Informe diário de evidências COVID-19: busca realizada em 28 de julho de 2020 / COVID-19 daily evidence report: search conducted on July 28, 2020

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 18 artigos e 3 protocolos.

Score Delphos 1: estimación del grado de afectación fetal en enfermedad hemolítica del recién nacido / Delphos I Score: estimation of the degree of fetal affectation in haemolytic disease of the newborn

Objetivos: Realizar un modelo de score de riesgo en pacientes sensibilizadas. Predecir el comportamiento futuro e identificar la población con mayor probabilidad de complicaciones feto-neonatales. Métodos: Se realizó un modelo de score de riesgo, DELPHOS l. Se analizaron las fichas inmunohematológicas de 91 pacientes embarazadas sensibilizadas en el período 1999-2008. Se incluyeron: pacientes puérperas, sensibilizadas a anticuerpos anti D solo o asociado a otro productor de enfermedad hemolítica (EH), parto o cesárea con recién nacido en este hospital. Se excluyeron: pacientes embarazadas, sensibilizadas a anticuerpos no productores de EH, pacientes con recién nacido derivado a otro nosocomio. Para su construcción se confeccionó una tabla valorando: antecedentes obstétricos, edad gestacional, titulo, tipo, número de anticuerpos y causas de incremento del título de anticuerpos. Se dio a cada punto citado un puntaje mínimo y máximo. Se procedió al ensayo del mismo comparando la puntuación obtenida con la evolución del feto/neonato en cada caso. Resultados: El 66% de las pacientes consultaron antes de la semana 25 de embarazo presentando score más alto respecto a las que consultaron a las 25 semanas o más. El número de recién nacidos Rh positivos no afectados fue mayor hasta el score 5; a partir de este, aumentó el número y la gravedad de la afectación. Las pacientes sometidas a transfusión intrauterina (TIU) fueron aquellas con score igual o mayor a 6. Por lo tanto el score 6 resultó ser punto de corte a partir del cual se incrementó la afectación feto-neonatal. Conclusión: Un modelo de score permitiría simplificar y mejorar la elección de la conducta a tomar frente a pacientes sensibilizadas.

Objectives: Create a score model to assess risk in sensitized patients. Predict future behaviour and identify the population with higher probability of fetal and neonatal complications. Methods: A risk score model was created, DELPHOS l. The immunohematological record cards of 91 sensitized pregnant patients (1999 through 2008) were surveyed. The following were included: sensitized puerperal patients with anti-D as sole causing antibody or associated to another Haemolytic Disease (HD)-producing antibody, vaginal birth or Caesarean section, with their newborn still in this hospital. The following were excluded: pregnant patients, sensitization by non HD­-producing antibodies, patients with newborn sent to other healthcare facilities. For its construction, a chart was designed evaluating: obstetric medical records, gestational age, titre, type, number of antibodies and causes for antibody increase. A minimum and maximum number of points was assigned to each of the mentioned criteria. A test run was carried out, comparing the obtained number of points with the clinical status of the fetus/newborn in each case. Results: 66% of the patients consulted before 25 weeks pregnancy exhibiting higher scores; as opposed to those that consulted at 25 or more weeks pregnancy. The number of non-affected Rh-positive newborns was higher, up until score 5; from that point on, the number and severeness of affectation increased. The patients to undergo intra-uterine transfusion, were those with score 6 or higher. Therefore score 6 turned out to be the breaking-point starting from which, the fetal/neonatal affectation increased. Conclusion: A score model would allow to simplify and improve the course of action in the management of sensitized patients.

Immune thrombocytopenic purpura.

Immune thrombocytopenic purpura (ITP) is the commonest cause of sudden onset thrombocytopenia in a healthy child. The condition is frequently preceded by a viral infection. The hematological parameters are essentially normal except a low platelet count. Bone marrow examination is not routinely indicated except in specific situations. The pros and cons of drug treatment have been discussed as the disease is benign with excellent prognosis in majority of the cases. The various treatment options including low and high dose steroids, intravenous immunoglobulins and anti D have been discussed at length with other modalities of treatment and role of splenectomy. Current therapeutic options with rituximab and other drugs for stimulating platelet production in chronic cases have also been included in discussion.

Evaluación de la enfermedad hemolítica por anti-D: resultados en el recién nacido / evaluationEvaluation of hemolytic disease by anti-D. Results in the newborn

Introducción. Objetivo: describir la condición al nacimiento y evolución intrahospitalaria del neonato con enfermedad hemolítica por anti-D.Material y métodos. Se estudiaron a embarazadas Rh negativo, con isoinmunización al antígeno RhD y sometidas a espectrofotometría de bilirrubina (Br) en líquido amniótico (EBLA). Se compararon los datos clínicos y demográficos de neonatos con enfermedad hemolítica (EH), comparándose el último estudio de EBLA con el esquema de Liley-Sentíes. Se formaron los grupos 1, 2 y 3, para estratificar la EH fetal como leve, moderada y grave.Resultados. Se incluyeron 67 casos, con 31, 17 y 19 neonatos, para cada grupo. Los casos del grupo 3 fueron de menor edad gestacional, 34.4 semanas (P< 0.001), peso 2 223 g (P <0.001) y hematócrito 36 por ciento (P <0.01). Los valores máximos de Br y días de estancia en fototerapia fueron similares. La transfusión eritrocitaria fue en proporción de 0.09, 0.23 y 0.52, para cada grupo (P <0.003). La exsanguinotransfusión fue de 0.16, 0.29 y 0.68 (P< 0.001). Los días de estancia fueron de 5, 9 y 23 días, respectivamente (P< 0.001).Conclusión. La estancia hospitalaria prolongada depende de la edad gestacional, la severidad de la EH y de la morbilidad hospitalaria asociada. El esquema de Liley-Sentíes, es un criterio vigente para la estratificación de la EH con utilidad pronóstica y terapéutica.

In-vitro inhibition of antiplatelet autoantibodies by intravenous immunoglobulins and Rh immunoglobulins.

Autoimmune thrombocytopenia (AITP) is caused by autoantibodies to platelet glycoprotein antigens. Intravenous immunoglobulin (i.v.IgG) and Rh immunoglobulin infusions have found great significance in the treatment of AITP patients not responding to corticosteroids and other modes of therapy. In our study, it was observed that immunoglobulins (i.v.IgG & Rh), and their Fab fragments inhibited the binding of antiplatelet autoantibodies to normal platelets, from 15.8 to 90.7% and 25.6 to 90.08% respectively; whereas, their Fc portion did not show any inhibition. The presence of specific anti-idiotypic antibodies to antiplatelet autoantibodies was established by using monoclonal antibodies to Glycoprotein IIb/IIa and Glycoprotein Ib/IX, as the specific idiotype source. The i.v.IgG and Rh immunoglobulin products reacted with the monoclonal antibodies, only through their Fab and not through the Fc portions, thereby confirming its specific anti-idiotype activity.

Anti-D immunoglobulin in the treatment of idiopathic thrombocytopenic purpura.

Anti-D was evaluated in 8 RhD positive patients (6 males, 2 females) aged 2-21 years (mean 10 years) with Idiopathic Thrombocytopenic Purpura (ITP). Five patients with chronic ITP and 3 patients with acute ITP were administered Anti-D in the dosage of 50 micrograms/kg intramuscularly (IM) for 3 consecutive days. One patient of chronic ITP received two courses of Anti-D. Patients were followed up for 7 to 16 months (mean 9 months). All three cases of acute ITP had a complete response and are in remission between 3 to 12 months of follow up. Two of five cases of chronic ITP had a partial response. Rise in platelet count was observed within 72-124 hours, and duration of response varied between 10 to 15 days. None of these patients had any significant side effects of anti-D immunoglobulin therapy. Intramuscular administration of Anti-D is safe, effective and low cost alternative to IVIgG in the treatment of acute ITP.

Teste de Kleihauer-Brow-Betke: análise de 27 casos / Kleihauer-Brown-Betke test: analysis of 27 cases

Foram submetidas ao teste de Kleihauer-Brown-Betke no período pós-parto e pós-aborto 27 mulheres Rh-negativo co a variante D negativa, visando calcular a quantidade de imunoglobulina a ser administrada. A operaçäo cesariana foi a forma de parto na qual encontrou-se a maior quantidade de células fetais na circulaçäo materna. Apenas uma terça parte (33,3 por cento) das pacientes recebeu imunoglobulina anti-RH após gestaçäo anterior. Salienta-se, por fim, a importância do teste de Kleihauer-Brown-Betke, assim como a necessidade de uma maior consciência sobre profilaxia da sensibilizaçäo materna pelo fator Rh.