Aplicación y aceptabilidad de la Guía Clínica de Dengue OMS-2009: la percepción de Ecuador / Aplicability and Aceptability and of the Dengue Clinical Guidelines WHO 2009: Ecuador's perception

Introducción: la infección por virus dengue se ha diseminado a más de 100 países a nivel mundial, con un cambio en su patrón que hizo que la clasificación OMS 1997 no sea aplicable. Objetivo: determinar la aceptabilidad y aplicabilidad de la guía OMS-2009. Materiales y métodos: fue conducido un estudio de corte transversal con diseño mixto, entre abril a noviembre del 2009 posterior a una intervención formativa dirigida a médicos, para lo cual se aplicó un cuestionario previamente elaborado y se realizó un trabajo de grupos focales. Resultados: los médicos mostraron una aceptación del 91,9% por la clasificación OMS-2009. El 100% realiza monitoreo de los signos vitales, considerando plaquetas (98,4%) y hematocrito (96.9%). El 96,9% utiliza las plaquetas como signos de alarma, seguido de letargia o inquietud (95,3%), dolor abdominal (95,3%), vómitos persistentes (92,2%). Los participantes refieren que es útil en la clasificación de los pacientes, especialmente los graves (30,56%), fácil de entender y manejar (30,56%), y como una ventaja que ayuda en el manejo y tratamiento de los casos (44,4%). El 80% considera que es necesaria su difusión a través de capacitaciones. De los grupos focales se considera que es sencilla, practica y didáctica para los niveles de severidad, orienta al triage de los pacientes y permite mejor su clasificación. Conclusiones: la guía OMS-2009 tiene una amplia aceptación por el personal de salud (AU).

Introduction: dengue virus infection has spread to more than 100 countries worldwide, with a change in its pattern that made the 1997 WHO classification not applicable. Objective: to determine the acceptability and applicability of the WHO-2009 guide. Materials and methods: a cross-sectional study with a mixed design was conducted between April and November 2009 following a training intervention directed at physicians, for which a previously elaborated questionnaire was applied and a focus group work was carried out. Results: physicians showed an acceptance of 91.9% for the WHO-2009 classification. 100% performed vital signs monitoring, considering platelets (98.4%) and hematocrit (96.9%). 96.9% used platelets as warning signs, followed by lethargy or restlessness (95.3%), abdominal pain (95.3%), persistent vomiting (92.2%). Participants report that it is useful in the classification of patients, especially severe (30.56%), easy to understand and manage (30.56%), and as an aid to the management and treatment of cases (44.4%). Eighty percent consider it necessary to disseminate it through training. Conclusions: gráficothe WHO-2009 guide has a wide acceptance by the health personnel, the health professionals, the health professionals, the health professionals (AU).

Evaluation of the WHO classification of dengue disease severity during an epidemic in 2011 in the state of Ceara, Brazil

In 2009, the World Health Organization (WHO) issued a new guideline that stratifies dengue-affected patients into severe (SD) and non-severe dengue (NSD) (with or without warning signs). To evaluate the new recommendations, we completed a retrospective cross-sectional study of the dengue haemorrhagic fever (DHF) cases reported during an outbreak in 2011 in northeastern Brazil. We investigated 84 suspected DHF patients, including 45 (53.6%) males and 39 (46.4%) females. The ages of the patients ranged from five-83 years and the median age was 29. According to the DHF/dengue shock syndrome classification, 53 (63.1%) patients were classified as having dengue fever and 31 (36.9%) as having DHF. According to the 2009 WHO classification, 32 (38.1%) patients were grouped as having NSD [4 (4.8%) without warning signs and 28 (33.3%) with warning signs] and 52 (61.9%) as having SD. A better performance of the revised classification in the detection of severe clinical manifestations allows for an improved detection of patients with SD and may reduce deaths. The revised classification will not only facilitate effective screening and patient management, but will also enable the collection of standardised surveillance data for future epidemiological and clinical studies.

Clasificación de dengue hemorrágico utilizando árboles de decisión en la fase temprana de la enfermedad / Classification of dengue hemorrhagic fever using decision trees in the early phase of the disease

Introducción: el dengue es una enfermedad viral con comportamiento epidémico, a su inicio no es posible saber qué pacientes evolucionarán desfavorablemente, sin embargo, pueden presentar signos de alarma que anuncian deterioro clínico. Objetivo: aplicar la técnica de árboles de decisión a la búsqueda de signos de alarma de gravedad en la fase temprana de la enfermedad. Métodos: la muestra de estudio la constituyeron 230 pacientes ingresados con dengue en el Instituto de Medicina Tropical "Pedro Kourí" en 2001. Las variables consideradas para la clasificación fueron los signos, síntomas y exámenes de laboratorio al tercer día de evolución de la enfermedad. Se aplicó el algoritmo de árboles de clasificación y regresión utilizando el índice de Gini. Se consideraron diferentes matrices de pérdida para mejorar la sensibilidad. Resultados: el algoritmo ARC, correspondiente a la mejor pérdida, tuvo una sensibilidad de 98,68 por ciento y error global de 0,36. Sin considerar pérdida, el árbol resultante obtuvo una sensibilidad de 74 por ciento con un error de 0,25. En ambos casos las variables de mayor importancia fueron plaqueta y hemoglobina. Conclusiones: se proponen reglas de decisión con alta sensibilidad y valor predictivo negativo de utilidad en la práctica clínica. Las variables de laboratorio resultan tener mayor importancia que las clínicas para discriminar las formas clínicas de dengue.

Introduction: dengue is a viral disease with endemic behavior. At the beginning of the illness it is not possible to know which patients will have an unfavorable evolution and develop a severe form of dengue. However, some warning symptoms and signs may be present. Objective: to apply decision tree techniques to the exploration of signs of severity in the early phase of the illness. Methods: the study sample was made up of 230 patients admitted with dengue to "Pedro Kourí" Institute of Tropical Medicine in 2001. The variables considered for the classification were the signs, symptoms and laboratory exams on the third day of evolution of the illness. The algorithm of classification and regression trees using the Gini's index was applied. Different loss matrices to improve the sensitivity were considered. Results: the algorithm CART, corresponding to the best loss, had a sensitivity of 98.68 percent and global error of 0.36. Without considering loss, it obtained its sensitivity reached 74 percent with an error of 0.25. In both cases, the most important variables were platelets and hemoglobin. Conclusions: the study submitted rules of decision with high sensitivity and negative predictive value of utility in the clinical practice. The laboratory variables resulted more important from the informational viewpoint than the clinical ones to discriminate clinical forms of dengue.

Dengue hemorrágico sin hemorragias: otra categoría? / Hemorrhagic dengue without hemorrhaging: a novel diagnostic category?

Objetivo: Comparar el comportamiento clínico del dengue clásico (DC) y dengue hemorrágico (DH). Material y métodos: Estudio transversal en casos seropositivos de la Delegación Veracruz Norte del Instituto Mexicano del Seguro en 2004. Se analizaron antecedentes epidemiológicos, sintomatología, parámetros clínicos y evolución. Se obtuvieron frecuencias, proporciones y promedios. Se compararon datos clínicos y tiempos de evolución. Resultados: Estudiamos 404 pacientes integrados en tres grupos: 75 con DC, 120 con DH y 212 sin datos hemorrágicos pero con plaquetopenia (DcP). Los síntomas generales fueron menos frecuentes en los casos de dengue; el dolor abdominal, hepatomegalia y esplenomegalia fueron más comunes en los que presentaron hemorragias. El escape de líquidos y hemorragias ocurrieron en 75 y 46% de este último grupo. Los antecedentes de infección previa fueron semejantes. Todos los enfermos de DH presentaron plaquetopenia y 3%, hemoconcentración. La media del hematócrito fue menor (p=0.02) y el conteo plaquetario mayor (p<0.01) en los de DC. La hemoglobina no mostró diferencias. El promedio entre el inicio de la enfermedad y la aparición de plaquetopenia fue similar en los casos con DH (4.3±1.6 días) y DcP (4.3±1.6); aunque, a diferencia de éstos, en los primeros el escape de líquidos (3.7±1.8) y hemorragias (3.4±1.7) se identificaron previamente. Conclusiones: Los resultados demuestran la presencia de casos con una evolución atípica, sin datos hemorrágicos externos pero con trombocitopenia importante que puede pasar desapercibida y predisponer el agravamiento del cuadro.

OBJECTIVE: Compare the clinical course of Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF). MATERIAL AND METHODS: Cross-sectional study among seropositive cases reported by the Northern Veracruz District IMSS Office in 2004. We analyzed the epidemiology, symptomology, clinical findings and disease progression. We calculated frequencies, proportions and averages. Clinical data and disease progression were compared. RESULTS: We studied 404 patients, divided into three groups: 75 with CD, 120 DHF and 212 cases with no hemorrhagic data although displaying Dengue with Thrombocytopenia (DwT). General symptoms were much less common among Dengue cases. Abdominal pain, hepatomegaly and splenomegaly were more frequent among patients with DHF. Fluid leakage and hemorrhaging were observed in 75% and 46%, respectively, of the latter group. The history of prior infection was proportional. All patients presenting DHF showed thrombocytopenia, though only 3% showed hemoconcentration. The mean value for hematocrit was low (p=0.02) and the platelet count greater (p<0.001) among Dengue cases. Hemoglobin concentration showed no difference. The average time between disease onset and appearance of thrombocytopenia was similar in DHF cases (4.3+/- 1.6 days) and Dengue with Thrombocytopenia (4.3+/-1.6); even though, contrary to these, in the first group fluid leakage (3.7+/-1.8) and hemorrhaging (3.4+/-1.7) were previously identified. CONCLUSIONS: Our results confirm the presence of cases showing atypical disease course, without external hemorrhaging data but showing significant thrombocytopenia that may go unnoticed and worsen disease progression.

Dengue clássica e dengue hemorrágica / Dengue and dengue hemorrhagyc fever

A epidemia de dengue, iniciada no Brasil na década de 80, tem sido percebida, interpretada e acompanhada pelo poder público através das variaçöes no tempo dos níveis de incidência da doença. Nesse trabalho, os autores procuram demonstrar que essas variaçöes säo muito mais dependentes da imunopatologia da doença do que da eficiência do poder público em combater as causas da epidemia. Finalmente, sugerem que sejam observados como parâmetros epidemiológicos principalmente os percentuais de infestaçäo predial pelo vetor da dengue e febre amarela e, associado a esses índices de infestaçäo predial, o crescente percentual de populaçäo já primoinfectada e, conseqüentemente, predisposta a eventos de dengue hemorrágica.

Dengue hemorrhagic fever: clinical manifestations and management.

Dengue virus infection may remain asymptomatic or manifest as nonspecific viral infection to life threatening dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Patients with DHF/DSS have fever, hemorrhagic manifestations along with thrombocytopenia and hemoconcentration. Thrombocytopenia and hemoconcentration are distinguishing features between DHF/DSS and dengue fever (DF). Some patients with dengue fever may have significant bleed and mild thrombocytopenia but no hemoconcentration. These patients are labelled to have dengue fever with unusual bleeds. Laboratory findings in DHF/DSS include rising hematocrit, thrombocytopenia and transformed lymphocytes on peripheral smear. There may be increased transaminases, hyponatremia, transient increase in blood urea nitrogen and creatinine. In severe disease there may be lab evidence of dissemination intravascular coagulation. X-ray film of the chest may show pleural-effusion. Ultrasonogram of abdomen may detect thickened gall bladder wall with hepatomegaly and ascitis. In some patients there may be abnormality in electrocardiogram and echocardiogram. The diagnosis of DHF/DSS is based on typical clinical findings. For confirmation of dengue virus infection viral culture can be done on blood obtained from patients during early phase of illness. In later part of illness antibodies against dengue virus can be demonstrated by various techniques. The treatment of DF is symptomatic. For control of fever nonsteroidal anti-inflammatory drugs should be avoided. DHF/DSS are managed by intravenous fluid infusion with repeated monitoring of vital parameters and packed cell volume (PCV).