Análise espacial dos óbitos por tuberculose pulmonar no estado do Amazonas / Spatial analysis of deaths from pulmonary tuberculosis in the state of Amazonas / Análisis espacial de muertes por tuberculosis pulmonar en el estado de las Amazonas

Objetivo: analisar a distribuição dos óbitos por tuberculose pulmonar no estado do Amazonas. Método: trata-se de um estudo ecológico com dados secundários do Sistema de Informação de Mortalidade, durante o período de 2007 a 2017. O software QGIs foi utilizado para elaborar um mapa digital e o software RStudio para as análises estatísticas. Na análise dos dados foi aplicado a regressão linear múltipla, o índice de Moran Global e o teste multiplicador de Lagrange. Resultados: identificou-se 1.267 casos de óbitos por tuberculose pulmonar no estado do Amazonas. A maioria dos óbitos ocorreram no sexo masculino (64,64%); solteiros (47,43%); com faixa etária ≥ 60 anos (51,14%); raça/cor parda (71,11%). Verificou-se que não existe autocorrelação espacial através do índice de Moran Global (0.0094). Conclusão: A distribuição espacial dos óbitos ocorreu de forma heterogênea nas diferentes regiões do estado Amazonas, apresentando elevadas taxas de mortalidade durante o período de 2007 a 2017.(AU)

Objective: to analyze the distribution of deaths from pulmonary tuberculosis in the state of Amazonas. Method: it is an ecological study with secondary data from the Mortality Information System, during the period from 2007 to 2017. The QGIs software was used to create a digital map and the RStudio software for statistical analysis. In the data analysis, multiple linear regression, the Moran Global index and the Lagrange multiplier test were applied. Results: 1,267 cases of deaths from pulmonary tuberculosis were identified in the state of Amazonas. Most deaths occurred in males (64.64%); singles (47.43%); aged ≥ 60 years (51.14%); race / brown color (71.11%). It was found that there is no spatial autocorrelation using the Moran Global index (0.0094). Conclusion: The spatial distribution of deaths occurred heterogeneously in different regions of the state of Amazonas, with high mortality rates during the period from 2007 to 2017.(AU)

Objetivo: analizar la distribución de muertes por tuberculosis pulmonar en el estado de Amazonas. Método: se trata de un estudio ecológico con datos secundarios del Sistema de Información de Mortalidad, durante el período de 2007 a 2017. Se utilizó el software QGIs para crear un mapa digital y el software RStudio para análisis estadístico. En el análisis de datos se aplicó regresión lineal múltiple, el índice Moran Global y la prueba del multiplicador de Lagrange. Resultados: se identificaron 1.267 casos de defunciones por tuberculosis pulmonar en el estado de Amazonas. La mayoría de las muertes ocurrieron en hombres (64,64%); solteros (47,43%); edad ≥ 60 años (51,14%); raza / color marrón (71,11%). Se encontró que no existe autocorrelación espacial usando el índice Moran Global (0.0094). Conclusión: La distribución espacial de las defunciones ocurrió de manera heterogénea en diferentes regiones del estado de Amazonas, con altas tasas de mortalidad durante el período 2007 a 2017.(AU)

La letalidad como un indicador influyente en la eliminación de la tuberculosis en La Habana / Lethality as an influential indicator in the elimination of tuberculosis in Havana

Introducción: Eliminar la tuberculosis para 2035, es la propuesta de la estrategia mundial "Fin de la Tuberculosis". Objetivo: Determinar la letalidad de la tuberculosis con virus de inmunodeficiencia negativo como un indicador en la eliminación de la enfermedad. Material y Método: Se realizó un estudio descriptivo de la letalidad de los casos diagnosticados con virus de inmunodeficiencia negativo del año 2000 al 2015 en La Habana a partir de las cohortes anuales de enfermos de tuberculosis según grupos de edades; por municipios; variabilidad; tuberculosis, tuberculosis pulmonar con baciloscopia positivas (BAAR+); y los retratamientos por años. Al análisis de la letalidad por municipio se añadió la variación de la enfermedad en el estudio y según la tuberculosis pulmonar y el resultado de la baciloscopia. Resultados: La letalidad de la tuberculosis en los casos nuevos con virus de inmunodeficiencia negativo fue de 8,8 por ciento con predominio de los fallecidos por tuberculosis con 5,4 por ciento. En los casos con retratamientos fue de 16,2 por ciento. La letalidad se incrementó en 43,5 por ciento con 2,9 por ciento anual y con la edad. Los fallecidos por tuberculosis pulmonar representaron 96,6 por ciento. En los resultados se destacan cinco municipios. Conclusiones: La letalidad de la tuberculosis de casos nuevos con virus de inmunodeficiencia negativo reveló un incremento anual en la tuberculosis pulmonar y en los retratamientos; esto sugiere dificultades en el control de la enfermedad, lo que potencialmente compromete su eliminación en La Habana. Intensificar la prevención de los factores influyentes pudiera reducir este indicador(AU)

Introduction: The proposal of the End TB Strategy is to end tuberculosis by 2035 globally. Objective: To determine the lethality of tuberculosis with negative immunodeficiency virus as an indicator in the elimination of the disease. Material and Method: A descriptive study on the lethality of cases diagnosed with negative immunodeficiency virus during 2000 and 2015 was conducted in Havana. The study considered the annual cohorts of tuberculosis patients according to age groups, municipalities, variability, tuberculosis, Smear-positive pulmonary tuberculosis (BAAR +), and the retreatments by years. The variation of the disease in the study as well as the variation of pulmonary tuberculosis and the results of sputum microscopies were added to the analysis of lethality carried out in every municipality. Results: The case fatality rate of tuberculosis in new cases with negative immunodeficiency virus was 8.8 percent with a predominance of those who died from Tuberculosis (5.4 percent). In the cases of retreatments, it was 16.2 percent. Case fatality increased by 43.5 percent with 2.9 percent per year and with age. Those patients who died from pulmonary tuberculosis represented 96.6 percent. Five municipalities stand out in the results. Conclusions: The lethality of tuberculosis in new cases with negative immunodeficiency virus revealed an annual increase in pulmonary tuberculosis and retreatments, suggesting difficulties related to the control of the disease and potentially compromising its elimination in Havana. Intensifying the prevention of influencing factors could reduce this indicator(AU)

Análisis de letalidad en pacientes con diagnóstico de tuberculosis en un centro de alta complejidad en Cali, Colombia / Lethality analysis in patients with tuberculosis diagnosis in a high complexity hospital in Cali, Colombia

Resumen Introducción: En el 2016 la tuberculosis (TBC) fue considerada la novena causa de muerte en el mundo y la primera por un único agente infeccioso, con aproximadamente 1,6 millones de muertes y una letalidad de 15%. Más de 95% de los casos de mortalidad mundial se presentan en países en vía de desarrollo como Colombia. Objetivo: Describir las características sociodemográficas y clínicas de los pacientes que fallecieron durante el tratamiento antituberculoso en un centro de alta complejidad en Cali, Colombia. Métodos: Estudio analítico de cohorte retrospectiva, realizado entre 2007-2016 en la Fundación Valle del Lili. Se incluyeron pacientes con diagnóstico de TBC con seguimiento clínico, que fallecirron por cualquier causa. Resultados: De 787 pacientes diagnosticados con TBC, murieron 69 (8,8%). La mayoría de los fallecidos (59%) fueron hombres, edad promedio de 51,9 años. Hubo retraso diagnóstico en 51% de los pacientes y 75% presentaron TBC pulmonar. El 64% murió en los primeros 30 días posteriores al diagnóstico de TBC y 61% de las muertes fueron atribuibles a TBC. Co-infección TBC e infección por VIH se presentó en 23% de los casos. La edad avanzada (> 65 años) se asoció a muerte en menos de 30 días desde el diagnóstico de TBC (p < 0,001). Discusión: La letalidad encontrada es superior a lo esperado (8,8%); la mayoría de los pacientes fallecidos presentó co-morbilidades graves. La edad avanzada se asoció a muerte temprana. El principal mecanismo fisiopatológico de muerte por TBC en este estudio fue el choque séptico secundario a neumonía grave tuberculosa.

Background In 2016 tuberculosis (TB) was considered the ninth leading cause of death worldwide and the leading cause of a single infectious agent, with approximately 1.6 million deaths worldwide and a lethality of 15%. Over 95% of cases and deaths are in developing countries like Colombia. Aim: To describe the sociodemographic and clinical characteristics of patients who died during TB treatment in a high complexity hospital in Cali, Colombia. Methods: We conducted an analytic retrospective cohort during 2007-2016 in Fundación Valle del Lili. We included patients with TB diagnosis, who died during TB treatment. Results: From 787 patients with TB, 69 died (8.8%). Fifty nine percent were male, the average of age was 51.9 years. There was diagnosis delay in 51% of the patients and 74% presented pulmonary TB. Sixty four percent 64 died in the first 30 days of the TB diagnosis and 61% of the deaths were attributable to TB. Twenty five percent of patients had TB/HIV coinfection. Elderly patients (> 65 years old) were associated with death in the first 30 days of TB diagnosis (p < 0,001). Discussion: The lethality found in this study was higher than expected (8.8%), the majority of patients had serious comorbidities. Elderly patients were associated with early death. The main pathophysiological mechanism of death was septic shock caused by severe tuberculous pneumonia.

Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country / Avaliação do impacto das mudanças do tratamento da tuberculose implantadas em 2009 no controle da tuberculose pulmonar no Brasil

ABSTRACT Objective: To analyze the impact that the 2009 changes in tuberculosis treatment in Brazil had on the rates of cure, tuberculosis recurrence, mortality, treatment abandonment, and multidrug-resistant tuberculosis (MDR-TB). Methods: An ordinary least squares regression model was used in order to perform an interrupted time series analysis of secondary data collected from the Brazilian Tuberculosis Case Registry Database for the period between January of 2003 and December of 2014. Results: The 2009 changes in tuberculosis treatment in Brazil were found to have no association with reductions in the total number of cases (β = 2.17; 95% CI: −3.80 to 8.14; p = 0.47) and in the number of new cases (β = −0.97; 95% CI: −5.89 to 3.94; p = 0.70), as well as having no association with treatment abandonment rates (β = 0.40; 95% CI: −1.12 to 1.93; p = 0.60). The changes in tuberculosis treatment also showed a trend toward an association with decreased cure rates (β = −4.14; 95% CI: −8.63 to 0.34; p = 0.07), as well as an association with increased mortality from pulmonary tuberculosis (β = 0.77; 95% CI: 0.16 to 1.38; p = 0.01). Although there was a significant increase in MDR-TB before and after the changes (p < 0.0001), there was no association between the intervention (i.e., the changes in tuberculosis treatment) and the increase in MDR-TB cases. Conclusions: The changes in tuberculosis treatment were unable to contain the decrease in cure rates, the increase in treatment abandonment rates, and the increase in MDR-TB rates, being associated with increased mortality from pulmonary tuberculosis during the study period. Keywords: Tuberculosis, pulmonary/epidemiology; Tuberculosis, pulmonary/drug therapy; Tuberculosis, pulmonary/mortality; Interrupted time series analysis; Drug resistance, multiple; Drug compounding.

RESUMO Objetivo: Analisar o impacto das mudanças do tratamento da tuberculose implantadas no Brasil em 2009 no número de casos de cura, de recidiva, de óbitos, de abandono e de tuberculose multirresistente (TBMR). Métodos: Foi realizada uma análise de séries temporais interrompida utilizando o modelo de regressão pelo método dos mínimos quadrados ordinários a partir de dados secundários coletados do Sistema de Informação de Agravos de Notificação da Tuberculose entre janeiro de 2003 e dezembro de 2014. Resultados: A análise mostrou independência entre as mudanças do tratamento e a redução do número total de casos (β = 2,17; IC95%: −3,80 a 8,14; 189 p = 0,47), a redução do número de novos casos (β = −0,97; IC95%: −5,89 a 3,94; p =190 0,70) e do abandono do tratamento (β = 0,40; IC95%: 199 −1,12 a 1,93; p = 0,60). Demonstrou ainda tendência à associação com a diminuição da cura (β = −4,14; IC95%: −8,63 a 0,34; p = 0,07) e associação com aumento da mortalidade por tuberculose pulmonar (β = 0,77; IC95%: 0,16 a 1,38; p = 0,01). A TBMR aumentou significativamente tanto no período anterior quanto no período posterior às mudanças do tratamento (p < 0,0001), embora de forma independente da intervenção (β = 0,13; IC95%: −0,03 a 0,29; p = 0,12). Conclusões: As mudanças no tratamento não impediram nem a diminuição na taxa de cura e nem o aumento do abandono e da TBMR; por outro lado, se associaram ao aumento de óbitos por tuberculose pulmonar durante o período do estudo.

Escrófula, forma frecuente de tuberculosis extrapulmonar. Presentación de un caso / Scrofula, a frequent form of extrapulmonary tuberculosis. Case presentation

Introducción: Las formas de presentación de la tuberculosis (Tb) incluyen: la tuberculosis pulmonar, la miliar y la extrapulmonar. Fuera del pulmón, los sitios donde con mayor frecuencia se localiza la tuberculosis son, por orden de frecuencia: ganglios linfáticos, pleura, aparato genitourinario, huesos y articulaciones, meninges, peritoneo y pericardio. Objetivo: Presentar un caso interesante en la clínica de Tuberculosis extrapulmonar y Tuberculosis pulmonar. Presentación del caso: Paciente masculino de 65 años de edad, alcohólico crónico y fumador, empezó a presentar un aumento de volumen en la región lateral derecha del cuello que fue creciendo progresivamente; además de tos húmeda con expectoración blanquecina, disfagia a los alimentos sólidos, astenia, anorexia y pérdida de peso. Al examen físico se evidencian múltiples adenopatías cervicales supurativas, la mayor de 6cm y estertores crepitantes en tercio superior de hemitórax derecho. La prueba de Mantoux fue positiva y la radiografía de tórax sugestiva de TB pulmonar. El paciente fue egresado por alta a petición con tratamiento antituberculoso y antibiótico ambulatorio, los cuales fueron abandonados por parte del paciente. Es ingresado en segunda ocasión en el Servicio de Geriatría por ulceración de la lesión mayor del cuello donde fallece al tercer día por una sepsis generalizada. Conclusiones: La tuberculosis de los ganglios linfáticos es la presentación más común de la tuberculosis extrapulmonar. Esta enfermedad ataca principalmente a personas inmunodeprimidas y en el caso presentado el paciente tenia factores que podrían haber deprimido su sistema inmune como la edad, el alcoholismo crónico y el tabaquismo(AU)

Introduction: The forms of presentation of the tuberculosis (Tb) include: the pulmonary, miliaria and extrapulmonary tuberculosis. Outside of the lung, the where places with major frequency localizes tuberculosis are, by order of frequency: lymphatic ganglions, pleura, genitourinary system, bones and joints, meninges, peritoneum and pericardium. Objective: To present an interesting case in the clinic of extrapulmonary Tb and lung Tb. Case presentation: Masculine 65-years patient of age, chronic alcoholic and smoker. That began to present an increase of volume in the lateral right region of the neck that went growing progressively; besides humid cough with whitish expectoration, dysphagia to the solid foods, asthenia, anorexia and loss of weight. The physical examination made evident multiple cervical suppurative adenopathias, the major of 6cm and crepitating rasps at the superior third of the right hemi-thorax. The Mantoux proof was positive and the thorax X-ray suggested a pulmonary TB. The patient was discharged with a treatment against tuberculosis and ambulatory antibiotic, which were abandoned by the patient. He was entered in second occasion in the service of geriatrics for ulceration of the major injury of the neck and dies at the third day for a generalized sepsis. Conclusions: The tuberculosis of the lymphatic ganglions is the more common presentation of the extrapulmonary tuberculosis. Illness attacks principally to the persons with low defenses and in the presented case the patient had factors that could have depressed his immune system as the age, the chronic alcoholism and the smoking(AU)

Facteurs associés aux décès des patients atteints de tuberculose pulmonaire au service de pneumo phtisiologie du Centre hospitalier universitaire Yalgado Ouédraogo de Ouagadougou, Burkina Faso : étude cas témoin

La tuberculose (TB) reste l'une des maladies transmissibles causant le plus de décès dans le monde. elle figure désormais au même titre que le Vih parmi les principales causes de décès dans le monde. le rapport 2015 de l'oMS décrit un total plus élevé de nouveaux cas de tuberculose (9,6 millions) que les années précédentes dont 6 millions (63%) ont été notifiés et 1,5 million de décès enregistrés (1,1 million de personnes Vih-négatives et 0,4 million personnes Vih-positives). l'afrique est le continent qui présente le taux d'incidence le plus élevé : 281 cas pour 100 000 habitants. les résultats des études menées montrent des niveaux de mortalités variables, le rôle favorisant de la co-infection au Vih, ainsi que du faible niveau socio-économique. Très peu d'études ont cependant exploré les facteurs de risque de décès des patients tuberculeux dans le contexte de la relative disponibilité des traitements antirétroviraux (TaRV). notre étude vise à identifier les facteurs de risque de décès des patients tuberculeux dans un contexte de disponibilité et d'accessibilité élargies aux TaRV au Burkina Faso. l'objectif de notre étude était d'identifier les facteurs de risque de décès des patients atteints de tuberculose pulmonaire dans le service de pneumo phtisiologie du Chu-Yo, de ouagadougou, Burkina Faso. une étude cas-témoin a été menée au service de pneumo phtisiologie du Chu-Yo, de ouagadougou, Burkina Faso, s'appuyant sur les données de 2011 à 2015. les cas de décès ont été identifiés à travers la revue des dessiers et registres d'hospitalisation. Ce groupe de cas de décès a été comparé à un groupe témoin constitué d'un nombre égal de malades adultes choisis parmi les malades également atteints de tuberculose pulmonaire à microscopie positive(TPM+) hospitalisés au cours de la même période et qui sont sortis vivants du service. les facteurs de risque ont été identifiés à partir d'une régression logistique simple en utilisant le logiciel stata version 13. au total, 54 cas de décès et 54 témoins ont été inclus dans l'analyse. l'analyse multi variée a identifié comme facteurs de risque de décès des patients atteints de TPM+ : le sexe masculin (oRa= 3,81 ; p= 0,04), l'absence de vaccination par le BCg (oRa= 15,34 ; p= 0,03), la co-infection par le Vih (oRa= 9,04 ; p= 0,002), la présence de comorbidités (oRa= 19,99 ; p= 0,000) et l'anorexie (oRa= 8,14 ; p= 0,000). les résultats de notre étude montrent que la co-infection par le Vih demeure un des facteurs de mauvais pronostic pour les malades atteints de la tuberculose à microscopie positive en dépit d'une plus grande disponibilité des aRVs. la vaccination par le BCg a aussi un effet protecteur contre le décès

Letalidad y sobrevida de pacientes con tuberculosis hospitalizados en el Instituto Nacional del Tórax / Fatality rate and survival amongst discharged inpatients with tuberculosis, Instituto Nacional del Torax, Chile

Background: Tuberculosis (TB) still is a public health issue in Chile. In the year 2015 TB incidence rate was 16 cases per 100.000 habitants and case fatality rate reached 10,8% of patients belonging to the last TB treatment follow-up of pulmonary cases cohort (2013). It is well noted higher case fatality rate in TB hospitalized patients. The aim of this study is to determine our hospital case-fatality rate, recognize main risks factors involved and establish survival at 6 months since hospital discharge. Methods: We conducted an observational retrospective study in the Instituto Nacional del Tórax (INT) including inpatients adults over 15 years old between July 2012 and June 2015 whose diagnosis at discharge time was tuberculosis. Demographic data, comorbidities, laboratory, microbiological and radiological test, hospital stay, treatment, complications and mortality at 6 months were recorded. We used a logistic regression model to identify mortality-associated factors and to analyze the survival using Kaplan-Meier’s method. Results: 100 patients whose average age was 46 ± 19 years-old were included. 64% were male. Pulmonary tuberculosis predominated (79 cases). The hospital stay was 27 ± 32 days. In-hospital case fatality rate was higher in pulmonary TB compared to other TB forms (11.4% and 8% respectively). Survival at 6 months was 91%. Multivariate analysis showed that increased case fatality rate was associated with albumin ≤ 3.0 g/dL, thrombocytopenia, and shock. Conclusions: case fatality rate in our hospitalized TB patients is similar to that described in the country. We must pay attention in pulmonary TB inpatients, which have decreased levels of albumin and platelet, or develop septic shock.

Introducción: La Tuberculosis (TBC) aún es un problema de salud pública en Chile. El 2015, la incidencia en todas las formas fue 16 casos x 100.000 habitantes, y en la cohorte de casos de TBC pulmonar adultos en tratamiento, la letalidad fue 10,8% (2013). Un subgrupo de estos pacientes requieren hospitalización y tienen mayor morbimortalidad. Objetivo: Conocer la letalidad hospitalaria, los factores riesgo y determinar la sobrevida a 6 meses del diagnóstico e inicio del tratamiento. Método: Estudio retrospectivo, observacional que incluyó a todos los pacientes >15 años, hospitalizados en el Instituto Nacional del Tórax (INT) entre el 1 julio 2012 al 30 Junio 2015 y cuyo diagnóstico de egreso fue TBC. Se registraron datos demográficos, comorbilidades, exámenes de laboratorio, microbiológicos, radiológicos, estadía hospitalaria, tratamiento, complicaciones y letalidad a 6 meses. Para identificar factores asociados a letalidad, utilizamos un modelo de regresión logística y para sobrevida se utilizó la curva de Kaplan-Meier. Resultados: Se incluyeron 100 pacientes, edad 46 ± 19 años, 64% varones. Predominó la TBC pulmonar (79%). La estadía hospitalaria fue 27 ± 32 días. La letalidad intrahospitalaria fue 8% en TBC y 11,4% en TBC pulmonar. La sobrevida a los 6 meses fue 91 %>. El análisis multivariado mostró que la letalidad se asoció estadísticamente con niveles de albúmina ≤ 3,0 g/dl, trombocitopenia y shock séptico. Conclusiones: La letalidad en pacientes hospitalizados con TBC es similar a la descrita en el país. Se debe poner especial atención en pacientes con TBC pulmonar que tienen hipoalbuminemia, trombocitopenia al ingreso, o desarrollan shock séptico.

Treatment outcome of human immunodeficiency virus and tuberculosis co-infected patients in public hospitals of eastern and southern zone of Tigray region, Ethiopia

Background: Tuberculosis is a leading cause of death among people living with human immunodeficiency virus. In sub-Saharan Africa, tuberculosis accounts for more than 78% of all deaths among people with human immunodeficiency virus. Objectives: To assess tuberculosis treatment outcome and the associated factors in adult tuberculosis/human immunodeficiency virus co-infected patients in four public hospitals of eastern and southern zone of Tigray region, Ethiopia. Methodology: Institution based cross-sectional study design was used to examine secondary data from tuberculosis/human immunodeficiency virus co-infected patients attending four public hospitals of eastern and southern zone of Tigray, from January 2009 to August 2011. Systematic random sampling technique was used to select individual patient cards from the respective hospitals. Univariate analysis and multivariate logistic regression modeling was used to assess the impact of each variable in predicting treatment outcome. Results: Out of 342 patients included, 199 (58.2%) patients completed treatment, 43 (12.6%) patients were cured, 88 (25.7%) died, 7 (2%) defaulted, and 5 (1.5%) patients failed treatment. Treatment success rate was around 71%. In the multivariate logistic regression analysis the factors that were strongly associated with unfavorable tuberculosis treatment outcomes were WHO stage IV (AOR = 3.2, CI = 1.58-6.82, p-value = 0.001), age greater than 45 years (AOR = 6.08, CI = 2.28-16.23) and baseline CD4 count less than 200 cells/L (AOR = 6.19, CI = 2.28-16.89, p-value = 0.001). Conclusion: The rate of treatment success in this study was lower than the rate newly recommended by WHO. Therefore, efforts should be undertaken to improve treatment success rates of both diseases. .

Comparative proteomic analysis of sequential isolates of Mycobacterium tuberculosis from a patient with pulmonary tuberculosis turning from drug sensitive to multidrug resistant.

Background & objectives: Tuberculosis is a major health problem in India, and the emergence of multidrug resistant (MDR) and extensively drug resistant (XDR) strains of Mycobacterium tuberculosis (Mtb) has further complicated the situation. Though several studies characterizing drug sensitive and drug resistant strains are available in literature, almost all studies are done on unrelated strains. Therefore, the objective of this study was to compare the proteomic data of four sequential isolates of Mtb from a single patient who developed MDR-TB during the course of anti-tuberculosis therapy (ATT). Methods: In this study, using two-dimensional (2D) gel electrophoresis and MALDI-TOF mass spectrometry, we compared and analyzed the cell lysate proteins of Mtb sequential clinical isolates from a patient undergoing anti-TB treatment. The mRNA expression levels of selected identified proteins were determined by quantitative real-time polymerase chain reaction (qRT-PCR). Results: The genotypes of all four isolates remained homologous, indicating no re-infection. The initial isolate (before treatment) was sensitive to all first-line drugs, but the consecutive isolates were found to be resistant to isoniazid (INH) and rifampicin (RIF) and developed mutations in the katG, inhA and rpoB. the intensities of 27 protein spots were found to be consistently overexpressed in INH and RIF resistant isolates. The most prominent and overexpressed proteins found during the development of drug resistance were GarA (Rv1827), wag31 (Rv2145c), Rv1437 and Rv2970c. Interpretation & conclusions: This preliminary proteomic study provides an insight about the proteins that are upregulated during drug resistance development. These upregulated proteins, identified here, could prove useful as immunodiagnostic and possibly drug resistant markers in future. However, more studies are required to confirm these findings.

Magnitude da tuberculose pulmonar na população fronteiriça de Mato Grosso do Sul (Brasil), Paraguai e Bolívia / Pulmonary tuberculosis among residents of municipalities in Mato Grosso do Sul State, Brazil, bordering on Paraguay and Bolivia / Magnitud de la tuberculosis pulmonar en la población fronteriza de Mato Grosso do Sul (Brasil), Paraguay y Bolivia

Este estudo analisou a magnitude da tuberculose pulmonar no período de 2007 a 2010 em municípios sul-mato-grossenses fronteiriços ao Paraguai e à Bolívia. Na região de fronteira, as taxas de incidência (49,1/100 mil habitantes), de mortalidade (4,0/100 mil) e de abandono do tratamento (11,3%) foram 1,6, 1,8 e 1,5 vez maiores do que na região não fronteiriça. Entre indígenas da fronteira, as taxas de incidência (253,4/100 mil habitantes), mortalidade (11,6/100 mil) e coinfecção por HIV (1,9/100 mil) foram, respectivamente, 6,4, 3,2 vezes e 1,9 vez maiores do que entre os não indígenas nesta região. Estar na região de fronteira revelou-se fator de proteção contra coinfecção por HIV. Constatou-se associação entre ser indígena e não abandonar o tratamento. Conclui-se que a população residente nesses municípios de fronteira vivencia elevado risco de adoecimento, de morte e de abandono do tratamento de tuberculose pulmonar, o que requer ações diferenciadas de vigilância em saúde.

This study analyzed the epidemiological profile of pulmonary tuberculosis from 2007 to 2010 in municipalities (counties) in Mato Grosso do Sul State, Brazil, that border on Paraguay and Bolivia. In the border region, the incidence rate (49.1/100,000 inhabitants), mortality rate (4.0/100,000 inhabitants), and treatment dropout rate (11.3%) were 1.6, 1.8, and 1.5 times higher than in the non-border region. Among indigenous individuals in the border region, the rates for incidence (253.4/100,000 inhabitants), mortality (11.6/100,000 inhabitants), and HIV/TB co-infection (1.9/100,000 inhabitants) were 6.4, 3.2, and 1.9 times higher than in non-indigenous individuals in this region. Living in the border regions was inversely associated with HIV/TB co-infection. Indigenous ethnicity was associated statistically with not abandoning TB treatment. The study concludes that the population residing in these municipalities along the border is exposed to high risk of pulmonary TB and TB mortality and treatment dropout, thus requiring special health surveillance interventions.

Este estudio examinó la magnitud de la tuberculosis pulmonar del 2007 al 2010 en los municipios de Mato Grosso do Sul (Brasil) limítrofes con Paraguay y Bolivia. En la región fronteriza, las tasas de incidencia (49,1/100.000 habitantes), mortalidad (4,0/100.000) y abandono del tratamiento (11,3%) fueron 1,6, 1,8 y 1,5 veces más altas que en la región no fronteriza. En la región fronteriza, las tasas de incidencia (253,4/100.000 habitantes), mortalidad (11,6/100.000) y co-infección por el VIH (1,9/100.000) entre residentes indígenas fueron 6,4, 3,2 y 1,9 veces más altas que en la población no indígena. Vivir en la región fronteriza resultó ser un factor protector contra la co-infección por el VIH. Se identificó asociación entre ser indígena y no abandonar el tratamiento. Los resultados mostraron que la población de estos municipios fronterizos está sujeta a un alto riesgo de enfermedad, muerte y abandono del tratamiento de la tuberculosis pulmonar, lo que requiere acciones de vigilancia de la salud específicas para este contexto.

Spatial analysis of deaths from pulmonary tuberculosis in the city of São Luís, Brazil / Análise espacial dos óbitos por tuberculose pulmonar em São Luís, Maranhão

OBJECTIVE: To characterize deaths from pulmonary tuberculosis, according to sociodemographic and operational variables, in the city of São Luís, Brazil, and to describe their spatial distribution. METHODS: This was an exploratory ecological study based on secondary data from death certificates, obtained from the Brazilian Mortality Database, related to deaths from pulmonary tuberculosis. We included all deaths attributed to pulmonary tuberculosis that occurred in the urban area of São Luís between 2008 and 2012. We performed univariate and bivariate analyses of the sociodemographic and operational variables of the deaths investigated, as well as evaluating the spatial distribution of the events by kernel density estimation. RESULTS: During the study period, there were 193 deaths from pulmonary tuberculosis in São Luís. The median age of the affected individuals was 52 years. Of the 193 individuals who died, 142 (73.60%) were male, 133 (68.91%) were Mulatto, 102 (53.13%) were single, and 64 (33.16%) had completed middle school. There was a significant positive association between not having received medical care prior to death and an autopsy having been performed (p = 0.001). A thematic map by density of points showed that the spatial distribution of those deaths was heterogeneous and that the density was as high as 8.12 deaths/km2. CONCLUSIONS: The sociodemographic and operational characteristics of the deaths from pulmonary tuberculosis evaluated in this study, as well as the identification of priority areas for control and surveillance of the disease, could promote public health policies aimed at reducing health inequities, allowing the optimization of resources, as well as informing decisions regarding the selection of strategies and specific interventions targeting the most vulnerable populations. .

OBJETIVO: Caracterizar os óbitos por tuberculose pulmonar em São Luís (MA) segundo variáveis sociodemográficas e operacionais e descrever sua distribuição espacial. MÉTODOS: Estudo ecológico e exploratório baseado em dados secundários oriundos das declarações de óbitos por tuberculose pulmonar do Sistema de Informação sobre Mortalidade. Foram incluídos todos os óbitos por tuberculose pulmonar ocorridos na zona urbana de São Luís entre 2008 e 2012. Foram realizadas análises univariadas e bivariadas das variáveis sociodemográficas e operacionais dos óbitos investigados e a distribuição espacial dos eventos por kernel density estimation. RESULTADOS: No período estudado, foram registrados 193 óbitos. A mediana de idade foi de 52 anos. Dos 193 indivíduos, 142 (73,60%) eram do sexo masculino, 133 (68,91%) da raça/cor parda, 102 (53,13%) eram solteiros, e 64 (33,16%) haviam completado o ensino fundamental. Observou-se que não ter recebido assistência médica antes do óbito teve uma associação estatisticamente significativa com a realização de necropsia (p = 0,001). O mapa temático por densidade de pontos demonstrou uma heterogeneidade na distribuição espacial dos óbitos, com taxas de até 8,12 óbitos/km2. CONCLUSÕES: As características sociodemográficas e operacionais dos óbitos por tuberculose pulmonar evidenciadas nessa investigação, bem como a identificação dos locais prioritários para o controle e a vigilância da doença, poderão auxiliar a gestão pública na diminuição das iniquidades em saúde e permitir uma otimização dos recursos, fornecendo subsídios para a escolha de estratégias e intervenções ...

Effect of pulmonary hypertension on outcome of pulmonary tuberculosis

Background: This study performed at the National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran, aimed to evaluate the effect of concomitant pulmonary hypertension on the outcome of pulmonary tuberculosis. Methods: New cases of pulmonary tuberculosis were recruited for the study. Pulmonary hypertension was defined as systolic pulmonary arterial pressure ≥35 mm Hg estimated by transthoracic Doppler echocardiography. We assessed the relationship between pulmonary hypertension and mortality during the six-month treatment of tuberculosis. Results: Of 777 new cases of pulmonary tuberculosis, 74 (9.5%) had systolic pulmonary arterial pressure ≥35 mm Hg. Ten of them (13.5%) died during treatment compared to 5% of cases with pulmonary arterial pressure less than 35 mm Hg (p = 0.007). Logistic regression analysis showed that pulmonary hypertension and drug abuse remained independently associated with mortality (OR = 3.1; 95% CI: 1.44–6.75 and OR = 4.4; 95% CI: 2.35–8.17, respectively). Conclusion: A significant association was found between mortality and presence of pulmonary hypertension and drug abuse among new cases of pulmonary tuberculosis. .

Tuberculosis in hospitalized patients: clinical characteristics of patients receiving treatment within the first 24 h after admission / Tuberculose em pacientes hospitalizados: características clínicas dos pacientes que iniciaram tratamento nas primeiras 24 h de permanência hospitalar

Objective: To evaluate clinical characteristics and outcomes in patients hospitalized for tuberculosis, comparing those in whom tuberculosis treatment was started within the first 24 h after admission with those who did not. Methods: This was a retrospective cohort study involving new tuberculosis cases in patients aged ≥ 18 years who were hospitalized after seeking treatment in the emergency room. Results: We included 305 hospitalized patients, of whom 67 (22.0%) received tuberculosis treatment within the first 24 h after admission ( ≤24h group) and 238 (88.0%) did not (>24h group). Initiation of tuberculosis treatment within the first 24 h after admission was associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001). In the ≤24h and >24h groups, respectively, the ICU admission rate was 22.4% and 15.5% (p = 0.258); mechanical ventilation was used in 22.4% and 13.9% (p = 0.133); in-hospital mortality was 22.4% and 14.7% (p = 0.189); and a cure was achieved in 44.8% and 52.5% (p = 0.326). Conclusions: Although tuberculosis treatment was initiated promptly in a considerable proportion of the inpatients evaluated, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment. .

Objetivo: Comparar as características clínicas e os desfechos de pacientes hospitalizados por tuberculose que iniciaram tratamento nas primeiras 24 h de permanência hospitalar com as daqueles que iniciaram tratamento após 24 h. Métodos: Estudo de coorte retrospectivo de casos novos de tuberculose com idade ≥ 18 anos que necessitaram internação hospitalar após atendimento no setor de emergência. Resultados: Foram incluídos 305 pacientes hospitalizados, dos quais 67 (22,0%) iniciaram o tratamento nas primeiras 24 h (grupo ≤24h), e 238 (88,0%) o iniciaram após (grupo >24h). Ser do sexo feminino (OR = 1,99; IC95%: 1,06-3,74; p = 0,032) e ter pesquisa de BAAR positiva no escarro espontâneo (OR = 4,19; IC95%: 1,94-9,00; p < 0,001) se associaram com o tratamento nas primeiras 24 h. Na comparação dos grupos ≤24h e >24h, a taxa de internação em UTI foi de, respectivamente, 22,4% e 15,5% (p = 0,258), enquanto a ventilação mecânica foi utilizada em 22,4% e 13,9% (p = 0,133), a taxa de óbito hospitalar foi de 22,4% e 14,7% (p = 0,189), e a taxa de cura foi de 44,8% e 52,5% (p = 0,326). Conclusões: Embora o tratamento antituberculose tenha sido iniciado rapidamente em uma proporção considerável dos pacientes hospitalizados, as taxas de mortalidade hospitalar, internação em UTI e uso de ventilação mecânica permaneceram elevadas. Estratégias para o controle de tuberculose na atenção primária devem considerar que pacientes atendidos em hospitais chegam muito tardiamente e com doença avançada, sendo necessário implementar medidas de busca ativa na comunidade para o diagnóstico e o tratamento mais precoce. .

Tuberculosis among HIV-1-infected subjects in a tertiary out-patient service in São Paulo city, Brazil / Tuberculose entre pacientes infectados pelo HIV-1 em ambulatório terciário de São Paulo, Brasil

TB is currently considered to be the most important infectious disease among HIV-1-infected subjects in developing countries, such as Brazil. A retrospective analysis of TB cases was performed, occurring from January 1995 to December 2010 in our cohort of 599 HIV positive patients. The primary outcome was the occurrence of active TB. Forty-one TB cases were diagnosed over this period of 16 years, among 599 HIV positive patients in an open cohort setting in the city of Sao Paulo, Brazil. All-time lowest mean CD4 T cell count at the time of TB diagnosis was 146 and 186 cells/mm³, respectively. The mean HIV viral load was 5.19 log10 copies/mL, and 59% of the patients were on HAART. TB incidence was 1.47 per 100 person-years, for a total follow-up time of 2775 person-years. The probability of surviving up to 10 years after diagnosis was 75% for TB patients as opposed to 96% for patients with other, non-TB opportunistic diseases (p = 0.03). TB can be considered a public health problem among people living with HIV in Brazil despite of the widespread use of antiretrovirals for the treatment of HIV infection/AIDS.

Atualmente, a tuberculose (TB) é considerada a doença infecciosa mais importante entre os pacientes infectados pelo HIV-1 nos países em desenvolvimento, como o Brasil. Análise retrospectiva dos casos de tuberculose ocorridos a partir de janeiro 1995 até dezembro de 2010 foi realizada em nossa coorte de 599 pacientes HIV positivos. O desfecho primário foi a ocorrência de TB ativa, e 41 casos da doença foram diagnosticados durante este período de 16 anos. As contagens médias do nadir de células T CD4 e ao momento do diagnóstico de TB foram de 146 e 217 células/mm³, respectivamente. A carga viral média de HIV foi de 5,19 log10 cópias/mL, e 59% dos pacientes estavam em tratamento com ART. A incidência de TB foi de 1,47 casos por 100 pessoas-ano, para um tempo total de seguimento da coorte de 2775 pessoas-ano. A probabilidade de sobreviver até 10 anos após o diagnóstico foi de 75% para pacientes com TB, em oposição a 96% para pacientes com outras doenças oportunistas não-TB (p = 0,03). A tuberculose pode ser considerada problema de saúde pública entre as pessoas que vivem com HIV no Brasil, apesar da ampla utilização de anti-retrovirais para o tratamento da infecção pelo HIV / AIDS.

Tuberculose grave com necessidade de internação em UTI / Severe tuberculosis requiring ICU admission

A tuberculose é uma doença curável que pode evoluir para formas graves com necessidade de tratamento dos pacientes em UTI, especialmente se essa não for diagnosticada em tempo ou se afetar pacientes idosos, aqueles em diálise e aqueles com infecção pelo HIV ou outros estados de imunossupressão, assim como nos casos de doença multirresistente. O conhecimento da apresentação radiológica dos casos pode auxiliar no diagnóstico dessas formas graves, assim como a introdução de novos testes, como a detecção rápida do agente por PCR e a TC de tórax, favorecendo o início precoce do tratamento. Além disso, o uso de esquemas sem isoniazida e rifampicina, a absorção entérica incerta e as baixas concentrações séricas das drogas antituberculose podem contribuir para a diminuição da eficácia do tratamento. O prognóstico desses pacientes geralmente é ruim, com elevadas taxas de mortalidade.

Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.

Tuberculosis, comportamiento de la mortalidad en pacientes de 60 años de edad o más / Tuberculosis, mortality behavior in patients aged 60 and over

Introducción: a pesar de los conocimientos alcanzados con respecto a la tuberculosis, esta enfermedad sigue siendo hoy en día la causa de muerte de muchos pacientes. Objetivo: describir el comportamiento de la mortalidad por o con tuberculosis, en los fallecidos de 60 años o más. Métodos: se estudiaron los 51 fallecidos de tuberculosis en Ciudad de La Habana entre los años 2005 y 2008. La informaci¾n se obtuvo a partir de la revisión de la base de datos de tuberculosis del Departamento de Higiene y Epidemiología de la Dirección Provincial de Salud de Ciudad de La Habana. Resultados: la investigación demostró que el 41,2 porciento falleció entre los 70 a 79 años de edad; predominó el sexo masculino con un 74,5 porciento y la pérdida de peso se asoció en el 47,1 porciento. Se realizó el diagnóstico en la atención secundaria de salud en el 68,2 porciento y la tuberculosis pulmonar representó el 96,1 porciento de los casos diagnosticados en vida, con esta localización. Predominaron los bacilos ácido alcohol resistente positivos (77,8 porciento) y el 100 porciento fueron casos nuevos. Conclusiones: aunque la atención primaria está totalmente estructurada a lo largo y ancho de nuestro país, los resultados de este trabajo indican que es una prioridad, el fortalecimiento en la detección de la enfermedad a este nivel de salud

Introduction: despite the knowledge gained on tuberculosis, this condition is still the cause of death for many patients. Objective: to describe the mortality behavior of tuberculosis in dead patients older than 60. Methods: an investigation was conducted on 51 deceased patients who died of tuberculosis from 2005 to 2008 in Havana City. The information was obtained by reviewing the Hygiene and Epidemiology Department tuberculosis database at Havana Public Health Provincial Direction. Results: this research showed that 41.2 percent of the patients died at 70 to 79 years old; there was male predominance (74.5 percent). Weight loss was associated in 47.1 percent of the cases. 68.2 percent had the diagnosis in secondary care level and pulmonary tuberculosis accounted for 96.1 percent of cases diagnosed when alive. Positive acid-fast bacilli resistant (77.8 percent) was predominant and 100 percent were new cases. Conclusions: although primary health care is fully structured throughout our country, the results of this study suggest the need for a strengthening in detecting this disease at this level of health care as a priority

Preditores dos desfechos do tratamento da tuberculose / Predictors of tuberculosis treatment outcomes

OBJETIVO: Analisar os desfechos do tratamento da tuberculose e seus preditores. MÉTODOS: Estudo longitudinal de coorte de pacientes com tuberculose tratados entre 2004 e 2006 no Instituto de Pesquisa Evandro Chagas, na cidade do Rio de Janeiro. As razões de risco ajustadas (RRa) dos preditores foram estimadas. RESULTADOS: Foram incluídos 311 pacientes. As taxas de cura, de abandono, de mortalidade e de falha terapêutica foram, respectivamente, 72 por cento, 19 por cento, 6 por cento e 2 por cento. A troca de regime terapêutico por eventos adversos foi necessária em 8 por cento. O alcoolismo (RRa, 0,30), uso do regime estreptomicina+etambutol+ofloxacina (SEO; RRa, 0,32), infecção por HIV sem tratamento antirretroviral (TARV; RRa, 0,36) e o uso do regime rifampicina+isoniazida+pirazinamida+etambutol (RRa, 0,58) reduziram a probabilidade de cura. A faixa etária mais jovem (RRa, 3,84) e o alcoolismo (RRa, 1,76) aumentaram a probabilidade do abandono. Não foi possível determinar as RRa para os demais desfechos devido a suas baixas prevalências. Entretanto, medidas do risco relativo (RR) identificaram os seguintes potenciais preditores do óbito: uso de esquema SEO (RR, 11,43), infecção pelo HIV sem TARV (RR, 9,64), forma clínica disseminada (RR, 9,09), ausência de confirmação bacteriológica (RR, 4,00), diabetes mellitus (RR, 3,94) e comportamento homo/bissexual (RR, 2,97). A baixa renda (RR, 11,70) foi potencial preditor para falha terapêutica, ao passo que infecção pelo HIV com uso de TARV (RR, 2,46) e forma clínica disseminada (RR, 3,57) foram potenciais preditores para troca do esquema por evento adverso. CONCLUSÕES: O esquema SEO deve ser utilizado transitoriamente quando possível. Os dados confirmam a importância de TARV e sugerem a necessidade de seu início precoce.

OBJECTIVE: To analyze tuberculosis treatment outcomes and their predictors. METHODS: This was a retrospective longitudinal cohort study involving tuberculosis patients treated between 2004 and 2006 at the Instituto de Pesquisa Evandro Chagas, in the city of Rio de Janeiro. We estimated adjusted risk ratios (ARRs) for the predictors of treatment outcomes. RESULTS: Among 311 patients evaluated, the rates of cure, treatment abandonment, treatment failure, and mortality were 72 percent, 19 percent, 2 percent, and 6 percent, respectively. Changes in the treatment regimen due to adverse events occurred in 8 percent. The factors found to reduce the probability of cure were alcoholism (ARR, 0.30), use of the streptomycin+ethambutol+ofloxacin (SEO) regimen (ARR, 0.32), HIV infection without the use of antiretroviral therapy (ART; ARR, 0.36), and use of the rifampin+isoniazid+pyrazinamide+ethambutol regimen (ARR, 0.58). Being younger and being alcoholic both increased the probability of abandonment (ARR, 3.84 and 1.76, respectively). It was impossible to determine the ARR for the remaining outcomes due to their low prevalence. However, using the relative risk (RR), we identified the following potential predictors of mortality: use of the SEO regimen (RR, 11.43); HIV infection without ART (RR, 9.64); disseminated tuberculosis (RR, 9.09); lack of bacteriological confirmation (RR, 4.00); diabetes mellitus (RR, 3.94); and homosexual/bisexual behavior (RR, 2.97). Low income was a potential predictor of treatment failure (RR, 11.70), whereas disseminated tuberculosis and HIV infection with ART were potential predictors of changes in the regimen due to adverse events (RR, 3.57 and 2.46, respectively). CONCLUSIONS: The SEO regimen should not be used for extended periods. The data confirm the importance of ART and suggest the need to use it early.

Desfechos de tratamento de tuberculose em pacientes hospitalizados e não hospitalizados no município de São Paulo / Outcomes of tuberculosis treatment among inpatients and outpatients in the city of São Paulo, Brazil

OBJETIVO: Comparar os desfechos de tratamento de tuberculose em pacientes hospitalizados e aqueles tratados exclusivamente na atenção primária na cidade de São Paulo (SP), bem como determinar as variáveis mais associadas à internação. MÉTODOS: Pesquisa prospectiva e longitudinal, realizada entre janeiro e dezembro de 2007 em dois hospitais de grande porte e em serviços de saúde em duas regiões na cidade de São Paulo. Os dados foram coletados através de um questionário estruturado, no caso dos pacientes internados, e no Banco de Dados de Tuberculose da Secretaria Estadual de Saúde de São Paulo. RESULTADOS: Dos 474 pacientes incluídos no estudo, 166 estavam hospitalizados, e 308 eram pacientes ambulatoriais. A análise multivariada mostrou associações entre internação por tuberculose e diagnóstico de tuberculose em hospital/pronto-socorro (OR = 55,42), coinfecção por HIV (OR = 18,57), retratamento (OR = 18,51) e procura por outro serviço anteriormente (OR = 12,32). Para os pacientes hospitalizados e ambulatoriais, as taxas gerais de cura foram de 41,6 por cento e 78,3 por cento, respectivamente, ao passo que, para aqueles coinfectados por HIV, essas foram de 30,4 por cento e 58,5 por cento, enquanto as taxas gerais de mortalidade foram de 29,5 por cento e 2,6 por cento, respectivamente, ao passo que, para aqueles coinfectados por HIV, essas foram de 45,7 por cento e 9,8 por cento. CONCLUSÕES: Este estudo evidenciou maior gravidade, maior dificuldade de diagnóstico, menor taxa de cura e maior taxa de mortalidade nos pacientes internados que naqueles ambulatoriais. Além disso, os desfechos foram piores no subgrupo de pacientes coinfectados com HIV.

OBJECTIVE: To compare inpatient and outpatient treatment of tuberculosis, in terms of outcomes, in the city of São Paulo, Brazil, as well to determine which variables are most frequently associated with hospitalization. METHODS: A prospective, longitudinal study carried out between January and December of 2007, at two large hospitals and at outpatient clinics, in two regions of the city of São Paulo. For inpatients, data were collected with a structured questionnaire. Additional data were obtained from the São Paulo State Department of Health Tuberculosis Database. RESULTS: Of the 474 patients included in the study, 166 were inpatients, and 308 were outpatients. The multivariate analysis showed that hospitalization for tuberculosis was associated with hospital/emergency room diagnosis of tuberculosis (OR = 55.42), with HIV co-infection (OR = 18.57), with retreatment (OR = 18.51), and with having previously sought treatment at another health care facility (OR = 12.32). For the inpatient and outpatient groups, the overall cure rates were 41.6 percent and 78.3 percent, respectively, compared with 30.4 percent and 58.5 percent for those who were co-infected with HIV, whereas the overall mortality rates were 29.5 percent and 2.6 percent, respectively, compared with 45.7 percent and 9.8 percent for those who were co-infected with HIV. CONCLUSIONS: Among inpatients, tuberculosis appears to be more severe and more difficult to diagnose, resulting in lower cure rates and higher mortality rates, than among outpatients. In addition, tuberculosis patients co-infected with HIV have less favorable outcomes.

Estudo dinâmico da mortalidade por tuberculose no Estado de São Paulo, Brasil: uma abordagem bayesiana / Dynamic study of tuberculosis mortality in São Paulo State, Brazil: a Bayesian approach

Neste trabalho, utilizamos a técnica bayesiana de modelos lineares dinâmicos para estudar a dinâmica da mortalidade por tuberculose (TB) no Estado de São Paulo, Brasil. O estudo confirma os resultados empíricos da literatura, que indicam o decaimento da mortalidade para esse estado na última década. Este trabalho também indica um crescimento no número de óbitos a partir de 2005. A análise das duas causas básicas com maior ocorrência revelou que tal aumento é em razão da coinfecção HIV/TB. Previsões para os próximos dois anos foram realizadas, dando poucas evidências para sustentar a continuidade de tendência decrescente do número de óbitos por TB.

This study used dynamic linear models to analyze the dynamics of tuberculosis (TB) mortality in São Paulo State, Brazil. The study confirms previous findings of a decline in TB mortality in State in the last decade, while pointing to an increase in deaths beginning in 2005. Analysis of the two most frequent underlying causes pointed to HIV/TB co-infection. Forecasts for the next two years were performed, providing little evidence to support a continuing downward trend in the number of TB-related deaths.

Monitoramento epidemiológico da tuberculose em um hospital geral universitário / Epidemiological monitoring of tuberculosis in a general teaching hospital

OBJETIVO: Descrever o monitoramento epidemiológico da exposição à tuberculose realizado em ambiente hospitalar e analisar o perfil da doença em um hospital geral universitário. MÉTODOS: Estudo descritivo e retrospectivo dos casos diagnosticados de tuberculose no período entre 2000 e 2006, com a determinação de indicadores de morbidade e mortalidade, que foram comparados a população geral de pacientes atendidos no hospital e com o total de funcionários do hospital que desenvolveram tuberculose ativa. RESULTADOS: Foram atendidos 763 pacientes com tuberculose ativa (média, 109 pacientes/ano), sendo 481 (63,1 por cento) do sexo masculino. A faixa etária mais atingida foi a de 30 a 59 anos. As formas clínicas pulmonares e extrapulmonares exclusivas foram predominantes. Entretanto, entre os pacientes internados, as formas pulmonares associadas às extrapulmonares e as formas pulmonares não bacilíferas exclusivas foram mais frequentes. A presença de comorbidades foi mais prevalente entre os pacientes internados e entre os que evoluíram para óbito. Apenas 52,8 por cento dos casos atendidos no hospital foram notificados. Os indicadores hospitalares gerais demonstraram maior tempo de internação hospitalar e mortalidade entre os pacientes com tuberculose. CONCLUSÕES: A incidência e prevalência indicam um alto risco de exposição à tuberculose no hospital no período estudado. Os indicadores propostos apresentam um potencial de padronização dos procedimentos de monitoramento da tuberculose hospitalar, e o perfil epidemiológico aqui descrito poderá contribuir para um melhor entendimento da situação da doença no país.

OBJECTIVE: To describe the epidemiological monitoring of exposure to tuberculosis in a hospital environment and to analyze the profile of the disease in a general teaching hospital. METHODS: A descriptive and retrospectivestudy of tuberculosis cases diagnosed between 2000 and 2006, with the determination of indicators of morbidity and mortality, which were compared with the general population of patients treated at the hospital and with the hospital employees who developed active tuberculosis. RESULTS: There were 763 patients who were treated for active tuberculosis (mean, 109 patients/year), 481 (63.1 percent) of whom were male. Most of the patients were in the 30-59 year age bracket. Tuberculosis that was exclusively pulmonary or extrapulmonary predominated. However, among the hospitalized patients, the combination of pulmonary and extrapulmonary tuberculosis, as well as exclusively noninfectious tuberculosis, predominated. Comorbidities were more prevalent among the hospitalized patients and among those who evolved to death. Only 52.8 percent of the cases treated at the hospital were reported. The overall hospital indicators showed longer length of hospital stay and greater mortality among the patients with tuberculosis. The incidence and prevalence show that there was a high risk of exposure to tuberculosis in the hospital during the period studied. CONCLUSIONS: The proposed indicators can potentially help standardize epidemiological monitoring procedures for nosocomial tuberculosis, and the epidemiological profile described in this study can contribute to a better understanding of the situation of tuberculosis in Brazil.