Sucesso terapêutico no controlo da tuberculose em Portugal : determinantes do resultado do tratamento e a sua capacidade preditiva

RESUMO - Enquadramento/objectivos: Apesar do elevado nível de comprometimento em estratégias eficazes para o controlo da tuberculose, em todo o mundo, esta constitui ainda um sério problema de Saúde Pública, com uma estimativa global de 9,4milhões de casos novos em 2008 e 1,8milhões de mortes/ano. O reduzido conhecimento das barreiras e facilitadores para o sucesso terapêutico constitui um importante obstáculo na procura de soluções eficazes de melhoramento da qualidade dos programas de controlo da tuberculose. Este estudo procura contribuir para a identificação atempada de doentes com perfis preditivos de insucesso terapêutico, através da identificação inicial de potenciais determinantes do resultado, com base num modelo epidemiológico e estatístico. Métodos: Foi desenvolvido um estudo de caso-controlo para a população de casos notificados ao Programa Nacional de Controlo da Tuberculose (n=24491), entre 2000-2007. Os factores preditivos de insucesso terapêutico foram identificados na análise bivariada e multivariada, com um nível de significância de 5%; a regressão logística foi utilizada para estimar a odds ratio de insucesso terapêutico, em comparação com o sucesso terapêutico, para diversos factores identificados na literatura, e para os quais os dados se encontravam disponíveis. Resultados: A dependência alcoólica (OR=2,889), o país de origem (OR=3,910), a situação sem-abrigo (OR=3.919), a co-infecção pelo VIH (OR=5,173), a interrupção (OR=60.615) ou falha terapêutica no tratamento anterior (OR=67.345) e a duração do tratamento inferior a 165 dias (OR=1930,133) foram identificados como factores preditivos de insucesso terapêutico. A duração do tratamento inferior a 165 dias provou ser o mais importante determinante do resultado terapêutico. Conclusões: Os resultados sugerem que um doente imigrante, em situação de sem-abrigo, dependente alcoólico, com tratamentos anteriores para a tuberculose e co-infectado pelo VIH apresenta uma elevada probabilidade de insucesso terapêutico. Assim, deverão ser definidas estratégias específicas, centradas no doente por forma a impedir este resultado. A base de dados (SVIG-TB), provou ser uma ferramenta de qualidade para a investigação sobre diversos aspectos do controlo da tuberculose. ------------------------------- ABSTRACT - Background/Objective: Despite the high commitment in good strategies for tuberculosis control worldwide, this is still a serious Public Health problem, with global estimates of 9,4million new cases in 2008 and 1,8million deaths/year. The poor understanding of the barriers and facilitators to treatment success is a major obstacle to find effective solutions to improve the quality of tuberculosis programs. This study tries to contribute to the timely identification of patients with predictive profiles of unsuccessful treatment outcomes, through the initial identification of characteristics probably affecting treatment outcome, found on the basis of an epidemiological and statistical model. Methods: A case-control study was conducted for the population of cases notified to the National Program for Tuberculosis Control (n=24 491), between 2000-2007. Predictive factors for unsuccessful outcome were assessed in a bivariate and multivariate analysis, using a significance level of 5%; a logistic regression was used to estimate the odds-ratio of unsuccessful, as compared to successful outcome, for several factors identified in the literature and to which data was available. Results: Alcohol abuse (OR=2,889), patient´s foreign origin (OR=3,910), homelessness (OR=3,919), HIV co-infection (OR=5,173), interruption (OR=60,615) or unsuccessful outcome in the previous treatment (OR=67,345) and treatment duration below 165 days (OR=1930,133) were identified as predictive of unsuccessful outcomes. A low treatment duration proved to be the most powerful factor affecting treatment outcome. Conclusions: Results suggest that a foreign-born patient, alcohol abuser, who has had a previous treatment for tuberculosis and is co-infected with HIV is very likely to have an unsuccessful outcome. Therefore, specific, patient-centered strategies should be taken to prevent an unsuccessful outcome. The database (SVIG-TB), has proved to be a quality tool on research of various aspects of tuberculosis control.

Age-related seroprevalence study for St. Louis encephalitis in a population from Cordoba, Argentina

A serological screening was performed in 615 individuals aged 0-87 years, living in the city of Cordoba, Argentina to study the relationship between antibody prevalence for the SLE virus and age. A 13.98% prevalence of neutralizing antibodies was obtained and its relation to age was significantly high (p = 0.045). The highest seroprevalence was noted on individuals over 60 years old (>20%), whereas no subject under 10 was seropositive for this virus. Our results confirm that the agent is endemic in this area and neurological pathology studies should be performed on those individuals aged 60 since they represent the most susceptible group to SLE virus.

A framework for using real data with distributed low cost sensors

Currently, due to the widespread use of computers and the internet, students are trading libraries for the World Wide Web and laboratories with simulation programs. In most courses, simulators are made available to students and can be used to proof theoretical results or to test a developing hardware/product. Although this is an interesting solution: low cost, easy and fast way to perform some courses work, it has indeed major disadvantages. As everything is currently being done with/in a computer, the students are loosing the “feel” of the real values of the magnitudes. For instance in engineering studies, and mainly in the first years, students need to learn electronics, algorithmic, mathematics and physics. All of these areas can use numerical analysis software, simulation software or spreadsheets and in the majority of the cases data used is either simulated or random numbers, but real data could be used instead. For example, if a course uses numerical analysis software and needs a dataset, the students can learn to manipulate arrays. Also, when using the spreadsheets to build graphics, instead of using a random table, students could use a real dataset based, for instance, in the room temperature and its variation across the day. In this work we present a framework which uses a simple interface allowing it to be used by different courses where the computers are the teaching/learning process in order to give a more realistic feeling to students by using real data. A framework is proposed based on a set of low cost sensors for different physical magnitudes, e.g. temperature, light, wind speed, which are connected to a central server, that the students have access with an Ethernet protocol or are connected directly to the student computer/laptop. These sensors use the communication ports available such as: serial ports, parallel ports, Ethernet or Universal Serial Bus (USB). Since a central server is used, the students are encouraged to use sensor values results in their different courses and consequently in different types of software such as: numerical analysis tools, spreadsheets or simply inside any programming language when a dataset is needed. In order to do this, small pieces of hardware were developed containing at least one sensor using different types of computer communication. As long as the sensors are attached in a server connected to the internet, these tools can also be shared between different schools. This allows sensors that aren't available in a determined school to be used by getting the values from other places that are sharing them. Another remark is that students in the more advanced years and (theoretically) more know how, can use the courses that have some affinities with electronic development to build new sensor pieces and expand the framework further. The final solution provided is very interesting, low cost, simple to develop, allowing flexibility of resources by using the same materials in several courses bringing real world data into the students computer works.

Standard commercial education robotic platform: intermediate solution to teaching robotics

Teaching robotics to students at the beginning of their studies has become a huge challenge. Simulation environments can be an effective solution to that challenge where students can interact with simulated robots and have the first contact with robotic constraints. From our previous experience with simulation environments it was possible to observe that students with lower background knowledge in robotics where able to deal with a limited number of constraints, implement a simulated robotic platform and study several sensors. The question is: after this first phase what should be the best approach? Should the student start developing their own hardware? Hardware development is a very important part of an engineer's education but it can also be a difficult phase that could lead to discouragement and loss of motivation in some students. Considering the previous constraints and first year engineering students’ high abandonment rate it is important to develop teaching strategies to deal with this problem in a feasible way. The solution that we propose is the integration of a low-cost standard robotic platform WowWee Rovio as an intermediate solution between the simulation phase and the stage where the students can develop their own robots. This approach will allow the students to keep working in robotic areas such as: cooperative behaviour, perception, navigation and data fusion. The propose approach proved to be a motivation step not only for the students but also for the teachers. Students and teachers were able to reach an agreement between the level of demand imposed by the teachers and satisfaction/motivation of the students.

Predictive Variables Affecting Transfusion Requirements in Orthotopic Liver Transplantation

INTRODUCTION AND AIMS: Adult orthotopic liver transplantation (OLT) is associated with considerable blood product requirements. The aim of this study was to assess the ability of preoperative information to predict intraoperative red blood cell (RBC) transfusion requirements among adult liver recipients. METHODS: Preoperative variables with previously demonstrated relationships to intraoperative RBC transfusion were identified from the literature: sex, age, pathology, prothrombin time (PT), factor V, hemoglobin (Hb), and platelet count (plt). These variables were then retrospectively collected from 758 consecutive adult patients undergoing OLT from 1997 to 2007. Relationships between these variables and intraoperative blood transfusion requirements were examined by both univariate analysis and multiple linear regression analysis. RESULTS: Univariate analysis confirmed significant associations between RBC transfusion and PT, factor V, Hb, Plt, pathology, and age (P values all < .001). However, stepwise backward multivariate analysis excluded variables Plt and factor V from the multiple regression linear model. The variables included in the final predictive model were PT, Hb, age, and pathology. Patients suffering from liver carcinoma required more blood products than those suffering from other pathologies. Yet, the overall predictive power of the final model was limited (R(2) = .308; adjusted R(2) = .30). CONCLUSION: Preoperative variables have limited predictive power for intraoperative RBC transfusion requirements even when significant statistical associations exist, identifying only a small portion of the observed total transfusion variability. Preoperative PT, Hb, age, and liver pathology seem to be the most significant predictive factors but other factors like severity of liver disease, surgical technique, medical experience in liver transplantation, and other noncontrollable human variables may play important roles to determine the final transfusion requirements.

Evolução do Rastreio da Comunicação Interventricular

De 24 de Outubro de 1969 a 31 de Dezembro de 1986 foram observadas e seguidas por comunica ção interventricular isolada em Cardiologia Pediátrica no Hospital de Santa Marta 1274 crianças, com idade compreendida entre 3 dias e 12 anos, sem síndromes, nascidas em território nacional. Seiscentas e cinquenta e nove eram do sexo masculino e 615 do sexo feminino. Dada a importância do rastreio precoce na prevenção do estabelecimento de doença vascular pulmonar com resistência arterial pulmonar fixa foi feito o estudo evolutivo anual da idade da primeira observação. Os resultados foram favoráveis a partir de 1972, verificando-se uma melhoria progressiva com aumento do número de casos /ano e diminuição da idade do rastreio, sobretudo durante os últimos 7 anos do estudo.

Low Socioeconomic Status is an Independent Risk Factor for Survival After Abdominal Aortic Aneurysm Repair and Open Surgery for Peripheral Artery Disease

OBJECTIVE/BACKGROUND: The association between socioeconomic status (SES), presentation, and outcome after vascular surgery is largely unknown. This study aimed to determine the influence of SES on post-operative survival and severity of disease at presentation among vascular surgery patients in the Dutch setting of equal access to and provision of care. METHODS: Patients undergoing surgical treatment for peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), or carotid artery stenosis between January 2003 and December 2011 were retrospectively included. The association between SES, quantified by household income, disease severity at presentation, and survival was studied using logistic and Cox regression analysis adjusted for demographics, and medical and behavioral risk factors. RESULTS: A total of 1,178 patients were included. Low income was associated with worse post-operative survival in the PAD cohort (n = 324, hazard ratio 1.05, 95% confidence interval [CI] 1.00-1.10, per 5,000 Euro decrease) and the AAA cohort (n = 440, quadratic relation, p = .01). AAA patients in the lowest income quartile were more likely to present with a ruptured aneurysm (odds ratio [OR] 2.12, 95% CI 1.08-4.17). Lowest income quartile PAD patients presented more frequently with symptoms of critical limb ischemia, although no significant association could be established (OR 2.02, 95% CI 0.96-4.26). CONCLUSIONS: The increased health hazards observed in this study are caused by patient related factors rather than differences in medical care, considering the equality of care provided by the study setting. Although the exact mechanism driving the association between SES and worse outcome remains elusive, consideration of SES as a risk factor in pre-operative decision making and focus on treatment of known SES related behavioral and psychosocial risk factors may improve the outcome of patients with vascular disease.

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.

Detection of road accident accumulation zones with a visual analytics approach

Nowadays, road accidents are a major public health problem, which increase is forecasted if road safety is not treated properly, dying about 1.2 million people every year around the globe. In 2012, Portugal recorded 573 fatalities in road accidents, on site, revealing the largest decreasing of the European Union for 2011, along with Denmark. Beyond the impact caused by fatalities, it was calculated that the economic and social costs of road accidents weighted about 1.17% of the Portuguese gross domestic product in 2010. Visual Analytics allows the combination of data analysis techniques with interactive visualizations, which facilitates the process of knowledge discovery in sets of large and complex data, while the Geovisual Analytics facilitates the exploration of space-time data through maps with different variables and parameters that are under analysis. In Portugal, the identification of road accident accumulation zones, in this work named black spots, has been restricted to annual fixed windows. In this work, it is presented a dynamic approach based on Visual Analytics techniques that is able to identify the displacement of black spots on sliding windows of 12 months. Moreover, with the use of different parameterizations in the formula usually used to detect black spots, it is possible to identify zones that are almost becoming black spots. Through the proposed visualizations, the study and identification of countermeasures to this social and economic problem can gain new grounds and thus the decision- making process is supported and improved.

Immediate and long term evolution of valve replacement in children less than 12 years old

OBJECTIVE: The aim of this work was the follow-up and evaluation of valve replacement in children under 12 years of age. METHODS: Forty-four children less than 12 years old were underwent valve replacement at INCOR-HCFMUSP between January 1986 and December 1992. Forty (91%) were rheumatic, 39 (88.7%) were in functional classes II or IV, 19 (43.2%) were operated upon on an emergency basis, and 6 (13.6%) had atrial fibrillation. Biological prostheses (BP) were employed in 26 patients (59.1%), and mechanical prostheses (MP) in 18 (40.9%). Mitral valves were replaced in 30 (68.7%), aortic valves in 8 (18.2%), a tricuspid valve in 1 (2.3%), and double (aortic and mitral) valves in 5 (11.4) of the patients. RESULTS: Hospital mortality was of 4.5% (2 cases). The mean follow-up period was 5.8 years. Re-operations occurred in 63.3% of the patients with BP and in 12.5% of those with MP (p=0.002). Infectious endocarditis was present in 26.3% of the BP, but in none of the cases of MP (p=0.049). Thrombosis occurred in 2 (12.5%) and hemorrhage in one (6.5%) of the patients with a MP. Delayed mortality occurred in 5 (11.9%) of the patients over a mean period of 2.6 years; four had had BP and one had a MP (NS). Actuarial survival and re-operation-free curves after 10 years were respectively, 82.5±7.7 (SD)% and 20.6±15.9%. CONCLUSION: Patients with MP required fewer re-operation, had less infectious endocarditis and lower late mortality rates compared with patients with bioprostheses. The former, therefore, appear to be the best valve replacement for pediatric patients.

Increase in mortality due to myocardial infarction in the Brazilian city of São Paulo during winter

OBJECTIVE: To study the seasonal variation in mortality due to myocardial infarction in the city of São Paulo. METHODS: We analyzed the database of PROAIM (Programa de Aprimoramento de Informações de Mortalidade) containing the registrations of the certificates of deaths due to myocardial infarction (International Classification of Diseases, 10th edition, classification I21) of the residents of the municipality of São Paulo during 12 months (from December 1996 to November 1997). The number of deaths was corrected for a standard period of 90 days and then it was divided by the corresponding population to obtain the event rate per 10 thousand inhabitants. The magnitude of the seasonal variation, which was defined by the difference of the relative risks between the seasons with higher and lower mortality, was estimated. RESULTS: A total of 5,615 deaths due to myocardial infarction were included in the study. Sixty-one per cent occurred in the male sex, and the mean age was 68 years. The mortality rate during winter was always higher and that during summer was lower than that during the other seasons (P<0.01), independent from age and sex. Seasonal variations in deaths due to myocardial infarction was 30% in the general group, being 23% in individuals who died younger than 75 years, and 44% in the older ones. CONCLUSION: A marked seasonal variation in mortality due to myocardial infarction was observed in the city of São Paulo, with a significant increase in its magnitude and age distribution during the winter, similar to those reported in regions of North America and Europe with temperate climates.

Indicadores ópticos de actividad emisiva de radiación X en sistemas binarios Be

El estudio de los fenómenos emisivos en estrellas Be es de importancia porque agrega información que puede conducir a mejorar la interpretación de la actividad que existe en la alta atmósfera de estas estrellas. Los procesos que se desean estudiar se refieren a las interacciones entre la estrella Be y la de neutrones que componen un sistema Be emisor de radiación X. Un procedimiento posible consiste en utilizar la información prevista por las líneas de hidrógeno, especialmente la línea H gamma, cuyas variaciones permiten predecir la sucesiva emisión de la radiación X producida durante el pasaje por el periastro de la estrella de neutrones. Esto es válido, probablemente en todos los sistemas de este tipo y es justamente lo que se desea comprobar. Se trata de fenómenos que requieren, para ser analizados adecuadamente, de un eficaz seguimiento de los objetivos que se estudian; con este objeto se solicitarán turnos de observación en el Complejo Astronómico CASLEO (Complejo Astronómico Leoncito, provincia de San Juan) y en la Estación Astrofísica de Bosque Alegre del Observatorio Astronómico de Córdoba. Objetivos generales Estos hechos son de gran interés para el estudio de la física y la dinámica de la transferencia de materia en el periastro y la subsecuente emisión explosiva de radiación X. En consecuencia, si estas explosiones emisivas X están originadas por el movimiento orbital excéntrico, un seguimiento multifrecuencial de estos sistemas en su pasaje alrededor del periastro dará una respuesta a muchos de los problemas que presentan. En las longitudes de ondas ópticas, el seguimiento de estos sistemas durante un período orbital puede dar prueba definitiva de la existencia de indicadores ópticos de la siguiente actividad emisiva de radiación X. Objetivos específicos En una lista de alrededor de 25 sistemas pulsantes en radiación X, varios son TXTS. El propósito de este programa es el de buscar indicadores ópticos de emisión de radiación X en algunos sistemas como son: i) A 0538-66, sistema HXTS con un período de 0.07s, en la Nube Mayor de Magallanes. (...) ii) A 1118-615: éste es un sistema SXTS con un período de 405s. (...)

Verteilung der AB0-, Rhesus- und Kell-Merkmale im Großraum Magdeburg. Beurteilung der Bereitstellung immunologisch möglichst kompatibler Konserven unter Berücksichtigung der aktuellen Hämotherapierichtlinien

Magdeburg, Univ., Med. Fak., Diss., 2002

Opiatmodulation der Monoamine im Vorderhirn des Haushuhnkükens (Gallus gallus domesticus) : eine mögliche Rolle in der emotionalen Regulation?

Mikrodialyse, Haushuhnküken, Naloxon, DAGO, Stressvokalisation