Diretrizes brasileiras do angioedema hereditário 2022 ­ Parte 1: definição, classificação e diagnóstico / 2022 Brazilian guidelines for hereditary angioedema ­ Part 1: definition, classification, and diagnosis

O angioedema hereditário é uma doença autossômica dominante caracterizada por crises recorrentes de edema que acometem o tecido subcutâneo e o submucoso, com envolvimento de diversos órgãos. Os principais locais afetados são face, membros superiores e inferiores, as alças intestinais e as vias respiratórias superiores. Em decorrência da falta de conhecimento dessa condição por profissionais de saúde, ocorre atraso importante no seu diagnóstico, comprometendo a qualidade de vida dos indivíduos afetados. Além disso, o retardo no diagnóstico pode resultar em aumento da mortalidade por asfixia devido ao edema de laringe. A natureza errática das crises com variação do quadro clínico e gravidade dos sintomas entre diferentes pacientes, e no mesmo paciente ao longo da vida, se constitui em desafio no cuidado dos doentes que têm angioedema hereditário. O principal tipo de angioedema hereditário é resultante de mais de 700 variantes patogênicas do gene SERPING1 com deficiência funcional ou quantitativa da proteína inibidor de C1, porém nos últimos anos outras mutações foram descritas em seis outros genes. Ocorreram avanços importantes na fisiopatologia da doença e novas drogas para o tratamento do angioedema hereditário foram desenvolvidas. Nesse contexto, o Grupo de Estudos Brasileiro em Angioedema Hereditário (GEBRAEH) em conjunto com a Associação Brasileira de Alergia e Imunologia (ASBAI) atualizou as diretrizes brasileiras do angioedema hereditário. O maior conhecimento dos diversos aspectos resultou na divisão das diretrizes em duas partes, sendo nessa primeira parte abordados a definição, a classificação e o diagnóstico.

Hereditary angioedema is an autosomal dominant disease characterized by recurrent attacks of edema that affect the subcutaneous tissue and the submucosa, involving several organs. The main affected sites are the face, upper and lower limbs, gastrointestinal tract, and upper airways. Because health professionals lack knowledge about this condition, there is a significant delay in diagnosis, compromising the quality of life of affected individuals. Furthermore, delayed diagnosis may result in increased mortality from asphyxia due to laryngeal edema. The erratic nature of the attacks with variations in clinical course and severity of symptoms among different patients and in one patient throughout life constitutes a challenge in the care of patients with hereditary angioedema. The main type of hereditary angioedema results from more than 700 pathogenic variants of the SERPING1 gene with functional or quantitative deficiency of the C1 inhibitor protein, but in recent years other mutations have been described in six other genes. Important advances have been made in the pathophysiology of the disease, and new drugs for the treatment of hereditary angioedema have been developed. In this context, the Brazilian Study Group on Hereditary Angioedema (GEBRAEH) in conjunction with the Brazilian Association of Allergy and Immunology (ASBAI) updated the Brazilian guidelines on hereditary angioedema. Greater knowledge of different aspects resulted in the division of the guidelines into two parts, with definition, classification, and diagnosis being addressed in this first part.

Diretrizes brasileiras de angioedema hereditário 2022 ­ Parte 2: terapêutica / 2022 Brazilian guidelines for hereditary angioedema ­ Part 2: therapy

O tratamento do angioedema hereditário tem início com a educação dos pacientes e familiares sobre a doença, pois é fundamental o conhecimento da imprevisibilidade das crises, assim como os seus fatores desencadeantes. O tratamento medicamentoso se divide em terapia das crises e profilaxia das manifestações clínicas. As crises devem ser tratadas o mais precocemente possível com o uso do antagonista do receptor de bradicinina, o icatibanto ou o concentrado de C1-inibidor. É necessário estabeler um plano de ação em caso de crises para todos os pacientes. A profilaxia de longo prazo dos sintomas deve ser realizada preferencialmente com medicamentos de primeira linha, como concentrado do C1-inibidor ou o anticorpo monoclonal anti-calicreína, lanadelumabe. Como segunda linha de tratamento temos os andrógenos atenuados. Na profilaxia de curto prazo, antes de procedimentos que podem desencadear crises, o uso do concentrado de C1-inibidor é preconizado. Existem algumas restrições para uso desses tratamentos em crianças e gestantes que devem ser consideradas. Novos medicamentos baseados nos avanços do conhecimento da fisiopatologia do angioedema hereditário estão em desenvolvimento, devendo melhorar a qualidade de vida dos pacientes. O uso de ferramentas padronizadas para monitorização da qualidade de vida, do controle e da atividade da doença são fundamentais no acompanhamento destes pacientes. A criação de associações de pacientes e familiares de pacientes com angioedema hereditário tem desempenhado um papel muito importante no cuidado destes pacientes no nosso país.

The treatment of hereditary angioedema begins with the education of patients and their families about the disease, as it is essential to know the unpredictability of attacks as well as their triggering factors. Drug treatment is divided into attack therapy and prophylaxis of clinical manifestations. Attacks should be treated as early as possible with the bradykinin receptor antagonist icatibant or C1-inhibitor concentrate. An action plan needs to be established for all patients with attacks. Long-term prophylaxis of symptoms should preferably be performed with first-line drugs such as C1-inhibitor concentrate or the anti-kallikrein monoclonal antibody lanadelumab. Attenuated androgens are the second line of treatment. In short-term prophylaxis, before procedures that can trigger attacks, the use of C1-inhibitor concentrate is recommended. There are some restrictions for the use of these treatments in children and pregnant women that should be considered. New drugs based on advances in knowledge of the pathophysiology of hereditary angioedema are under development and are expected to improve patient quality of life. The use of standardized tools for monitoring quality of life and controlling disease activity is essential in the follow-up of these patients. The creation of associations of patients and families of patients with hereditary angioedema has played a very important role in the care of these patients in Brazil.

Especificidad contextual diferencial en la habituación de las respuestas de parpadeo y aceleración cardiaca en humanos / Differential Context-Specificity in the Habituation of the Eyeblink and Cardiac Responses in Humans

Wagner (1978) propuso que la habituación, definida como una disminución en la respuesta a un estímulo que se repite, dependería de la formación de una asociación entre el contexto y el estímulo. Según este enfoque, la habituación debería ser contexto-específica, es decir, la respuesta habituada en un contexto debería deshabituarse al presentar el estímulo en un contexto novedoso. Esta hipótesis fue examinada a través de un experimento donde se sometió a un grupo de estudiantes a una sesión de habituación consistente en 60 repeticiones de un estímulo provocador de reacciones de parpadeo y aceleración cardiaca. Posteriormente, en una sesión de prueba se midió la amplitud de estas respuestas, presentando el estímulo en el mismo contexto (Grupo Igual) o en un contexto distinto a aquel donde ocurrió la habituación (Grupo Diferente). Los resultados de la prueba arrojaron evidencia de especificidad contextual diferencial para ambas respuestas, ya que la respuesta de aceleración cardiaca resultó disminuida en el grupo igual pero no en el grupo diferente (revelando especificidad), mientras que la respuesta de parpadeo estuvo igualmente disminuida en ambos grupos (revelando ausencia de especificidad). Estos hallazgos confirman observaciones previas con ratas que demuestran que el control contextual de la habituación depende de la naturaleza de la respuesta.

Wagner (1978) proposed that habituation, defined as a decrease in responding to a repeated stimulus, would depend on the formation of an association between the stimulus and the context. According to this approach, habitua-tion should be context-specific; that is, a response that was habituated in a given context should dishabituate when the stimulus is presented in a novel context. This hypothesis was examined in an experiment in which a group of students received a habituation session consisting of 60 repetitions of a stimulus capable of evoking eyeblink and heart-rate acceleration reactions. Subsequently, in a testing session the amplitude of these responses was examined by presenting the stimulus in the same context used in the habituation session (Group Same) or in an alternative context (Group Different). The results provided evidence of differential context-specificity for the two responses, since the heart-rate acceleration response was diminished in the group same but not in the group different (revealing specificity), while the eyeblink response was diminished in both groups (revealing no specificity). These findings are consistent with previous observations in rats demonstrating that the contextual control of habituation depends on the nature of the measured response.

Incidence of congenital toxoplasmosis among infants born to HIV-coinfected mothers: case series and literature review

Introduction: There is a paucity of data on the occurrence of congenital toxoplasmosis in children born to mothers dually infected with HIV and Toxoplasma gondii. Objective: To evaluate aspects of the mother–infant pairs associated with vertical transmission of toxoplasmosis in women co-infected with HIV in a referral center for perinatally acquired infections in Belo Horizonte, Brazil. Methods: Descriptive study of HIV vertically exposed children, with congenital toxoplasmosis, followed at a referral center (cohort/Belo Horizonte). Prenatal and post-natal variables for the mother–infant pairs were evaluated. A literature review with no filtering for time and language was performed to identify reports of congenital toxoplasmosis in HIV vertically exposed children. Results: Among 2007 HIV vertically exposed children evaluated in the period from 1998 to 2011, 10 cases of congenital toxoplasmosis were identified (incidence: 0.5%, 95% confidence interval: 0.24–0.91). In searching the literature 22 additional cases in 17 reports were found. Combining the findings of our cohort with other reported cases, 50% (16/32) of congenital toxoplasmosis in HIV vertically exposed children were from Brazil. The cases of congenital toxoplasmosis in HIV vertically exposed children identified in Brazil occurred mainly in the post-Highly Active Antiretroviral Therapy era (p = 0.002) and presented a lower death rate (p = 0.003) than those from other countries. In the cohort/Belo Horizonte, HIV infection was identified mainly during gestation; T. gondii vertical transmission was observed in pregnant women with CD4+>500 cells/mm3 and latent toxoplasmosis. High rates of ocular lesions (87.5%) and central nervous system involvement (70%) were detected. Conclusions: The risk of vertical transmission of T. gondii in HIV-infected women is low and has been usually associated with maternal immunosuppression and elevated viral load. However, ...

The impact of highly active antiretroviral therapy on the survival of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil

The use of highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV)-infected patients has reduced the number of acquired immune deficiency syndrome-related deaths worldwide. This study assessed the impact of HAART on the survival and death rates of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil. Data were obtained from a historic cohort of vertically HIV-infected children and adolescents aged zero-19 years old who were admitted from March 1989-December 2004 and were followed until June 2006. Patients who used HAART were included if they were treated for at least 12 weeks. Of 359 patients, 320 patients met the inclusion criteria. The overall mortality rate was 9.7% [31/320; 95% confidence interval (CI): 6.0-13%]. The median survival for the non-HAART and HAART groups was 31.5 and 55.9 months, respectively (log rank = 22.11, p < 0.0001). In the multivariate analysis, the statistically significant variables were HAART and the weight-for-age Z score < -2, with HAART constituting a protective factor [relative risk (RR): 0.13; CI 95%: 0.05-0.33] and malnutrition constituting a risk factor (RR: 3.44; CI 95%: 1.60-7.40) for death. The incidence of death was 5.1/100 person-years in the non-HAART group and 0.8/100 person-years in the HAART group (p < 0.0001).

Postpartum changes in plasma viral load and CD4 percentage among HIV-infected women from Latin American and Caribbean countries: the NISDI Perinatal Study

The goal of this study was to evaluate changes in plasma human immunodeficiency virus (HIV) RNA concentration [viral load (VL)] and CD4+ percentage (CD4 percent) during 6-12 weeks postpartum (PP) among HIV-infected women and to assess differences according to the reason for receipt of antiretrovirals (ARVs) during pregnancy [prophylaxis (PR) vs. treatment (TR)]. Data from a prospective cohort of HIV-infected pregnant women (National Institute of Child Health and Human Development International Site Development Initiative Perinatal Study) were analyzed. Women experiencing their first pregnancy who received ARVs for PR (started during pregnancy, stopped PP) or for TR (initiated prior to pregnancy and/or continued PP) were included and were followed PP. Increases in plasma VL (> 0.5 log10) and decreases in CD4 percent (> 20 percent relative decrease in CD4 percent) between hospital discharge (HD) and PP were assessed. Of the 1,229 women enrolled, 1,119 met the inclusion criteria (PR: 601; TR: 518). At enrollment, 87 percent were asymptomatic. The median CD4 percent values were: HD [34 percent (PR); 25 percent (TR)] and PP [29 percent (PR); 24 percent (TR)]. The VL increases were 60 percent (PR) and 19 percent (TR) (p < 0.0001). The CD4 percent decreases were 36 percent (PR) and 18 percent (TR) (p < 0.0001). Women receiving PR were more likely to exhibit an increase in VL [adjusted odds ratio (AOR) 7.7 (95 percent CI: 5.5-10.9) and a CD4 percent decrease (AOR 2.3; 95 percent CI: 1.6-3.2). Women receiving PR are more likely to have VL increases and CD4 percent decreases compared to those receiving TR. The clinical implications of these VL and CD4 percent changes remain to be explored.

Deficiência de IgA associada a Artrite reumatoide juvenil / IgA deficiency and Juvenile rheumatoid arthritis

Objetivo: descrever um caso de deficiência de IgA associado a artrite reumatoide juvenil e infecções de repetição.Relato do caso: paciente de 12 anos, sexo feminino, com diagnóstico de artrite reumatoide juvenil associada a infecção pulmonar grave. A deficiência de IgA foi suspeitada e o diagnósticoconfirmado através da dosagem de IgA sérica.Conclusão: os médicos devem estar atentos ao diagnóstico de deficiência de IgA pela grande associação não só com processos infecciosos e alérgicos, mas, também com doenças auto imunes.

Objective: to describe a case of IgA deficiency and juvenile rheumatoid arthritis and recurrent infections.Case report: a 12 year-old patient, female, diagnosed with juvenile rheumatoid arthritis associated with severe lung infection. IgA deficiency was suspected and the diagnosis was confirmed through serum IgA measurement.Conclusion: physicians should be aware of the diagnosis of IgA deficiency no only beca use of its close association with infectious and allergic processes, but also with auto immune diseases.

Quality of life of HIV-infected children in Brazil / Calidad de vida de niños infectados con VIH en Brasil

Introduction. Quality of life (QoL) is an important consideration in the management of chronic progressive illnesses such as acquired immunodeficiency syndrome (AIDS). It provides the opportunity to understand the effects of disease and treatment to include their impact on physical, psychological and social functioning. We evaluated the QoL of HIV-infected children and established the association between QoL and CD4 cell counts, viral load, clinical status and antiretroviral therapy (ART). Methods. QoL was assessed by the General Health Assessment for Children developed for PACTG 219 and examined domains of health perceptions, functional status, social and role functioning, health care utilization, symptoms and associated events. Children were divided into groups according to their AIDS status, viral load, CD4 and ART. Results. One hundred seventy four children and adolescents were evaluated. Good scores were obtained in all domains. No difference was found in QoL scores among patients with different AIDS status. Patients with higher CD4 cell percentages had better QoL in health perceptions and symptoms domains. Low viral load was related to better QoL in social and role functioning. No relationship was found between ART and QoL. Patients receiving highly active antiretroviral therapy (HAART) showed similar QoL scores in comparison with those without HAART. Conclusion. HIV children reached high scores in all QoL domains. CD4 and viral load presented positive association with some of the domains assessed. HAART was able to provide similar QoL compared to other treatment groups, pointing to a balance between clinical benefits and side effects of therapy.

Introducción. La calidad de vida (QoL) es una consideración importante en el manejo de enfermedades progresivas crónicas como el síndrome de inmunodeficiencia adquirida (SIDA). Proporciona la oportunidad de entender el efecto de la enfermedad y el tratamiento en el impacto del funcionamiento físico, psicológico y social. En este estudio se evalúa la QoL de niños infectados con virus de inmunodeficiencia humana y la asociación entre QoL y células CD4+, carga viral, estadio clínico y tratamiento antirretroviral (TAR). Métodos. La QoL fue medida por el instrumento Evaluación de Salud General para Niños (General Health Assessment for Children, GHAC) desarrollada por PACTG 219, el cual examina dominios de percepción de la salud, estatus funcional, función social y el rol en la misma, así como utilización de servicios de salud, síntomas y eventos asociados. Los niños fueron clasificados en grupos de acuerdo a su categoría de SIDA, carga viral, células CD4 y TAR. Resultados. Se evaluaron 174 niños y adolescentes. Se obtuvieron buenos puntajes en todos los dominios. No se observaron diferencias en los puntajes de QoL entre pacientes en diferentes categorías de SIDA. Los pacientes con mayor porcentaje de células CD4+ tuvieron mejor QoL en los dominios de percepción de la salud y síntomas. No hubo asociación entre TAR y QoL. Los pacientes que recibieron el tratamiento antirretroviral altamente activo (TARAA) mostraron similares puntajes de QoL en comparación con aquellos sin TARAA. Conclusión. Los niños con virus de inmunodeficiencia humana obtuvieron elevados puntajes en todos los dominios de QoL, células CD4 y carga viral, presentando asociación positiva con algunos de los dominios evaluados. El TARAA fue capaz de proporcionar similar QoL, comparado a otros grupos de tratamiento, indicando un balance entre beneficios clínicos y eventos adversos de la terapia.

Evaluation of hematological, virologic and anthropometric parameters as progression markers in HIV-1 infected children / Avaliação dos parâmetros hematológicos, virológicos e antropométricos como marcadores de progressão em crianças infectadas pelo HIV-1

OBJETIVO: Analisar a utilidade da contagem total de linfócitos, contagem global de leucócitos, hemoglobina, estado nutricional, contagem de linfócitos T CD4+ e carga viral como marcadores de progressão da doença e/ou óbito em crianças infectadas pelo HIV. MÉTODOS: Estudo de coorte retrospectiva em população de crianças infectadas pelo HIV, assintomáticas ou com sintomas leves e/ou moderados e virgens de tratamento antirretroviral. Os eventos de interesse foram: progressão para categoria clínica C (de acordo com a classificação dos Centers for Disease Control and Prevention - CDC, de 1994) ou óbito. Valores da contagem global de leucócitos, contagem total de linfócitos, hemoglobina, escore z peso/idade, contagem de linfócitos T CD4+ e carga viral plasmática obtidos à admissão foram considerados na análise do risco de ocorrência dos eventos de interesse. A população foi estratificada em faixas etárias: <12, > 12 e < 36, > 36 e < 60 meses. RESULTADOS: Cento e vinte pacientes, admitidos entre 1997 e 2003, preencheram os critérios para inclusão deste estudo. A mediana global do tempo de acompanhamento foi de 7,4 meses (intervalo interquartil 25-75% = 3,8-21,1). Em análise multivariada, apenas a contagem de linfócitos T CD4+, segundo as categorias da Organização Mundial da Saúde, e o escore z peso/idade ≤ -2 foram preditores do risco de progressão da doença em crianças maiores de 12 meses de idade. Em menores de 12 meses, nenhuma das variáveis analisadas esteve associada ao risco de progressão. CONCLUSÃO: Evidencia-se a importância do estado nutricional na avaliação do risco de progressão da doença em crianças maiores de 12 meses de idade infectadas pelo HIV.

OBJECTIVE: To analyze total lymphocyte count, total leukocyte count, hemoglobin levels, nutritional status, CD4+ T-lymphocyte count and viral load as markers of disease progression and/or death in HIV-infected children. METHODS: This retrospective cohort study assessed antiretroviral naïve HIV-infected children who were asymptomatic or had mild and/or moderate symptoms. The events of interest were: progression to clinical category C (according to the classification of the Centers for Disease Control and Prevention - CDC, 1994) or death. Values of total leukocyte count, total lymphocyte count, hemoglobin, weight-for-age z score, CD4+ T-lymphocyte count and plasma viral load obtained at admission were considered in the risk analysis of events of interest. The population was stratified into age groups: < 12, > 12 to < 36, > 36 to < 60 months. RESULTS: One hundred and twenty patients, admitted between 1997 and 2003, met the inclusion criteria for the present study. The total median of follow-up duration was 7.4 months (25-75% interquartile range = 3.8-21.1). In the multivariate analysis, only CD4+ T-lymphocytes count, according to the categories of the World Health Organization, and weight-for-age z score ≤ -2 were predictors of risk for disease progression in children older than 12 months. In children younger than 12 months, none of the variables was associated with risk of progression. CONCLUSION: Nutritional status is an important aspect in the assessment of risk of disease progression in HIV-infected children older than 12 months.

Determinants and trends in perinatal human immunodeficiency virus type 1 (HIV-1) transmission in the metropolitan area of Belo Horizonte, Brazil: 1998 - 2005

Significant decrease in human immunodeficiency virus type 1 (HIV-1) vertical transmission has been observed worldwide in centers where interventions such as antiretroviral therapy (ART), elective cesarean section, and avoidance of breastfeeding have been implemented. This prospective cohort study aimed to assess the determinants of and the temporal trends in HIV-1 vertical transmission in the metropolitan area of Belo Horizonte, Brazil from January 1998 to December 2005. The rate of HIV-1 vertical transmission decreased from 20 percent in 1998 to 3 percent in 2005. This decline was associated with increased use of more complex ART regimens during pregnancy. Multivariate analysis restricted to clinical variables demonstrated that non ART, neonatal respiratory distress/sepsis and breastfeeding were independently associated with HIV-1 vertical transmission. When laboratory parameters were included in the model, high maternal viral load and non maternal ART were associated with HIV-1 vertical transmission. The results from this study confirm the impact of ART in the reduction of HIV-1 vertical transmission and indicate the need for improvement in the care and monitoring of mother and infant pairs affected by HIV-1.

Experiências referentes à contracepção por mulheres sabidamente infectadas pelo HIV que engravidam / Experiences related to contraception by HIV-Infected women that become pregnant

Introdução: um crescente número de mulheres infectadas pelo HIV tem sido identificado, principalmente em idade reprodutiva. Apesar de receberem todas as medidas para a prevenção da transmissão vertical, observam-se dificuldades na assistência pós-natal, incluindo a ocorrência de gestações não-planejadas. Objetivo: investigar percepções sobre a contracepção por mulheres sabidamente infectadas pelo HIV com experiência prévia da maternidade e que engravidaram após o diagnóstico. Métodos: este foi um estudo clínico-qualitativo, desenvolvido no ambulatório Carlos Chagas do Hospital das Clínicas da Universidade Federal de Minas Gerais, de Janeiro de 2004 a Dezembro de 2005. Foram incluídas mulheres infectadas pelo HIV, com filhos vivos prévios e novas gestações após o diagnóstico. O número de entrevistadas foi definido pelo critério da saturação. Entrevistas semi-estruturadas foram gravadas e transcritas na íntegra. A análise foi realizada pelo processo de categorização. Resultados: vinte mulheres foram entrevistadas, com mediana de idade de 29 anos. A mediana de gestações foi de 3,5, mas após o diagnóstico 1,04. Dezenove gestações não foram planejadas. As mulheres tinham informações sobre métodos contraceptivos disponíveis, mas relatavam dificuldade do uso do preservativo pelo parceiro, dificuldades de uso de anticoncepcional oral e de acesso à salpingotripsia. Conclusão: a ocorrência de gestações não planejadas não dependeu do conhecimento prévio da infecção pelo HIV. As expectativas e o desejo podem ser modificados pelo estigma da doença, mas não foram determinantes na utilização do método contraceptivo eficaz. Profissionais de saúde devem atuar de forma integral, focando a utilização de contracepção eficaz e permitindo com que elas exerçam seus direitos reprodutivos.

Evaluation of atopy among mouth-breathing pediatric patients referred for treatment to a tertiary care center

OBJETIVO: Respirador bucal é o indivíduo que utiliza a cavidade oral como principal via aérea durante a respiração. Trata-se de síndrome de múltiplas etiologias, dentre as quais a rinite alérgica merece destaque por sua alta prevalência. Este trabalho teve como objetivo avaliar a presença de atopia entre respiradores bucais encaminhados a serviço de referência da região metropolitana de Belo Horizonte. MÉTODOS: Estudo transversal e descritivo, realizado no Hospital das Clínicas da Universidade Federal de Minas Gerais. Foram incluídos pacientes de 2 a 12 anos de idade, com período de admissão entre novembro de 2002 e abril de 2004. Os responsáveis responderam a um questionário completo, e os pacientes foram submetidos a teste alérgico cutâneo para inalantes. Houve 140 participantes do estudo. Foram classificados como atópicos aqueles que apresentaram teste positivo para, no mínimo, um alérgeno. As análises estatísticas foram feitas no programa SPSS, usando análises univariadas seguidas pela regressão logística. RESULTADOS: Entre os 140 pacientes, 44,3 por cento (62/140) tiveram teste alérgico positivo. Acaros foram os alérgenos predominantes, apresentando positividade em 100 por cento dos atópicos. Em análise multivariada, atopia esteve significativamente associada ao sexo masculino (p = 0,05), presença de asma (p = 0,014), menor número de pessoas dormindo no mesmo cômodo que o paciente (p = 0,005), ausência de tabagismo passivo (p = 0,005) e ausência de apnéia noturna (p = 0,003). CONCLUSÃO: A alta prevalência de positividade no teste alérgico enfatiza a importância da investigação alergológica em respiradores bucais, pois a alergia tem formas específicas de tratamento que podem reduzir a morbidade desses pacientes quando adequadamente utilizadas.

OBJECTIVE: A mouth breather is someone who uses his/her oral cavity as main airway during breathing. This is a syndrome with several etiologies, but allergic rhinitis plays a key role due to its high prevalence. The aim of this study was to assess the presence of atopy among mouth-breathing patients referred to a tertiary care center in the metropolitan region of Belo Horizonte, Brazil. METHODS: Cross-sectional, descriptive study carried out at Hospital das Clínicas of Universidade Federal de Minas Gerais. Patients aged 2 to 12 years, admitted between November 2002 and April 2004, were included. Parents or surrogates completed a comprehensive questionnaire, and patients were submitted to a skin test for inhalant allergens. A total of 140 patients participated in the study. Those with a positive result for at least one allergen were regarded as atopic. The statistical analyses were made using SPSS, with univariate analyses followed by logistic regression. RESULTS: Of 140 patients, 44.3 percent (62/140) obtained positive results on the allergic test. Mites were the most predominant allergens, with a positive rate of 100 percent among atopic patients. In the multivariate analysis, atopy was significantly associated with the male sex (p = 0.05), presence of asthma (p = 0.014), lower number of people sleeping in the same room with the patient (p = 0.005), absence of passive smoking (p = 0.005) and absence of sleep apnea (p = 0.003). CONCLUSION:The high prevalence of positive results on the allergic test highlights the importance of allergologic investigation in mouth-breathers, since allergy has specific treatments that may reduce morbidity in these patients when properly used.

Effectiveness of dual and triple antiretroviral therapy in the treatment of HIV-infected children

OBJETIVOS: Como iniciar a terapia anti-retroviral é uma questão amplamente discutida no manejo de crianças infectadas pelo HIV. O objetivo deste estudo foi comparar a efetividade da terapia dupla e tríplice em uma coorte de crianças infectadas pelo HIV. MÉTODO: Este estudo foi realizado em um serviço de referência para assistência à criança infectada da Faculdade de Medicina da UFMG. Foram incluídas crianças que iniciaram o primeiro regime anti-retroviral entre janeiro de 1998 e dezembro de 2000, com seguimento até dezembro de 2001. O evento final para análise foi a primeira falha terapêutica ou óbito. RESULTADOS: Foram analisados 101 pacientes, sendo 58 (57,4 por cento) e 43 (42,6 por cento) com terapia dupla e tríplice, respectivamente. Não houve diferença entre os grupos quanto ao sexo, idade, contagem de linfócitos CD4+ e carga viral basal. A média de duração da terapia dupla foi de 26,3 meses (IC95 por cento 21,3-31,3) e da terapia tríplice, de 34,3 meses (IC95 por cento 29,2-39,5 por cento). Falha terapêutica ocorreu em 33 (56,9 por cento) pacientes em terapia dupla e 11 (25,6 por cento) em terapia tríplice (log rank 5,03; p = 0,025). O risco relativo de falha para terapia dupla foi 2,2 vezes maior (IC = 1,3-3,9). O percentual de linfócitos T CD4+ inicial foi preditor de risco para falha terapêutica (p = 0,001). Pacientes em terapia tríplice apresentaram maior redução da carga viral (p = 0,001). CONCLUSÃO: A terapia tríplice permaneceu eficaz por mais tempo e apresentou melhor resposta virológica do que a terapia dupla nesta coorte de crianças infectadas pelo HIV, justificando a sua escolha como regime preferencial de tratamento.

OBJECTIVE: The use of antiretroviral therapy in HIV-infected children has been a widely discussed issue. The aim of this study was to compare the effectiveness of dual nucleoside analogue reverse transcriptase inhibitor (NRTI) regimens and three-drug regimens [2NRTI+ non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI)] in a cohort of HIV-infected children. METHODS: The study was carried out in a referral center for the management of infected children, which is affiliated with the School of Medicine of Universidade Federal de Minas Gerais (UFMG). Those children whose antiretroviral therapy was implemented between January 1998 and December 2000 and who were followed up until December 2001 were included in the study. Therapeutic failure or death was regarded as the endpoint in our analysis. RESULTS: A total of 101 patients were assessed, 58 (57.4 percent) on dual therapy and 43 (42.6 percent) on triple therapy. No statistically significant difference was observed between the groups in terms of gender, age, CD4+ count and baseline viral load. The average duration of dual therapy was 26.3 months (95 percentCI 21.3-31.3) and that of triple therapy was 34.3 months (95 percentCI 29.2-39.5 percent). There was therapeutic failure in 33 (56.9 percent) patients on dual therapy and in 11 (25.6 percent) patients on triple therapy (log rank = 5.03; p = 0.025). The relative risk of therapeutic failure of the dual therapy was 2.2 times higher (95 percentCI = 1.3-3.9). The percentage of initial CD4+ T cells was a predictor of risk for therapeutic failure (p = 0.001). Patients on triple therapy showed a more remarkable reduction in their viral load (p = 0.001). CONCLUSION: Triple therapy was efficient for a longer time period and showed better virologic response than dual therapy in this cohort of HIV-infected children. Therefore, triple therapy should be the treatment of choice.