was 50 PFU/ml; and this, together with its high specificity and rapid turnaround time, makes the LC-RT-PCR suitable for the detection of hRSV in clinical specimens.

Segurança alimentar nos refeitórios de uma universidade portuguesa : aplicação da teoria do comportamento planeado

A Organização Mundial de Saúde estima que nos países mais industrializados uma em cada três pessoas sofra, por ano, de uma doença de origem alimentar. De acordo com os dados da Agência Europeia para a Segurança Alimentar foram relatados pelos 27 Estados Membros da União Europeia, no ano 2012, um total de 5.363 surtos de origem alimentar, assistindo-se a uma prevalência do setor da restauração, como o local de maior ocorrência dos surtos de doenças de origem alimentar. Para o mesmo ano, Portugal reportou 7 surtos de origem alimentar, envolvendo 135 pessoas com 42 hospitalizações. Neste contexto, a aplicação de boas práticas de higiene, nomeadamente no setor da restauração, é essencial para proteger o consumidor das doenças de origem alimentar. Neste estudo, pretendeu-se identificar os constructos do modelo da Teoria do Comportamento Planeado (Theory of Planned Behaviour – TPB, segundo a terminologia anglo-saxónica), de Icek Ajzen, que melhor explicam a intenção dos operadores de alimentos em adotarem os comportamentos de higiene, a saber: i) utilização de luvas e touca de proteção de cabelos, e ii) remoção de adornos pessoais, durante a manipulação de alimentos. Para o efeito, foi aplicado um questionário tendo por base a Teoria do Comportamento Planeado, a uma amostra de cento e vinte e três operadores dos vários refeitórios de uma universidade portuguesa, na sua grande maioria do sexo feminino (91,1%) e que manipulam alimentos numa base diária, recorrendo-se primeiramente a uma fase preliminar de estudo qualitativo, ou pré-inquérito, para melhor selecionar os temas essenciais e as principais categorias a considerar na construção deste inquérito. Os inquéritos foram tratados estatisticamente recorrendo-se à estatística descritiva, à análise fatorial e avaliação da consistência interna dos fatores resultantes, seguido da aplicação de regressão linear e metodologia de análise de trajetórias (path modeling) com vista à validação do TPB. Os resultados obtidos apontam para o fato de a Atitude ser o melhor preditor da Intenção em adotar os comportamentos em estudo. Verificou-se também que a motivação de cumprir resulta da pressão exercida pelos superiores hierárquicos ou colegas, influenciando positivamente a intenção, na medida em que as crenças normativas assumiram-se como sendo o segundo preditor que melhor previu a intenção.

Poverty levels and children's health status: study of risk factors in an urban population of low socioeconomic level

To test the hypothesis that the low socioeconomic population living is shanty towns in Porto Alegre presents different levels of poverty which are reflected on its health status, a cross-sectional study was designed involving 477 families living in Vila Grande Cruzeiro, Porto Alegre, Brazil. The poverty level of the families was measured by using an instrument specifically designed for poor urban populations. Children from families living in extreme poverty (poorest quartile) were found to have higher infant mortality rate, lower birth weights, more hospitalizations, and higher malnutrition rates, in addition to belonging to more numerous families. Thus, the shanty town population of Porto Alegre is not homogeneous, and priority should be given to the more vulnerable subgroups.

Quality of life in dilated cardiomyopathy with refractory chronic heart failure undergoing devices implantation

Heart failure is the final stage of most of cardiac diseases. It is a complex syndrome in which the patients should have the following features: symptoms of heart failure, typically shortness of breath at rest or during exertion, and/or fatigue; signs of fluid retention such as pulmonary congestion or ankle swelling; and objective evidence of an abnormality of the structure or function of the heart at rest. This progressive syndrome as a high incidence and prevalence and poor prognosis: four-year mortality is around 50% with 40% of the patients admitted to hospital dying or readmitted within a year. With ageing, many patients will develop chronic heart failure, which, because of its symptoms, patient’s awareness of their risk of dying, and the effects of therapy, together with frequent hospitalizations, has considerable impact on patient’s health-related quality of life.

Avaliação da atividade anti-hRSV da quercetina e seus derivados acetilados

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Infância Institucionalizada: Narrativas das crianças sobre o antes, o durante e o pós alta hospitalar

Dissertação apresentada à Escola Superior de Educação de Lisboa para a obtenção do grau de Mestre em Ciências da Educação, especialização em Educação Social e Intervenção Comunitária

Hospitalization rates for pneumococcal disease in Brazil, 2004 - 2006

OBJECTIVE: To estimate hospitalization rates for pneumococcal disease based on the Brazilian Hospital Information System (SIH). METHODS: Descriptive study based on the Hospital Information System of Brazilian National Health System data from January 2004 to December 2006: number of hospitalizations and deaths for pneumococcal meningitis, pneumococcal sepsis, pneumococcal pneumonia and Streptococcus pneumoniae as the cause of diseases reported in Brazil. Data from the 2003 Brazilian National Household Survey were used to estimate events in the private sector. Pneumococcal meningitis cases and deaths reported to the Notifiable Diseases Information System during the study period were also analyzed. RESULTS: Pneumococcal disease accounted for 34,217 hospitalizations in the Brazilian National Health System (0.1% of all hospitalizations in the public sector). Pneumococcal pneumonia accounted for 64.8% of these hospitalizations. The age distribution of the estimated hospitalization rates for pneumococcal disease showed a "U"-shape curve with the highest rates seen in children under one (110 to 136.9 per 100,000 children annually). The highest hospital case-fatality rates were seen among the elderly, and for sepsis and meningitis. CONCLUSIONS: PD is a major public health problem in Brazil. The analysis based on the SIH can provide an important input to pneumococcal disease surveillance and the impact assessment of immunization programs.

Depressive symptoms in institutionalized older adults

OBJECTIVE To estimate the prevalence of depressive symptoms among institutionalized elderly individuals and to analyze factors associated with this condition. METHODS This was a cross-sectional study involving 462 individuals aged 60 or older, residents in long stay institutions in four Brazilian municipalities. The dependent variable was assessed using the 15-item Geriatric Depression Scale. Poisson’s regression was used to evaluate associations with co-variables. We investigated which variables were most relevant in terms of presence of depressive symptoms within the studied context through factor analysis. RESULTS Prevalence of depressive symptoms was 48.7%. The variables associated with depressive symptoms were: regular/bad/very bad self-rated health; comorbidities; hospitalizations; and lack of friends in the institution. Five components accounted for 49.2% of total variance of the sample: functioning, social support, sensory deficiency, institutionalization and health conditions. In the factor analysis, functionality and social support were the components which explained a large part of observed variance. CONCLUSIONS A high prevalence of depressive symptoms, with significant variation in distribution, was observed. Such results emphasize the importance of health conditions and functioning for institutionalized older individuals developing depression. They also point to the importance of providing opportunities for interaction among institutionalized individuals.

Disability in instrumental activities of daily living among older adults: gender differences

OBJECTIVE To analyze gender differences in the incidence and determinants of disability regarding instrumental activities of daily living among older adults. METHODS The data were extracted from the Saúde, Bem-Estar e Envelhecimento (SABE – Health, Wellbeing and Ageing) study. In 2000, 1,034 older adults without difficulty in regarding instrumental activities of daily living were selected. The following characteristics were evaluated at the baseline: sociodemographic and behavioral variables, health status, falls, fractures, hospitalizations, depressive symptoms, cognition, strength, mobility, balance and perception of vision and hearing. Instrumental activities of daily living such as shopping and managing own money and medication, using transportation and using the telephone were reassessed in 2006, with incident cases of disability considered as the outcome. RESULTS The incidence density of disability in instrumental activities of daily living was 44.7/1,000 person/years for women and 25.2/1,000 person/years for men. The incidence rate ratio between women and men was 1.77 (95%CI 1.75;1.80). After controlling for socioeconomic status and clinical conditions, the incidence rate ratio was 1.81 (95%CI 1.77;1.84), demonstrating that women with chronic disease and greater social vulnerability have a greater incidence density of disability in instrumental activities of daily living. The following were determinants of the incidence of disability: age ≥ 80 and worse perception of hearing in both genders; stroke in men; and being aged 70 to 79 in women. Better cognitive performance was a protective factor in both genders and better balance was a protective factor in women. CONCLUSIONS The higher incidence density of disability in older women remained even after controlling for adverse social and clinical conditions. In addition to age, poorer cognitive performance and conditions that adversely affect communication disable both genders. Acute events, such as a stroke, disables elderly men more, whereas early deficits regarding balance disable women more.