Efeitos do lockdown na incidência da COVID-19 na fase de emergência sanitária da pandemia / Effects of lockdown on COVID-19 incidence in the health emergency phase of the pandemic

RESUMO Objetivo avaliar os efeitos do lockdown na incidência da COVID-19 na fase de emergência sanitária da pandemia. Métodos trata-se de um estudo ecológico transversal. Os dados foram coletados nas páginas da Fundação Sistema Estadual de Análise de Dados e da Prefeitura Municipal de Araraquara. Para analisar a incidência da COVID-19 foram considerados os casos notificados no referido município. Para comparar os períodos em relação aos casos diários, foi utilizado o modelo de regressão com distribuição binomial-negativa com função de ligação logarítmica. Resultados para todas as faixas etárias, com exceção de menores de 20 anos, verificou-se diferença estatística nos coeficientes de incidência. Para o sexo feminino o declínio na incidência da doença foi mais expressivo. Considerando ambos os sexos e todas as faixas etárias, observou-se uma redução de 49% na incidência de casos. Conclusão houve uma redução significativa na incidência da doença considerando a população geral do município. Contribuições para a prática: a disponibilidade e adoção de medidas tradicionais de saúde pública, como o lockdown, mostraram-se essenciais para reduzir casos e óbitos de doenças de vírus respiratórios emergentes sem tratamento e vacina.

ABSTRACT Objective to assess the effects of lockdown on the incidence of COVID-19 during the health emergency phase of the pandemic. Methods this is a cross-sectional ecological study. Data was collected from the websites of the State Data Analysis System Foundation and Araraquara City Hall. To analyze the incidence of COVID-19, cases reported in the municipality were considered. A regression model with a negative binomial distribution and a logarithmic link function was used to compare the periods in terms of daily cases. Results for all age groups except those under 20, there was a statistical difference in the incidence coefficients. For females, the decline in the incidence of the disease was more significant. Considering both sexes and all age groups, there was a 49% reduction in the incidence of cases. Conclusion there was a significant reduction in the incidence of the disease in the general population of the municipality. Contributions to practice: the availability and adoption of traditional public health measures, such as lockdown, proved essential to reducing cases and deaths from emerging respiratory virus diseases without treatment or vaccine.

Organização e assistência da atenção primária à saúde no enfrentamento da COVID-19 / Organization and assistance of primary health care facing COVID-19 / Organización y asistencia de la atención primaria de salud en el enfrentamiento al COVID-19

Objetivo: analisar a organização e assistência dos serviços da Atenção Primária à Saúde no enfrentamento da COVID-19. Método: estudo transversal realizado com 49 profissionais da saúde de unidades básicas de saúde e estratégia de saúde da família no município de São Carlos. Os dados foram coletados por meio de questionário auto respondido no período de maio de 2021 a fevereiro de 2022. As associações foram analisadas por teste qui-quadrado e estimadas as razões de prevalência. O protocolo de pesquisa foi aprovado pelo Comite de Ética em Pesquisa. Resultados: a identificação de sinais e sintomas do paciente, orientações sobre as medidas de prevenção e verificação da disponibilidade de leitos em hospitais de referência, foram variáveis que se apresentaram diferentes entre os serviços de saúde. Conclusão: a APS exerce papel central no enfrentamento da pandemia, com necessidade de os gestores identificarem as fragilidades e direcionarem ações de educação permanente diante de novos cenários.

Objective: to analyze the organization and assistance of Primary Health Care services facing COVID-19. Method: cross-sectional study carried out with 49 health professionals from basic health units and family health strategy in the city of São Carlos. Data were collected through a self-answered questionnaire from May 2021 to February 2022. Associations were analyzed using the chi-square test and prevalence ratios were estimated. The research protocol was approved by the Research Ethics Committee. Results: identification of the patient's signs and symptoms, guidance on prevention measures and checking the availability of beds in reference hospitals were variables that differed between health services. Conclusion: Primary Health Care services play a central role facing COVID-19 pandemic, with managers needing to identify weaknesses and direct ongoing education actions in the face of new scenarios.

Objetivo: analizar la organización y asistencia de los servicios de Atención Primaria de Salud en el combate al COVID-19. Método: estudio transversal realizado con 49 profesionales de la salud de unidades básicas de salud y estrategia de salud de la familia de la ciudad de São Carlos. Los datos se recolectaron a través de un cuestionario de auto respuesta desde mayo de 2021 hasta febrero de 2022. Se analizaron las asociaciones mediante la prueba de chi-cuadrado y se estimaron las razones de prevalencia. El protocolo de investigación lo aprobó el Comité de Ética en Investigación. Resultados: la identificación de los signos y síntomas del paciente, las orientaciones sobre medidas de prevención y la verificación de la disponibilidad de camas en los hospitales de referencia fueron variables que difirieron entre los servicios de salud. Conclusión: La APS juega un papel central en el enfrentamiento a la pandemia, siendo necesario que los gestores identifiquen debilidades y orienten acciones educativas continuas ante nuevos escenarios.

Influência dos fatores socioeconômicos na mortalidade por COVID-19 na população infantil: revisão de escopo / Influence of socioeconomic factors on COVID-19 mortality in children: a scoping review

RESUMO Objetivo identificar as evidências científicas sobre a relação entre os fatores socioeconômicos e a mortalidade em crianças por COVID-19. Métodos trata-se de uma revisão de escopo. As buscas foram realizadas nas seguintes bases de dados: US National Library of Medicine - National Institutes of Health; Scientific Electronic Library Online; Institute for Scientific Information; Cumulative Index to Nursing and Allied Health Literature; e SciVerse Scopus. Resultados foram selecionados 15 artigos que evidenciaram a influência dos fatores socioeconômicos na mortalidade infantil pelo Severe Acute Respiratory Syndrome Coronavirus 2. Conclusão evidenciou-se que os fatores socioeconômicos estão relacionados ao aumento da mortalidade por COVID-19 na população infantil, baixa renda e à residência em localidades consideradas de maior vulnerabilidade socioeconômica, as quais se apresentaram como importantes variáveis a serem consideradas na pandemia de COVID-19. Contribuições para a prática diversos fatores estão relacionados ao aumento da suscetibilidade à infecção do Severe Acute Respiratory Syndrome Coronavirus e agravamento da doença em crianças. No entanto, compreender que os fatores socioeconômicos podem se apresentar como um determinante na incidência e mortalidade por COVID-19 na população infantil ressalta a necessidade de investimentos em ações direcionadas à redução das desigualdades socioeconômicas, para assim reduzir as mortes evitáveis.

ABSTRACT Objective to identify the scientific evidence on the relationship between socioeconomic factors and mortality in children due to COVID-19. Methods this is a scoping review. Searches were carried out in the following databases: US National Library of Medicine - National Institutes of Health; Scientific Electronic Library Online; Institute for Scientific Information; Cumulative Index to Nursing and Allied Health Literature; and SciVerse Scopus. Results 15 articles were selected that showed the influence of socioeconomic factors on infant mortality from Severe Acute Respiratory Syndrome Coronavirus 2. Conclusion it was shown that socioeconomic factors are related to increased mortality from COVID-19 in the infant population, low income and residence in locations considered to be of greater socioeconomic vulnerability, which were presented as important variables to be considered in the COVID-19 pandemic. Contributions to practice several factors are related to increased susceptibility to Severe Acute Respiratory Syndrome Coronavirus infection and worsening of the disease in children. However, understanding that socioeconomic factors can be a determinant of COVID-19 incidence and mortality in children highlights the need to invest in actions aimed at reducing socioeconomic inequalities, to reduce preventable deaths.

Aumento do risco de mortalidade por COVID-19 em pessoas com obesidade / Increased risk of mortality from COVID-19 in people with obesity

RESUMO Objetivo analisar o risco de mortalidade por COVID-19 em pessoas com obesidade. Métodos estudo observacional, retrospectivo e analítico. Os dados foram coletados no Sistema Estadual de Análise de Dados. Para a análise comparativa de pessoas com e sem obesidade, adotou-se n=168.808. As análises foram realizadas por meio do modelo de regressão log-binomial e cálculo de risco relativo. O modelo comparativo foi ajustado ao sexo, faixa etária, cardiopatia e diabetes. Resultados em mais de 95% das notificações de COVID-19, a informação quanto ao fator de risco obesidade foi registrada como ignorado. Pessoas obesas com COVID-19 apresentaram 26% maior risco de óbito quando comparadas às pessoas sem obesidade. Indivíduos obesos nas faixas etárias entre 11 a 60 anos apresentaram os maiores riscos de mortalidade comparados aos indivíduos sem obesidade. As mulheres obesas nas faixas etárias de 31 a 50 anos e idosas acima de 71 anos apresentaram menor risco de mortalidade quando comparadas aos homens obesos. Conclusão pessoas obesas, principalmente os adultos, possuem risco aumentado de mortalidade por COVID-19. Contribuições para a prática auxiliar o estabelecimento de estratégias de saúde pública que atuem na identificação dos perfis dos indivíduos considerados de alto risco na pandemia ocasionada pelo vírus SARS-CoV-2.

ABSTRACT Objective to analyze the risk of mortality from COVID-19 in people with obesity. Methods observational, retrospective, and analytical study. Data were collected in the State System of Data Analysis. For the comparative analysis of people with and without obesity, n=168,808 was adopted. The analyses were performed using the log-binomial regression model and relative risk calculation. The comparative model was adjusted for sex, age group, heart disease and diabetes. Results in more than 95% of COVID-19 notifications, information regarding the risk factor obesity was recorded as ignored. Obese individuals with COVID-19 had 26% higher risk of death when compared to those without obesity. Obese individuals in the 11 to 60 age groups had the highest mortality risks compared to individuals without obesity. Obese women in the age groups 31 to 50 years and elderly women over 71 years had the lowest mortality risk when compared to obese men. Conclusion obese people, especially adults, have an increased risk of mortality from COVID-19. Contributions to practice to help establish public health strategies to identify the profiles of individuals considered at high risk in the SARS-CoV-2 pandemic.

Post-acute COVID-19 in three doses vaccinated autoimmune rheumatic diseases patients: frequency and pattern of this condition

Abstract Background Data on post-acute COVID-19 in autoimmune rheumatic diseases (ARD) are scarce, focusing on a single disease, with variable definitions of this condition and time of vaccination. The aim of this study was to evaluate the frequency and pattern of post-acute COVID-19 in vaccinated patients with ARD using established diagnosis criteria. Methods Retrospective evaluation of a prospective cohort of 108 ARD patients and 32 non-ARD controls, diagnosed with SARS-CoV-2 infection (RT-PCR/antigen test) after the third dose of the CoronaVac vaccine. Post-acute COVID-19 (≥ 4 weeks and > 12 weeks of SARS-CoV-2 symptoms) were registered according to the established international criteria. Results ARD patients and non-ARD controls, balanced for age and sex, had high and comparable frequencies of ≥ 4 weeks post-acute COVID-19 (58.3% vs. 53.1%, p = 0.6854) and > 12 weeks post-acute COVID-19 (39.8% vs. 46.9%, p = 0.5419). Regarding ≥ 4 weeks post-acute COVID-19, frequencies of ≥ 3 symptoms were similar in ARD and non-ARD controls (54% vs. 41.2%, p = 0.7886), and this was also similar in > 12 weeks post-acute COVID-19 (68.3% vs. 88.2%, p = 0.1322). Further analysis of the risk factors for ≥ 4 weeks post-acute COVID-19 in ARD patients revealed that age, sex, clinical severity of COVID-19, reinfection, and autoimmune diseases were not associated with this condition (p > 0.05). The clinical manifestations of post-acute COVID-19 were similar in both groups (p > 0.05), with fatigue and memory loss being the most frequent manifestations. Conclusion We provide novel data demonstrating that immune/inflammatory ARD disturbances after third dose vaccination do not seem to be a major determinant of post-acute COVID-19 since its pattern is very similar to that of the general population. Clinical Trials platform (NCT04754698).

Extra-articular manifestations of rheumatoid arthritis remain a major challenge: data from a large, multi-centric cohort

Abstract Introduction Although Rheumatoid Arthritis (RA) extra-articular manifestations (ExtRA) occurrence has been decreasing over time, they are still a major mortality risk factor for patients. Objective To determine the prevalence of ExtRA in a large cohort, and its association with demographic and clinical variables. Method Cross-sectional and observational study, based on a multi-centric database from a prospective cohort, in which 11 public rheumatology centres enrolled RA patients (1987 ARA or 2010 ACR-EULAR). Data collection began in 08-2015, using a single online electronic medical record. Continuous variables were compared using Mann-Whit-ney U-test, and Fisher's exact test or chi-square test, as appropriate, were used for categorical variables. The level of significance was set at 5% (p < 0.05). Results 1115 patients were included: 89% women, age [mean ± SD] 58.2 ± 11.5 years, disease duration 14.5 ± 12.2 years, positive Rheumatoid Factor (RF, n = 1108) in 77%, positive anti-cyclic citrullinated peptide (ACPA, n = 477) in 78%. Regarding ExtRA, 334 occurrences were registered in 261 patients, resulting in an overall prevalence of 23.4% in the cohort. The comparison among ExtRA and Non-ExtRA groups shows significant higher age (p < 0.001), disease duration (p < 0.001), RF high titers (p = 0.018), Clinical Disease Activity index (CDAI) (p < 0.001), Disease Activity Index 28 (DAS 28) (p < 0.001), and Health Assessment Questionnaire (HAQ) (p < 0.001) in ExtRA group. Treatment with Azathioprine (p = 0.002), Etanercept (p = 0.049) Glucocorticoids (GC) ('p = 0.002), and non-steroidal anti-inflammatory drugs (NSAIDs) (p < 0.001) were more frequent in ExtRA group. Conclusions ExtRA manifestations still show an expressive occurrence that should not be underestimated. Our findings reinforce that long-term seropositive disease, associated with significant disability and persistent inflammatory activity are the key factors related to ExtRA development.

Mortalidade por COVID-19 em pessoas cardiopatas no estado de São Paulo / Mortality from COVID-19 in people with heart disease in São Paulo State / Mortalidad por COVID-19 en cardiópatas en el estado de São Paulo

Objetivo: analisar a mortalidade pela doença causada pelo coronavírus do tipo 2 (COVID-19) em pessoas com cardiopatia no estado de São Paulo. Métodos: estudo observacional, retrospectivo e analítico. Os dados foram coletados no período de 4 de fevereiro de 2020 a 25 de julho de 2021. O modelo comparando pessoas com e sem cardiopatia foi ajustado por sexo, faixa etária, obesidade e diabetes, possíveis variáveis de confusão. As comparações foram analisadas por meio do modelo de regressão log-binomial e cálculo de risco relativo. Resultados: pessoas do estado de São Paulo com cardiopatia infectadas pela COVID-19 entre 21 e 50 anos apresentaram risco maior de óbito quando comparadas as pessoas sem cardiopatia. Ainda, mulheres cardiopatas acima de 51 anos apresentaram risco menor de óbito comparadas aos homens cardiopatas na mesma faixa etária. Conclusão: pessoas com cardiopatia infectadas pelo COVID-19, principalmente homens, possuem um risco aumentado de morte no estado de São Paulo.

Objective: to examine mortality from the disease caused by type-2 Coronavirus (COVID-19) in people with heart disease in São Paulo State. Methods: in this, retrospective, analytical, observational study, data were collected from February 4, 2020, to July 25, 2021. The model comparing people with and without heart disease was adjusted for the possible confounding variables sex, age group, obesity, and diabetes. Comparisons were analyzed using log-binomial regression models and relative risk calculation. Results: risk of death was higher among people between 21 and 50 years old infected by COVID-19 and with heart disease than among people without heart disease. Also, risk of death was lower among women with heart disease over 51 years old than among men with heart disease in the same age group. Conclusion: people, especially men, with heart disease and infected by COVID-19 are at increased risk of death.

Objetivo: analizar la mortalidad por la enfermedad causada por el coronavírus del tipo 2 (COVID-19) en personas cardiópatas en el estado de São Paulo. Métodos: estudio observacional, retrospectivo y analítico. Los datos se recopilaron del 4 de febrero de 2020 al 25 de julio de 2021. El modelo que compara personas con y sin cardiopatía se ajustó por sexo, grupo de edad, obesidad y diabetes, posibles variables de confusión. Las comparaciones se analizaron mediante el modelo de regresión log-binomial y el cálculo del riesgo relativo. Resultados: las personas del estado de São Paulo, con cardiopatías, infectadas por COVID-19 entre 21 y 50 años tenían mayor riesgo de muerte en comparación con las personas sin cardiopatías. Además, las mujeres con cardiopatías mayores de 51 años tenían un menor riesgo de muerte en comparación con los hombres con cardiopatías del mismo grupo de edad. Conclusión: las personas con cardiopatías infectadas por COVID-19, especialmente los hombres, tienen mayor riesgo de muerte, en el estado de São Paulo.

Assisted therapy model for dispensing immunobiological drugs for rheumatoid arthritis by the Brazilian Unified Health System: rational use of resources reduces expenses

Objective: The incorporation of immunobiological agents for rheumatoid arthritis (RA) treatment at the Brazilian Unified Health System (SUS) represented a significant advance but had an important impact on the budget. As the current model of direct patient delivery had deficiencies, the CEDMAC model of assisted therapy was implemented to focus on rational use to minimize expenses and increase access. However, there is no data to compare the two models. Thus, this study aimed to compare the number of bottles effectively dispensed by the CEDMAC model to direct dispensing and assess its financial impact. Methods: Care of RA patients at CEDMAC in 2015, whose immunobiological drugs were provided by the Ministry of Health, were included. Drug and dose received, prescribed dose, the number of bottles, cancellations due to contraindication, and absences were recorded. As a comparison, the number of bottles that would be delivered by direct dispensing was estimated. The difference between the total number of bottles dispensed by the two systems and the financial impact of the purchase price in 2015 was calculated. Results: In 2015, CEDMAC provided 3,784 consultations for RA patients. The total number of bottles of immunobiological agents prescribed was 10,000 bottles, and 1,946 (19.5%) were not used for bottle optimization, contraindications, or absenteeism. Unused bottles reduced expenses by R$ 806,132.62. The expansion of the model to the entire SUS would reduce costs by R$ 121,110,388.27. Conclusion: The CEDMAC assisted therapy model considerably reduces the volume of dispensed bottles and can significantly reduce expenses in the supply of immunobiological agents for RA at SUS.

Modelo de terapia assistida para dispensação de medicamentos imunobiológicos para artrite reumatoide no Sistema Único de Saúde: uso racional de recursos reduz despesas / Assisted therapy model for dispensing immunobiological drugs for rheumatoid arthritis by the Brazilian Unified Health System: rational use of resources reduces expenses

Objetivo: A incorporação dos imunobiológicos para tratamento da artrite reumatoide (AR) no Sistema Único de Saúde (SUS) representou um avanço significativo, porém teve um impacto importante no orçamento. Como o modelo vigente de dispensação direta ao paciente apresentava deficiências, implementou-se o modelo do CEDMAC de terapia assistida com foco no uso racional, visando minimizar despesas e potencializar o alcance. Entretanto, não há dados que comparem os dois modelos. Assim, esse estudo objetivou comparar o número de frascos efetivamente dispensados pelo modelo do CEDMAC à dispensação direta e avaliar seu impacto financeiro. Métodos: Foram incluídos atendimentos de pacientes com AR no CEDMAC em 2015, cujo imunobiológico foi fornecido pelo Ministério da Saúde. Foram registrados medicamento e dose recebidos, dose prescrita, número de frascos, cancelamentos por contraindicação e faltas. Como comparação, foi estimado o número de frascos que seriam entregues pela dispensação direta. Calculou-se a diferença entre o número total de frascos dispensados pelos dois sistemas e o impacto financeiro pelo valor de aquisição em 2015. Resultados: Em 2015, o CEDMAC realizou 3.784 atendimentos para pacientes com AR. O total de frascos de imunobiológicos prescritos foi de 10.000 frascos e 1.946 (19,5%) não foram utilizados por otimização de frascos, contraindicações ou absenteísmo. Os frascos não utilizados reduziram as despesas em R$ 806.132,62. A expansão do modelo para todo SUS reduziria as despesas em R$ 121.110.388,27. Conclusão: O modelo de terapia assistida do CEDMAC reduz consideravelmente o volume de frascos dispensados e pode trazer uma relevante redução de despesas no fornecimento dos imunobiológicos para AR no SUS.

Objective: The incorporation of immunobiologicals for the treatment of rheumatoid arthritis (RA) in the Brazilian Unified Health System (SUS) represented a significant advance but had an important impact on the budget. As the current model of direct delivery to the patient presented deficiencies, the CEDMAC model of assisted therapy focusing on rational use was implemented to minimize expenses and increase access. However, there is no data comparing the two models. Thus, this study aimed to compare the number of vials effectively dispensed by the CEDMAC model compared to direct delivery and to evaluate its financial impact. Methods: We included RA patients attended at CEDMAC during 2015, whose immunobiological was provided by Ministry of Health. Drug and dose received, prescribed dose, number of vials, cancellations due to contraindication and absences were recorded. As comparison, the number of vials that would be delivered by the direct delivery model were estimated. Savings were calculated by the difference between the total number of vials dispensed by the two systems and the financial impact by acquisition value in 2015. Results: During 2015, CEDMAC performed 3,784 consultations for RA patients. The total number of immunobiological vials prescribed was 10,000 vials and 1,946 (19.5%) were not used for vial optimization, contraindications or absenteeism. Saved vials reduced expenses by R$ 806,132.62. The expansion of the model for all SUS would reduce expenses by R$ 121,110,388.27. Conclusion: CEDMAC's model of assisted therapy considerably reduces the volume of dispensed vials and can bring significant cost offsets in the supply of RA immunobiologicals by SUS.

Chronic inflammatory diseases, subclinical atherosclerosis, and cardiovascular diseases: Design, objectives, and baseline characteristics of a prospective case-cohort study ‒ ELSA-Brasil

Abstract Objectives This analysis describes the protocol of a study with a case-cohort to design to prospectively evaluate the incidence of subclinical atherosclerosis and Cardiovascular Disease (CVD) in Chronic Inflammatory Disease (CID) participants compared to non-diseased ones. Methods A high-risk group for CID was defined based on data collected in all visits on self-reported medical diagnosis, use of medicines, and levels of high-sensitivity C-Reactive Protein >10 mg/L. The comparison group is the Aleatory Cohort Sample (ACS): a group with 10% of participants selected at baseline who represent the entire cohort. In both groups, specific biomarkers for DIC, markers of subclinical atherosclerosis, and CVD morbimortality will be tested using weighted Cox. Results The high-risk group (n = 2,949; aged 53.6 ± 9.2; 65.5% women) and the ACS (n=1543; 52.2±8.8; 54.1% women) were identified. Beyond being older and mostly women, participants in the high-risk group present low average income (29.1% vs. 24.8%, p < 0.0001), higher BMI (Kg/m2) (28.1 vs. 26.9, p < 0.0001), higher waist circumference (cm) (93.3 vs. 91, p < 0.0001), higher frequencies of hypertension (40.2% vs. 34.5%, p < 0.0001), diabetes (20.7% vs. 17%, p = 0.003) depression (5.8% vs. 3.9%, p = 0.007) and higher levels of GlycA a new inflammatory marker (p < 0.0001) compared to the ACS. Conclusions The high-risk group selected mostly women, older, lower-income/education, higher BMI, waist circumference, and of hypertension, diabetes, depression, and higher levels of GlycA when compared to the ACS. The strategy chosen to define the high-risk group seems adequate given that multiple sociodemographic and clinical characteristics are compatible with CID.

Ankylosing spondylitis and psoriatic arthritis: revisiting screening of latent tuberculosis infection and its follow-up during anti-tumor necrosis factor therapy in an endemic area

OBJECTIVES: To retrospectively evaluate the performance and distinctive pattern of latent tuberculosis (TB) infection (LTBI) screening and treatment in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) under anti-tumor necrosis factor (TNF) therapy and determine the relevance of re-exposure and other risk factors for TB development. METHODS: A total of 135 and 83 patients with AS and PsA, respectively, were evaluated for LTBI treatment before receiving anti-TNF drugs via the tuberculin skin test (TST), chest radiography, and TB exposure history assessment. All subjects were evaluated for TB infection at 3-month intervals. RESULTS: The patients with AS were more often treated for LTBI than were those with PsA (42% versus 30%, p=0.043). The former also presented a higher frequency of TST positivity (93% versus 64%, p=0.002), although they had a lower frequency of exposure history (18% versus 52%, p=0.027) and previous TB (0.7% versus 6%, p=0.03). During follow-up [median, 5.8 years; interquartile range (1QR), 2.2-9.0 years], 11/218 (5%) patients developed active TB (AS, n=7; PsA, n=4). TB re-exposure was the main cause in seven patients (64%) after 12 months of therapy (median, 21.9 months; IQR, 14.2-42.8 months) and five LTBI-negative patients. TB was identified within the first year in four patients (36.3%) (median, 5.3 months; IQR, 1.2-8.8 months), two of whom were LTBI-positive. There was no difference in the TB-free survival according to the anti-TNF drug type/class; neither synthetic drug nor prednisone use was related to TB occurrence (p>0.05). CONCLUSION: Known re-exposure is the most critical factor for incident TB cases in spondyloarthritis. There are also some distinct features in AS and PsA LTBI screening, considering the higher frequency of LTBI and TST positivities in patients with AS. Annual risk reassessment taking into consideration these peculiar features and including the TST should be recommended for patients in endemic countries.

Anti-collagen type v: a marker of early systemic sclerosis?

Abstract Objective: To evaluate the frequency of anti-collagen type V in humans with early systemic sclerosis (SSc) compared to defined SSc patients and healthy controls, since collagen type V was shown to be overexpressed in early SSc patients' skin and there is no data concerning the presence of this antibody in early stages of human SSc. Experimental studies showed that animal models immunized with collagen type V developed a disease similar to human systemic sclerosis (SSc), with antibodies production, mainly in early stages post-immunization. Methods: Eighty-one female SSc patients were included and divided into two groups: early-SSc (18 patients-EULAR Preliminary Criteria) and defined-SSc (63 patients-ACR Criteria 1980). The control group consisted of 19 healthy women age-matched to Early-SSc group. Anti-collagen type V was performed by ELISA. Data was analyzed by appropriate tests. Results: The prevalence of anti-collagen type V in early-SSc, defined-SSc and control groups was respectively 33, 17 and 5% (p = 0.07). SSc patients with anti-collagen type V had shorter disease duration compared to those without this antibody (8.8 ± 5.1 vs. 14.7 ± 8.9, p = 0.006). Likewise, early-SSc patients with anti-collagen V also had a shorter disease duration than patients negative for this antibody (4.6 ± 2.2 vs. 9.7 ± 5.2, p = 0.04). No association with clinical subsets or scleroderma antibodies specificities was observed (p > 0.05). Conclusion: The production of anti-collagen type V in SSc seems to be an early event independent of other antibodies specificities. Further studies are necessary to determine if the underlying mechanism for this chronology involves a primary immune response to abnormal expression of collagen type V.(AU)

Avaliação higienicossanitária da água de restaurantes universitários da cidade de São Luís - MA

Objetivou-se no presente artigo avaliar a qualidade da água de dois restaurantes universitários da cidade de São Luís - MA, por meio da pesquisa de coliformes totais e Escherichia coli, utilizando Método Rápido Colilert® (Substrato Cromogênico Enzimático). Quanto à água empregada no preparo de alimentos (oriundas de pontos de água como: cisternas, torneiras) e nos bebedouros nos dois Restaurantes Universitários avaliados, seis (54,54%) foram positivas para Coliformes totais e três (27,27%) positivas para E. coli no restaurante A e dez (100%) no restaurante B mostraram-se impróprias para o consumo humano.

The objective of this article is to evaluate the water quality of two university restaurants in São Luís - MA, through the research of total coliforms and Escherichia coli by Colilert Quick Method (Chromogenic Enzyme Substrate). As for the used in food preparation (derived from water points as cisterns, taps) and troughs in University Restaurants evaluate, six (54.54%) were positive for total coliform and three (27.27%) positive for E. coli in the restaurant and ten 100% B at the restaurant proved to be unfit for consumption.

Immunogenicity of influenza H1N1 vaccination in mixed connective tissue disease: effect of disease and therapy

OBJECTIVE: To assess the potential acute effects regarding the immunogenicity and safety of non-adjuvanted influenza A H1N1/2009 vaccine in patients with mixed connective tissue disease and healthy controls. METHODS: Sixty-nine mixed connective tissue disease patients that were confirmed by Kasukawa's classification criteria and 69 age- and gender-matched controls participated in the study; the participants were vaccinated with the non-adjuvanted influenza A/California/7/2009 (H1N1) virus-like strain. The percentages of seroprotec-tion, seroconversion, geometric mean titer and factor increase in the geometric mean titer were calculated. The patients were clinically evaluated, and blood samples were collected pre- and 21 days post-vaccination to evaluate C-reactive protein, muscle enzymes and autoantibodies. Anti-H1N1 titers were determined using an influenza hemagglutination inhibition assay. ClinicalTrials.gov: NCT01151644. RESULTS: Before vaccination, no difference was observed regarding the seroprotection rates (p = 1.0) and geometric mean titer (p = 0.83) between the patients and controls. After vaccination, seroprotection (75.4% vs. 71%, (p = 0.7), seroconversion (68.1% vs. 65.2%, (p = 1.00) and factor increase in the geometric mean titer (10.0 vs. 8.0, p = 0.40) were similar in the two groups. Further evaluation of seroconversion in patients with and without current or previous history of muscle disease (p = 0.20), skin ulcers (p = 0.48), lupus-like cutaneous disease (p = 0.74), secondary Sjogren syndrome (p = 0.78), scleroderma-pattern in the nailfold capillaroscopy (p = 1.0), lymphopenia #1000/mm³ on two or more occasions (p = 1.0), hypergammaglobulinemia $1.6 g/d (p = 0.60), pulmonary hypertension (p = 1.0) and pulmonary fibrosis (p = 0.80) revealed comparable rates. Seroconversion rates were also similar in patients with and without immunosuppressants. Disease parameters, such as C-reactive protein (p = 0.94), aldolase (p = 0.73), creatine phosphokinase (p = 0.40) and ribonucleoprotein antibody levels (p = 0.98), remained largely unchanged pre and post-vaccination. No severe side effects were reported. CONCLUSIONS: The non-adjuvanted influenza A/H1N1 vaccination immune response in mixed connective tissue disease patients is adequate and does not depend on the disease manifestations and therapy.

Insuficiência respiratória aguda secundária a bócio mergulhante da tireoide / Acute respiratory insufficiencysecondary to substernal thyroid goiter

Relato de caso de bócio mergulhante (BM) em idosa com longa história de bócio nodular tóxico (BNT) e que evoluiu com insuficiência respiratória aguda enquanto aguardava cirurgia eletiva para extirpação do bócio. A evolução das complicações respiratórias dessa paciente sugere que o tratamento cirúrgico do BM em idosos deveria ser feito o mais breve possível, após o surgimento de sintomatologia respiratória, para evitar complicações.

Case report of substernal thyroid goiter in an elderly woman with long record of toxic nodular goiter that progressed to acute respiratory insufficiency while waiting for elective surgery for extirpation of goiter. The development of respiratory complications suggests that the surgical treatment of substernal thyroid goiter affecting elderly people should be pursuit as soon as possible after the appearance of respiratory symptomatology as a means of avoiding complications.

Intestinal microsporidiosis: a hidden risk in rheumatic disease patients undergoing anti-tumor necrosis factor therapy combined with disease-modifying anti-rheumatic drugs?

OBJECTIVE: Immunosuppressed patients are at risk of microsporidiosis, and this parasitosis has an increased rate of dissemination in this population. Our objective was to evaluate the presence of microsporidiosis and other intestinal parasites in rheumatic disease patients undergoing anti-tumor necrosis factor/disease-modifying anti-rheumatic drug treatment. METHODS: Ninety-eight patients (47 with rheumatoid arthritis, 31 with ankylosing spondylitis and 11 with psoriatic arthritis) and 92 healthy control patients were enrolled in the study. Three stool samples and cultures were collected from each subject. RESULTS: The frequency of microsporidia was significantly higher in rheumatic disease patients than in control subjects (36 vs. 4 percent, respectively; p<0.0001), as well as in those with rheumatic diseases (32 vs. 4 percent, respectively; p<0.0001), ankylosing spondylitis (45 vs. 4 percent, respectively; p<0.0001) and psoriatic arthritis (40 vs. 4 percent, respectively; p<0.0001), despite a similar social-economic class distribution in both the patient and control groups (p = 0.1153). Of note, concomitant fecal leukocytes were observed in the majority of the microsporidia-positive patients (79.5 percent). Approximately 80 percent of the patients had gastrointestinal symptoms, such as diarrhea (26 percent), abdominal pain (31 percent) and weight loss (5 percent), although the frequencies of these symptoms were comparable in patients with and without this infection (p>0.05). Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis disease activity parameters were comparable in both groups (p>0.05). The duration of anti-tumor necrosis factor/disease-modifying anti-rheumatic drugs and glucocorticoid use were also similar in both groups. CONCLUSION: We have documented that microsporidiosis with intestinal mucosa disruption is frequent in patients undergoing concomitant anti-tumor necrosis factor/disease-modifying anti-rheumatic drug therapy. Impaired host defenses due to the combination of the underlying disease and the immunosuppressive therapy is the most likely explanation for this finding, and this increased susceptibility reinforces the need for the investigation of microsporidia and implementation of treatment strategies in this population.

Pesquisa de autoanticorpos em pacientes com artrite psoriásica sob terapia anti-TNFα / Autoantibodies in patients with psoriatic arthritis on anti-TNFα therapy

INTRODUÇÃO: A terapia imunobiológica anti-TNFα tem-se mostrado efetiva no tratamento de pacientes com artrite psoriásica (APs) refratária. No entanto, não está bem definido o risco de desenvolvimento de autoanticorpos comumente encontrados nas doenças reumatológicas em pacientes com APs na vigência desse tratamento. OBJETIVO: avaliar a indução de autoanticorpos específicos durante a terapia anti-TNFα em pacientes com APs. PACIENTES E MÉTODOS: Foram analisadas amostras de soro de 23 pacientes com APs (mulheres: 61 por cento, idade: 45,04 ± 12,68 anos, quadro poliarticular: 69,6 por cento, duração da doença: 13,3 ± 7,7 anos, infliximabe: 82,60 por cento) obtidas imediatamente antes (basal) e cerca de um ano após a introdução da terapia anti-TNF (última amostra) (385 ± 131,45 dias). A pesquisa incluiu a detecção de anticorpos antinucleares (ANA) e anticorpos para dsDNA (imunofluorescência indireta em células Hep-2 e em Crithidia luciliae, respectivamente); RNP e Sm (hemaglutinação passiva); Ro/SS-A e/ou La/SS-B, cromatina, histona, peptídeo citrulinado (CCP) e cardiolipina (ELISA). RESULTADOS: A pesquisa basal de ANA revelou positividade em 47,8 por cento dos pacientes, com predomínio do padrão nuclear homogêneo (81,8 por cento). Todas as amostras de soro testadas foram negativas para fator reumatoide e anticorpos anticardiolipina, RNP, Sm, Ro/SS-A, La/SS-B, histona e dsDNA, enquanto dois pacientes apresentaram positividade para anticromatina e um para anti-CCP. Todas as amostras de ANA positivas no tempo basal, exceto uma, mantiveram essa reatividade após a introdução da terapia anti-TNF. Reatividade "de novo" ANA foi observada em quatro dos pacientes originalmente negativos (33,3 por cento). Anticorpos anti-Ro/SS-A, La/SS-B, cardiolipina, histona, dsDNA e fator reumatoide foram sistematicamente negativos em todas as amostras finais de soro testadas e positividade anticromatina foi detectada em outros três...

INTRODUCTION: Anti-TNFα therapy has been effective in the treatment of patients with refractory psoriatic arthritis (PSA). However, the risk of developing autoantibodies commonly found in rheumatic diseases in PSA patients undergoing this therapy is not clear. OBJECTIVE: To evaluate the induction of specific autoantibodies after anti-TNFα therapy in PSA patients. PATIENTS AND METHODS: Serum samples from 23 PSA patients (women: 61 percent, age: 45.04 ± 12.68 years, polyarticular: 69.6 percent, disease duration: 13.3 ± 7.7 years, infliximab: 82.60 percent) obtained immediately before (baseline) and approximately one year after the introduction of anti-TNF therapy (last sample) (385 ± 131.45 days), were analyzed. The analysis included detection of antinuclear antibodies (ANA) and anti-dsDNA antibodies (indirect immunofluorescence on Hep-2 cells and Crithidia luciliae, respectively); anti-RNP and anti-Sm (passive hemagglutination); and anti-Ro/ SS-A and/or anti-La/SS-B, anti-chromatin, anti-histones, anti-citrullinated peptide (CCP), and anti-cardiolipin (ELISA) antibodies. RESULTS: At baseline, ANA was positive in 47.8 percent of patients, with predominance of homogeneous nuclear pattern (81.8 percent). All baseline serum samples were negative for rheumatoid factor and antibodies to cardiolipin, RNP, Sm, Ro/SS-A, anti-La/SS-B, anti-histone, and anti-dsDNA antibodies, while two patients were positive for anti-chromatin and one for anti-CCP. All ANA-positive samples at baseline, except for one, remained positive after the introduction of anti-TNF therapy; however, de novo ANA reactivity was observed in four originally negative patients (33.3 percent). Anti-Ro/SS-A, La/SS-B, cardiolipin, histones, dsDNA, and rheumatoid factor antibodies remained negative in all final serum samples tested, and anti-chromatin positivity was detected in three other patients. CONCLUSION: Our findings have shown that anti-TNF therapy induced ANA positivity...

Complicações imediatas de 3.555 aplicações de agentes anti-TNFα / Immediate complications of 3, 555 injections of anti-TNFα

OBJETIVO: Avaliar as complicações imediatas da aplicação de agentes anti-TNFα no Centro de Dispensação de Medicação deAlto Custo do HC-FMUSP. PACIENTES E MÉTODOS: Foram incluídos todos os pacientes que receberam agentes anti-TNFα entre agosto/2007 e março/2009.As complicações imediatas (até 1 hora após o término da aplicação) foram classificadas em leves (cefaleia, rash, tontura, prurido, náuseas), moderadas (febre, urticária, palpitação, dor torácica, dispneia, variação da pressão arterial de 20 a 40 mmHg) ou graves (febre com calafrios, dispneia com sibilância, variação da pressão arterial > 40 mmHg). RESULTADOS: Foram avaliados 242 pacientes: 94 (39 por cento) com artrite reumatoide, 64 (26 por cento) com espondilite anquilosante, 32 (13 por cento) com artrite psoriásica, 26 (11 por cento) com artrite idiopática juvenil e 27 (11 por cento) com outros diagnósticos. O número total de aplicações foi de 3.555, sendo 992 (28 por cento) de adalimumabe, 1.546 (43 por cento) de etanercepte e 1.017 (29 por cento) de infliximabe. Complicações imediatas foram observadas em 39/242 (16 por cento) pacientes. As complicações ocorreram em 45/3.555 (1,2 por cento) aplicações. Estas foram mais frequentes com infliximabe comparado com adalimumabe (3,7 por cento vs. 0,5 por cento, P < 0,0001), e com etanercepte (3,7 por cento vs. 0,25 por cento, P < 0,0001). As complicações foram: leves 14/45 (31 por cento), moderadas 21/45 (47 por cento) e graves 10/45 (22 por cento); ocorreram principalmente nos primeiros seis meses de tratamento (56 por cento) e nas aplicações endovenosas, predominantemente na primeira hora de infusão (76 por cento). CONCLUSÃO: As reações agudas, apesar de raras, são potencialmente graves e ocorrem principalmente nas primeiras aplicações tanto no uso de medicações endovenosas como de subcutâneas...

OBJECTIVE: To evaluate the immediate complications of anti-TNFα drugs at the "Center for Dispensation of High Cost Medications" of HC-FMUSP. PATIENTS AND METHODS: All patients who received anti-TNFα agents between August 2007 and March 2009 were included in this study. Immediate complications (up to 1 hour after the injection) were classified as mild (headache, rash, dizziness, itching, nausea), moderate (fever, urticaria, palpitation, chest pain, dyspnea, blood pressure variations between 20 and 40 mmHg), or severe (fever with chills, dyspnea with wheezing, variations in blood pressure > 40 mmHg). RESULTS: Two hundred and forty-two patients were evaluated: 94 (39 percent) with rheumatoid arthritis, 64 (26 percent) with ankylosing spondylitis, 32 (13 percent) with psoriatic arthritis, 26 (11 percent) with juvenile idiopathic arthritis; and 27 (11 percent) with other diagnoses. A total of 3,555 injections were administered: 992 (28 percent) adalimumab, 1,546 (43 percent) etanercept, and 1,017 (29 percent) infliximab. Immediate adverse events were observed in 39/242 (16 percent) patients. Injectionrelated complications were observed in 46/3,555 (1.2 percent) injections. They were more common with infliximab than adalimumab (3.7 percent vs. 0.5 percent, P < 0.0001) and etanercept (3.7 percent vs. 0.25 percent, P < 0.0001). Complications were classified as mild 14/45 (31 percent), moderate 21/45 (47 percent), and severe 10/45 (22 percent), and occurred mainly in the first six months of treatment (56 percent) and after intravenous injections, especially (76 percent) in the first hour. CONCLUSION: Although rare, acute reactions can be severe, being observed more commonly after the initial injections, both intravenous and subcutaneous...

Acute splenic sequestration in a cohort of children with sickle cell anemia / Sequestro esplênico agudo em coorte de crianças com anemia falciforme

OBJETIVO: Analisar o sequestro esplênico agudo (SEA) em crianças com anemia falciforme, provindas da triagem neonatal de Minas Gerais e acompanhadas pelo Hemominas de Belo Horizonte (MG). MÉTODOS: Coorte retrospectiva de 255 crianças com hemoglobinopatia SS/Sβº, nascidas entre 01/01/2000 e 31/12/2004 e acompanhadas até 31/12/2006. Os dados foram extraídos dos prontuários médicos. RESULTADOS: Oitenta e nove pacientes apresentaram 173 eventos de SEA (10,2 primeiros eventos por 100 pacientes/ano), sendo que 75% dos primeiros episódios de SEA ocorreram até 2 anos de vida. A probabilidade estimada de ocorrência do primeiro episódio de SEA foi de 40%. A recorrência atingiu 57,3%. Após o primeiro episódio de SEA, a esplenectomia foi indicada em apenas 12,4% dos casos; após o segundo, em 60,4% dos casos. Após o terceiro episódio, 41,7% dos casos ainda permaneceram sob observação clínica. A mediana do tempo entre indicação e realização da esplenectomia foi de 2 meses. Nesse intervalo, 37,2% das crianças tiveram novo episódio de SEA e uma delas faleceu. A letalidade no primeiro episódio foi de 1,1% e de 7,8% em episódios subsequentes. Entre as 255 crianças ocorreram 19 óbitos: 36,8% devido a infecções e 26,3% após SEA. CONCLUSÕES: O SEA é um evento comum na anemia falciforme, principalmente nos 2 primeiros anos de vida, com recidiva em mais da metade dos casos. Predominou conduta conservadora na indicação da esplenectomia. Embora a letalidade tenha sido baixa, o SEA representou a segunda causa de óbito. Isso aponta para fragilidades estruturais do sistema de saúde de MG e para a necessidade de melhor capacitação profissional na abordagem do problema.

OBJECTIVE: To analyze acute splenic sequestration (ASS) in children with sickle cell anemia diagnosed through a newborn screening program in the state of Minas Gerais, Brazil, and followed up at the hematology center in the city of Belo Horizonte, Minas Gerais, Brazil. METHODS: Retrospective cohort of 255 children with sickle cell anemia (Hb SS/Sβº) born between January 01, 2000, and December 31, 2004, and followed up until December 31, 2006. Data were abstracted from the patients' medical records. RESULTS: A total of 89 patients had 173 episodes of ASS (10.2 first episodes per 100 patient-years); 75% of the first episodes occurred before 2 years of age. The estimated probability of occurrence of the first episode of ASS during the study period was 40%. Recurrence rate reached 57.3%. After the first episode, splenectomy was indicated in only 12.4% of the cases; after the second, in 60.4% of the cases. After the third episode, 41.7% of the patients remained under clinical observation. The median time between indication for splenectomy and the actual surgical procedure was 2 months. During the intervening period, 37.2% of the children suffered a new episode of ASS and one child died. Case-fatality rate was 1.1% for the first episode and 7.8% for the subsequent episodes. Among a total of 255 children, 19 died: 36.8% due to infections and 26.3% after ASS. CONCLUSIONS: ASS is relatively common in sickle cell anemia, mainly in the first 2 years of life; relapse occurs in more than half of the cases. Conservative management instead of immediate splenectomy was the method of choice. Although the case-fatality rate was low, ASS was the second most common cause of death. These results disclose some fragilities of the health system in the state of Minas Gerais and the need for better professional education to approach ASS crises.