Predictors of mortality among patients with acute leukemias admitted to an intensive care unit specialized in patients with hematological disease at a Brazilian hospital

Abstract Introduction Hematologists deal every day with high mortality rates of acute leukemia patients. Many times these patients need Intensive Care Unit (ICU) support and some general ICU teams believe that these patients have a much greater chance of dying than patients with other pathologies. In Brazil, data related to mortality rates and ICUs for acute leukemia patients are scarce. Methods Therefore, to assess mortality predictors in patients with acute leukemia admitted to a specialized hematological ICU, we evaluated demographics, supportive care, hospitalization time, disease status, admitting diagnosis, neutropenia, number of transfusions and Acute Physiology and Chronic Health Evaluation (APACHE)/Sepsis Related Organ Failure Assessment (SOFA) scores as possible factors associated with mortality. Data were extracted from the first admission records of 110 patients with acute leukemia admitted to the Hemocentro de Pernambuco (Hemope) ICU between 2006 and 2009. Results In this retrospective cohort study, 72/110 of the patients were men, and 64/110 were from the metropolitan area of Recife. The patients' age median was 43.5 years (±17.9); 67.3% had acute myeloid leukemia (AML) and 32.7% had acute lymphoid leukemia. The main admitting diagnosis in the ICU was sepsis (66.7%). The mean APACHE II score was 18.3. Of the total, 65 (59%) died, and the mortality rate was independently related to longer hospitalization (p < 0.001), the increase in the APACHE II score (p < 0.038) and having received hemodialysis (p < 0.006). Neutropenia, receiving multiple transfusions and using any kind of mechanical ventilation or vasoactive drug on admission were not relevant to mortality. Factors associated with higher mortality rates were: longer hospitalization, increase in the APACHE II score, and use of hemodialysis. Conclusion With these data, to prevent organ lesions before admission to the ICU, a better strategy might be to reduce mortality for leukemia patients.

Test seeking: are healthcare professionals referring people to blood centers for infections marker testing?

ABSTRACT Background: Test-seeking is associated with HIV in Brazilian blood donors. This study sought to investigate the frequency with which three different donor groups: deferred donors, accepted donors who tested HIV positive [HIV (+)], and accepted donors who tested infectious disease markers negative [IDM (−)], came to the blood bank at the suggestion of a health care professional. Study design and methods: Donors deferred for reporting high-risk behaviors and participants in an HIV risk factor case-control study completed a confidential audio computer-assisted self-interview (ACASI) that included two questions related to health care professionals and test-seeking. Results: Of 4013 enrolled deferred donors, 468 (11.8%) reported a health care professional suggested donation as a way to be tested for infection. Of 341 HIV (+) and 791 IDM (−) participants, 43 (12.6%) and 11 (1.4%), respectively, reported a health care professional suggested donation as a way to be tested for infection. Physicians were the most frequently reported source of referral: [(61.5% of deferred, 69.1% of HIV (+), and 9.1% of IDM (−) donors)]. Conclusion: HIV (+) donors and deferred donors were 10 times more likely to report test-seeking behavior by suggestion of health care professional than IDM (−) donors. If true, efforts should be made to educate health care professionals and blood donors on how to safeguard the blood supply, emphasizing that HIV testing should be done at volunteer testing centers rather than at the blood centers.

NLRP3 polymorphism is associated with protection against human T-lymphotropic virus 1 infection

Inter-individual heterogeneity in the response to human T-lymphotropic virus 1 (HTLV-1) infection has been partially attributed to host genetic background. The antiviral activity of the inflammasome cytoplasmic complex recognises viral molecular patterns and regulates immune responses via the activation of interleukin (IL)-1 family (IL-1, IL-18 and IL-33) members. The association between polymorphisms in the inflammasome receptors NLRP1 and NLRP3 and HTLV-1 infection was evaluated in a northeastern Brazilian population (84 HTLV-1 carriers and 155 healthy controls). NLRP3 rs10754558 G/G was associated with protection against HTLV-1 infection (p = 0.012; odds ratio = 0.37). rs10754558 affects NLRP3 mRNA stability; therefore, our results suggest that higher NLRP3 expression may augment first-line defences, leading to the effective protection against HTLV-1 infection.

Contribution of the Retrovirus Epidemiology Donor Study (REDS) to research on blood transfusion safety in Brazil

The Retrovirus Epidemiology Donor Study (REDS) program was established in the United States in 1989 with the purpose of increasing blood transfusion safety in the context of the HIV/AIDS and human T-lymphotropic virus epidemics. REDS and its successor, REDS-II were at first conducted in the US, then expanded in 2006 to include international partnerships with Brazil and China. In 2011, a third wave of REDS renamed the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) was launched. This seven-year research program focuses on both blood banking and transfusion medicine research in the United States of America, Brazil, China, and South Africa. The main goal of the international programs is to reduce and prevent the transmission of HIV/AIDS and other known and emerging infectious agents through transfusion, and to address research questions aimed at understanding global issues related to the availability of safe blood. This article describes the contribution of REDS-II to transfusion safety in Brazil. Articles published from 2010 to 2013 are summarized, including database analyses to characterize blood donors, deferral rates, and prevalence, incidence and residual risk of the main blood-borne infections. Specific studies were developed to understand donor motivation, the impact of the deferral questions, risk factors and molecular surveillance among HIV-positive donors, and the natural history of Chagas disease. The purpose of this review is to disseminate the acquired knowledge and briefly summarize the findings of the REDS-II studies conducted in Brazil as well as to introduce the scope of the REDS-III program that is now in progress and will continue through 2018.

Temporal distribution of blood donations in three Brazilian blood centers and its repercussion on the blood supply

BACKGROUND:Seasonal distribution of blood donation hinders efforts to provide a safe and adequate blood supply leading to chronic and persistent shortages. This study examined whether holidays, geographical area and donation type (community versus replacement) has any impact on the fluctuation of donations. METHODS: The numbers of blood donations from 2007 through 2010 in three Brazilian Retrovirus Epidemiological Donor Study II (REDS-II) participating centers were analyzed according to the week of donation. The weeks were classified as holiday or non-holiday. To compare donations performed during holiday versus non-holiday weeks, tabulations and descriptive statistics for weekly donations by blood center were examined and time series analysis was conducted. RESULTS: The average weekly number of donations varied according to the blood center and type of week. The average number of donations decreased significantly during Carnival and Christmas and increased during the Brazilian National Donor Week. The fluctuation was more pronounced in Recife and Belo Horizonte when compared to São Paulo and higher among community donors. CONCLUSION: National bank holidays affect the blood supply by reducing available blood donations. Blood banks should take into account these oscillations in order to plan local campaigns, aiming at maintaining the blood supply at acceptable levels. .

Evaluation of rapid tests for human immunodeficiency virus as a tool to detect recent seroconversion

The identification of recent HIV infection is important for epidemiological studies and to monitor the epidemic. The objective of this study was to evaluate two rapid tests that are easily available to the Brazilian scientific community for using as markers of recent HIV infection. The Rapid Test - HIV-1/2 Bio-Manguinhos (Bio-Manguinhos/Fiocruz, Brazil) and the Rapid Check HIV 1&2 (NDI-UFES, Center for Infectious Diseases, Universidade Federal do Espírito Santo) were tested, using 489 samples with HIV positive serology, from blood donors, previously classified as recent or long-term infection by serological testing algorithm for recent HIV seroconversion (STARHS) or LS-HIV Vitros assay methods. The samples were diluted prior to testing (1:50 and 1:100 for the Rapid Test - HIV-1/2 Bio-Manguinhos, and 1:500 and 1:600 for the Rapid Check HIV 1&2). Negative samples were considered recent infection, whereas those showing any color intensity were associated with long-term infection. The best dilutions were 1:100 for HIV-1/2 Bio-Manguinhos test (Kappa = 0.840; overall agreement = 0.93), and 1:500 for the Rapid Check HIV 1&2 (Kappa = 0.867; overall agreement = 0.94). The results suggest that both rapid tests can be used to detect recent seroconversion.

Minilaparoscopic fundoplication: technical adaptations and initial experience / Fundoplicatura por minilaparoscopia: adaptações técnicas e experiência inicial

CONTEXT: Gastroesophageal reflux diasease (GERD) is a highly prevalent disease. Treatment is divided into lifestyle modifications, medical and surgical treatment. Surgical laparoscopy is the gold standard treatment. In the last decade, there were an extensive research on procedures, less aggressive than laparoscopy and with better esthetic results. Minilaparoscopy is "reemerging" as a safe, effective and with excellent cosmetic results in selected patients treated for gastroesophageal reflux diasease. We present a serie of 27 patients treated for GERD by minilaparoscopic laparoscopy. MATERIAL: Between October 2009July 2011 a total of 27 patients underwent fundoplication by minilaparoscopy. It is used one 10mm trocar, a telescope of 30 degrees and four 3 mm trocars at regular positions. Regular surgical steps are done with no modifications. Cardiac tape, suture needles, and eventually extracting bag, gauze, are placed and taked out through the umbilical port. With these technical adjustments, we can perform the procedure safely and effectively, similarly to standard laparoscopic technique. RESULTS: Of the 27 patients, 22 were female and 5 male. The average body mass index was 25.5 kg/m². Hiatal hernias were small (<3 cm) in 24 patients. Mean operative time was 60 minutes. In all cases the hiatoplasty was performed with simple or 'x' stiches of 2.0 Ethibond. There was no need for conversion to standard laparoscopy or open surgery. The length of hospital stay was less than or equal to 24 hours in all patients. In this series of patients there were no postoperative complications. We did not observe any complication of the surgical wound. There were no evidence of recurrence of symptoms or endoscopic changes. CONCLUSION: Hiatoplasty associated with fundoplication using minilaparoscopic instruments is safe, feasible and effective. If compared to other "new access", has a spectacular esthetic results. Can be done with only minor technical adjustments, for any experienced laparoscopic surgeon, and is perfectly adaptable to our financial reality.

CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma doença altamente prevalente. O seu tratamento é dividido em modificações de estilo de vida, tratamento médico e cirúrgico. A cirurgia laparoscópica é o tratamento padrãoouro. Nas últimas décadas houve uma extensa pesquisa sobre procedimentos menos agressivos do que a laparoscopia e com melhores resultados estéticos. A minilaparoscopia vem "reemergindo" como método seguro, eficaz e com excelentes resultados estéticos em pacientes selecionados, tratados para DRGE. É apresentada uma série de 27 pacientes tratados para a DRGE por minilaparoscopia. MÉTODOS: Entre outubro de 2009 e julho de 2011, o total de 27 pacientes foi submetido a fundoplicatura por videominilaparoscopia. Foram utilizados um trocarte de 10 mm, um telescópio de 30 graus e quatro trocarteres de 3 mm nas posições regulares. Os passos cirúrgicos são feitos sem modificações, de maneira habitual. Fita cardíaca, agulhas de sutura e, eventualmente, saco extrator e gaze são colocados e retirados através do portal umbilical. Com esses ajustes técnicos, podese realizar o procedimento de forma segura e eficaz, semelhantemente à técnica laparoscópica padrão. CONCLUSÃO: Hiatoplastia associada à fundoplicatura laparoscópica, utilizandose de instrumentos minilaparoscópicos é método seguro, viável e eficaz. Se comparado a outros "novos acessos", tem resultado estético espetacular. Pode ser realizado com apenas pequenos ajustes técnicos, por qualquer cirurgião experiente em laparoscopia e é perfeitamente adaptável a nossa realidade financeira.

Evaluation of real time PCR technique to diagnosis of human T-lymphotropic virus type I (HTLV-I) in patients in the Hematologia da Fundação Hemope Hospital, in Northeastern Brazil / Avaliação da técnica de PCR em tempo real para o diagnóstico do virus linfotrópico tipo I de células T humana (HTLV-I) em pacientes do Hospital de Hematologia da Fundação Hemope, no Nordeste do Brasil

As a high degree of homology exists between the proviral genomes of HTLV-I and HTLV-II, there is significant cross-reactivity. Therefore although detection of HTLV antibodies is characteristic of viral infection, it is not sufficient to confirm the presence of the viral type. Molecular tests used to diagnose the HTLV-I/II viruses are based oninvestigations of proviral genomic sequences, and allow for an infection to be diagnosed prior to the appearance of any sign or symptom. The HTLV proviral load in infected individuals can be determined using real-time PCR, a faster method with less risk of contamination than simple or nested PCR. We analyzed 63 samples from the Hemope Hospital, of which 33 were from HTLV seropositive individuals and 30 from blood donors, to determine the type of virus and the proviral load. The sensitivity of qualitative PCR in comparison to ELISA was 87.5% (95% IC: 70.1 - 95.9%) and the specificitywas 100% (IC 95%: 85.9 - 100.0%). The sensitivity and specificity of real-time PCR in comparison to the serological test (ELISA) were 100% (95% IC: 86.7 - 100.0%) and 96.67% (95% IC: 80.9 - 99.8%) respectively. The proviral load in the seropositiveindividuals ranged from 13 to 343820 copies/106 PBMC cells. Our study also observed that individuals with TSP/HAM had a higher proviral load than those who showed no symptoms. The use of real time PCR for routine clinical testing of infected individuals will play a significant role in identifying the virus type and determining the proviral load, thereby providing more appropriate treatment.

Como os genomas provirais do HTLV-I e HTLV-II exibem grande homologia, há uma expressiva sororeatividade cruzada. Assim, a detecção de anticorpos anti-HTLV-I/II embora caracterize infecção viral, não permite estabelecer distinção entre os agentes. Os testes moleculares empregados para o diagnóstico dos vírus HTLV-I/II, baseiam-se na pesquisa de seqüências genômicas provirais permitindo o diagnóstico da infecção antes de aparecer sinal ou sintoma. A carga proviral de HTLV pode ser determinadaatravés da utilização da PCR em tempo real, uma técnica rápida e com menor risco de contaminação que a PCR simples ou nested PCR. Analisamos, 63 amostras do Hospital HEMOPE, das quais 33 foram de indivíduos com sorologia reagente para HTLV e 30 de doadores de sangue, para determinar o tipo de vírus e a carga proviral. A sensibilidade da PCR qualitativa emrelação ao ELISA foi de 87,9% (IC 95%: 70,9-96,0%) e a especificidade foi de 100% (IC 95%: 85,9-100,0%). A sensibilidade e especificidade da PCR em tempo real foram de 100% (IC95%: 86,7-100,0%) e 96,67% (IC 95%: 80,9-99,8%), respectivamente.A carga proviral variou entre 13 cópias/106 células PBMC e 343820 cópias/106 células PBMC. Nosso estudo também observou que os indivíduos com PET/MAH tiveram carga proviral mais elevada que a dos indivíduos assintomáticos. A utilização da PCR em tempo real na rotina clínica dos indivíduos infectados poderá desempenhar um papel relevante na identificação do vírus e na determinação da carga proviral, contribuindo para direcionar um tratamento adequado.

Infecção pelo HTLV-1: diagnóstico e determinação da carga proviral em indivíduos assintomáticos e com enfermidades associadas em serviço de referência no Nordeste / HTLV-1 infection: diagnosis and proviral load level among asymptomatic carriers and patients with associated diseases in reference center in the Northeastern

A infecção pelo HTLV-1 causa, nos indivíduos portadores do retrovírus, enfermidades associadas que estão relacionadas ao nível da carga proviral. O objetivo deste estudo é diagnosticar a infecção pelo HTLV-1 e determinar a carga proviral de indivíduos assintomáticos e com enfermidades associadas. Duas questões centrais foram levantadas: 1) Para o diagnóstico da infecção pelo HTLV-1, qual a definição do conjunto de testes laboratoriais indicados? 2) Averiguar a relação da carga proviral do HTLV-1 com as manifestações clínicas e enfermidades associadas. Uma população de 166 indivíduos foi incluída no estudo. Testes sorológicos e moleculares da PCR qualitativa para HTLV e carga proviral expressa em cópias por 1.000.000 células PBMC foram realizados. Destes, em 104 foi 6 confirmada a presença do HTLV, sendo 101 HTLV-1 (97,1 por cento) e três HTLV-2 (2,9 por cento). Nos 101 pacientes, foi realizada a determinação da carga proviral para o HTLV-1 e analisada a associação com as manifestações clínicas e laboratoriais. A análise da população estudada mostrou maior freqüência do HTLV-1 em mulheres com idade acima de 50 anos. A maioria dos pacientes tem baixa escolaridade e baixa renda. O status clínico dos pacientes foi: 54,5 por cento assintomáticos; 7,9 por cento sintomáticos; 5,9 por cento com LLTA; 12,9 por cento com PET/MAH; 3,9 por cento com PET/MAH-provável; e 14,9 por cento com PET/MAH-possível. Observou-se co-infecção com escabiose 5 por cento, 12,9 por cento de DST e estrongiloidíase em 6,9 por cento. O nível da carga proviral foi acima de 10.000 cópias/1.000.000 células PBMC em 54,5 por cento dos pacientes, sendo a média em mulheres 6 duas vezes maior do que em homens. Os pacientes com PET/MAH apresentaram a maior carga proviral média. Estabelecendo uma relação entre a carga proviral dos assintomáticos e a daqueles com enfermidades associadas, foi constatada carga proviral média 2,1 vezes maior para PET/MAH; 1,1 vez para PET/MAH-provável; 1,4 vez PET/MAH-possível; e 1,2 vez para LLTA. A população analisada apresentou elevado nível de carga proviral, não demonstrando diferença significativa entre doentes e assintomáticos.

Soroprevalência do HTLV I/II nos pacientes com uveítes da Fundação Altino Ventura, Pernambuco / Soroprevalence of HTLV I/II in uveitis patients at the Altino Ventura Foundation, Recife, Brazil

Estabelecer a prevalência da uveíte associada ao vírus linfotrópico de células T humana do tipo I e II (HTLV I/II) em um ambulatório especializado em uveítes no Estado de Pernambuco. Examinaram-se, durante o período de maio de 98 a abril de 99, 224 pacientes assistidos no ambulatório de uveítes da Fundação Altino Ventura. Estes pacientes foram clinicamente examinados mediante protocolo oftalmológico previamente estabelecido, e em seguida encaminhados para realizar o teste HTLV I/II (Elisa como "screaning" e Western blot 2.4 como confirmatório). Cento e vinte e cinco pacientes apresentaram uveíte, cuja etiologia foi definida em 62,4 por cento e indeterminada em 37,6 por cento. Detectaram-se cinco casos de HTLV I reagentes (4,0 por cento), que apresentavam uveítes anatomicamente classificadas em: três anteriores e duas difusas. Em relação à etiologia, quatro casos de uveítes (80,0 por cento) eram inespecíficos e um (20,0 por cento) de provável associação com hanseníase. Estes quatro pacientes HTLV I reagentes com uveíte de causa indeterminada representam 8,5 por cento do grupo de uveítes indeterminadas. A prevalência da uveíte associada ao HTLV pareceu ser alta em Pernambuco (4,0 por cento) quando comparada a outros Estados do Brasil, e especialmente alta nos casos de uveítes indeterminadas.

Htlv-I infection and adult T-cell leukemia in Brazil: an overview

Human T-cell lymphotropic Virus Type I (HTLV-1) is the etiologic factor for adult T-cell leukemia/lymphoma (ATL). HTLV-1 infection can aiso lead to other diseases, such as HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), uveitis, arthropathy and infectious dermatitis. Studies of the infectious mode of transmission of HTLV-1 and risk factors for HTLV-l-related diseases have been conducted in several countries, and differences in the prevalence, age patterns, ethnic groups and clinical presentation of the related diseases have been described worldwide. Based on the geographical characteristics of Brazil and data from the literature, we have summarized the distribution of seroprevalence in blood donors in different states around the country, as well as the incidence of ATL in regards to the endemic foci. ATL in Brazil has the same characteristics as those described elsewhere, but is reported more frequently at a younger age. In order to better evaluate ATL in Brazil, a registry has been established at the several hematologic centers under the sponsorship of the Instituto Nacional de Cancer and the Brazilian Society of Hematology and Hemotherapy, for the purpose of recording all cases originally diagnosed in Brazil.

Aspectos psicológicos, observados em doadores, relacionados à comunicaçäo da infecçäo pelo HTLV-1 / Psychological aspects in donors related to communication of HTLV-1 infection

A comunicaçäo de diagnóstico muitas vezes pode provocar reaçöes de medo, insegurança, ansiedade e tensäo, até outras reaçöes imprevisíveis. Um aspecto importante a ser considerado é a maneira como se faz essa comunicaçäo, podendo isso suscitar fantasias errôneas e demasiado apressadas como o verificado da associaçäo do HTLV-1 com o HIV. Assim este trabalho compreende duas partes: Na primeira, descreve-se as reaçöes de ansiedade decorrentes da informaçäo, bem como a ansiedade apresentada como traço de personalidade do indivíduo. Na segunda parte, apresentamos outros aspectos que de modo geral podem interferir na qualidade de vida e no comportamento dessas pessoas.