Clinical-epidemiological profile and factors related to the mortality of patients with nontuberculous mycobacteria isolated at a reference hospital in Ceará, Northeastern Brazil.

Background: There is a significant shortage of official records that enable estimating the real prevalence of nontuberculous mycobacteria (NTM) infections in Brazil. The study aims to investigate the clinical, laboratory, and epidemiological aspects of patients with NTM isolation at an infectious diseases reference hospital, and to identify factors associated with mortality. Methods: This was an observational study in which clinical, epidemiological, and laboratory aspects were evaluated in patients with NTM isolated at care in Hospital São José, located in Northeastern Brazil, from 2005 to 2016. The records of the reference laboratory for NTM isolates were searched from the culture results of patients. Afterward, the medical records of the patients were reviewed. The analytical assessment was conducted by the Mann-Whitney and Fisher's exact test. The adopted level of significance was 5%. Results: A total of 69 patients were described, with a predominance of males (73.9%). The main clinical forms identified were: pulmonary (60.9%) and disseminated (27.5%). The most frequently NTM identified were Mycobacterium avium (24.6%) and Mycobacterium fortuitum (10.1%). Forty-eight (69.6%) patients had HIV infection. The mortality was 24.6%, and the risk factors for deaths identified were: origin from outside the metropolitan region; weight loss; HIV infection; anemia; hyperbilirubinemia; increased serum glutamic-oxaloacetic transaminase, alkaline phosphatase, lactate dehydrogenase; and impaired renal function. Among the patients with HIV, the main changes related to death were: lower counts of CD4+ and CD8+ T lymphocytes. Conclusion: Maintaining constant vigilance regarding the possibility of NTM infection is required, namely in patients co-infected with HIV/AIDS.

Physical violence inside female prisons in Brazil: prevalence and related factors.

The present study aims to identify the prevalence of physical violence against female prisoners in Brazil, as well as related factors. This is a cross-sectional national survey conducted in 15 female prisons in five regions of Brazil selected in multiple stages. The following types of analysis were performed: univariate analysis; stratified analysis relating the outcome (suffer physical violence inside prison) to predictor variables, using the Pearson chi-square test; calculation of the Odds Ratio (O.R.); and multiple logistic regression. The Hosmer-Lemeshow test was used for analysis of goodness of fit and adequacy of the model. The prevalence of physical violence inside female prisons was 37.4%. There was a correlation between physical violence victimization in prison and the following variables: physical victimization prior to arrest (p = 0.013), solitary confinement (p = 0.000), mental suffering (p = 0.003), current or previous abusive intake of alcohol (p = 0.011), current or previous injection of cocaine (p = 0.002) and not performing prison labor (p = 0.003). Physical violence has become inherent in the Brazilian female prison system. Continued studies are needed to monitor the situation and to develop  interventions to prevent physical violence inside the facilities.

Physical violence inside female prisons in Brazil: prevalence and related factors / Violência física dentro das prisões femininas no Brasil: prevalência e fatores relacionados

Abstract The present study aims to identify the prevalence of physical violence against female prisoners in Brazil, as well as related factors. This is a cross-sectional national survey conducted in 15 female prisons in five regions of Brazil selected in multiple stages. The following types of analysis were performed: univariate analysis; stratified analysis relating the outcome (suffer physical violence inside prison) to predictor variables, using the Pearson chi-square test; calculation of the Odds Ratio (O.R.); and multiple logistic regression. The Hosmer-Lemeshow test was used for analysis of goodness of fit and adequacy of the model. The prevalence of physical violence inside female prisons was 37.4%. There was a correlation between physical violence victimization in prison and the following variables: physical victimization prior to arrest (p = 0.013), solitary confinement (p = 0.000), mental suffering (p = 0.003), current or previous abusive intake of alcohol (p = 0.011), current or previous injection of cocaine (p = 0.002) and not performing prison labor (p = 0.003). Physical violence has become inherent in the Brazilian female prison system. Continued studies are needed to monitor the situation and to develop interventions to prevent physical violence inside the facilities.

Resumo O presente artigo objetiva identificar a prevalência de violência física no interior das prisões femininas brasileiras, bem como fatores associados. Estudo transversal de abrangência nacional, realizado em 15 unidades prisionais femininas nas cinco regiões do Brasil em amostra selecionada por múltiplos estágios. Realizou-se análise univariada; análise estratificada em relação ao desfecho (sofrer violência física dentro da prisão) e as variáveis preditoras através do teste de Chi-quadrado de Pearson; cálculo da Odds Ratio; e regressão logística múltipla. Utilizou-se o teste Hosmer-Lemeshow para análise de qualidade de ajuste e adequação do modelo. A prevalência de violência física dentro das prisões femininas brasileiras foi de 37.4%. Houve correlação entre a vitimização da violência física na prisão e as seguintes variáveis: vitimização física prévia (p = 0.013), isolamento (p = 0.000), sofrimento mental (p = 0.003), ingestão abusiva e/ou dependência alcoólica (p = 0.011), uso atual ou prévio de cocaína injetável (p = 0.002) e ócio prisional (p = 0.003). A violência física tornou-se inerente ao sistema prisional feminino brasileiro. Estudos futuros são necessários no intuito de fornecer propostas para intervenções efetivas de modo a prevenir a violência física dentro das instalações prisionais.

Lifetime Syphilis Prevalence and Associated Risk Factors Among Female Prisoners in Brazil.

BACKGROUND: In 2016, approximately 42,000 women were incarcerated in Brazil. The objectives of this study were to measure the lifetime prevalence of syphilis and sociodemographic and behavior correlates of antibody positivity among female prisoners in Brazil. METHODS: We conducted a cross-sectional survey of 1327 incarcerated women in 2014 to 2015 sampled through a multistage cluster design to represent the penitentiary system throughout Brazil. A rapid treponemal antibody test approved by the Ministry of Health (Rapid Test DPP Sífilis Bio-Manguinhos) was used to detect lifetime history of infection. Analyses were adjusted using weights based on the inverse of the product of the probabilities of the sampling units at each stage of the design. Variables significantly associated with syphilis infection at P < 0.05 in multivariate analyses were retained in the final model. RESULTS: Prevalence of syphilis antibody among female prisoners in Brazil was 11.6% (95% confidence interval [CI], 9.8%-13.8%). Higher syphilis prevalence was associated with black/Afro-Brazilian or mixed race/ethnicity (adjusted odds ratio [AOR], 1.78; 95% CI, 1.10-2.87), homelessness (AOR, 4.58; 95% CI, 2.78-7.56), abortion (AOR, 1.56; 95% CI, 1.02-2.38), and sexual violence (AOR, 1.59; 95% CI, 1.01-2.49). Syphilis prevalence was lower among women who had received condoms in school (AOR, 0.28; 95% CI, 0.08-1.00) as a marker for reproductive health education. CONCLUSIONS: Women within the vast Brazilian prison system demonstrate a high lifetime cumulative incidence of syphilis. Our data advocate for increased screening and treatment of syphilis of incarcerated women and help identify women at higher risk within the prison system and within their communities of origin.

The 12 city HIV Surveillance Survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics.

INTRODUCTION: This paper details the methods used in the second national Biological and Behavioral Surveillance Survey (BBSS) of HIV, syphilis, and hepatitis B and C among men who have sex with men in Brazil. METHODS: Respondent-driven sampling (RDS) was used in 12 cities in 2016. The targeted sample size was initiated with five to six seeds in each city. HIV, syphilis, and Hepatitis B and C rapid tests were offered to participants. RDS Analyst with Gile's successive sampling (SS) estimator was used to adjust results as recommended and a weight for each individual was generated for further analysis. Data for the 12 cities were merged and analyzed using Stata 14.0 complex survey data tools with each city treated as its own stratum. RESULTS: Duration of data collection varied from 5.9 to 17.6 weeks. 4,176 men were recruited in the 12 cities. Two sites failed to achieve targeted sample size due to a six-month delay in local IRB approval. No city failed to reach convergence in our major outcome variable (HIV). CONCLUSION: The comprehensive BBSS was completed as planned and on budget. The description of methods here is more detailed than usual, due to new diagnostic tools and requirements of the new STROBE-RDS guidelines.

The 12 city HIV Surveillance Survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics / Inquérito sobre o HIV entre HSH no Brasil em 2016 usando respondent-driven sampling (RDS): descrição dos métodos e dos diagnósticos do RDS

ABSTRACT: Introduction: This paper details the methods used in the second national Biological and Behavioral Surveillance Survey (BBSS) of HIV, syphilis, and hepatitis B and C among men who have sex with men in Brazil. Methods: Respondent-driven sampling (RDS) was used in 12 cities in 2016. The targeted sample size was initiated with five to six seeds in each city. HIV, syphilis, and Hepatitis B and C rapid tests were offered to participants. RDS Analyst with Gile's successive sampling (SS) estimator was used to adjust results as recommended and a weight for each individual was generated for further analysis. Data for the 12 cities were merged and analyzed using Stata 14.0 complex survey data tools with each city treated as its own stratum. Results: Duration of data collection varied from 5.9 to 17.6 weeks. 4,176 men were recruited in the 12 cities. Two sites failed to achieve targeted sample size due to a six-month delay in local IRB approval. No city failed to reach convergence in our major outcome variable (HIV). Conclusion: The comprehensive BBSS was completed as planned and on budget. The description of methods here is more detailed than usual, due to new diagnostic tools and requirements of the new STROBE-RDS guidelines.

RESUMO: Introdução: Este artigo detalha os métodos utilizados na segunda Pesquisa Nacional de Vigilância Biológica e Comportamental (BBSS) do HIV, sífilis e hepatite B e C entre os homens que fazem sexo com homens no Brasil. Métodos: O método Respondent-driven Sampling (RDS) foi utilizado em 12 cidades em 2016. A amostra foi iniciada com cinco a seis sementes em cada cidade. Testes rápidos para o HIV, sífilis e Hepatite B e C foram oferecidos aos participantes. O software RDS Analyst com o estimador de amostragem sucessiva (SS) de Gile foi utilizado para ajustar os resultados como recomendado, gerando um peso para cada indivíduo para análises. Osdados das 12cidades foram unidos em um único banco e analisados usando as ferramentas de dados complexos do Stata 14.0, com cada cidade sendo tratada como seu próprio estrato. Resultados: A duração da coleta de dados variou de 5,9 a 17,6 semanas e 4.176 homens foram recrutados nas 12 cidades. Dois sites não alcançaram o tamanho da amostra alvo devido a uma demora de seis meses na aprovação local do Comitê de Ética. Todas as cidades atingiram a convergência na principal variável estudada (HIV). Conclusão: O BBSS foi representativo e concluído conforme planejado e dentro do orçamento. A descrição dos métodos aqui é mais detalhada do que o habitual, devido às novas ferramentas e requisitos de diagnóstico das novas diretrizes do STROBE-RDS.

Incentives and barriers to HIV testing among female sex workers in Ceará.

OBJECTIVE: Estimating HIV prevalence and describing the incentives and barriers for HIV testing among female sex workers. METHODS: This cross-sectional study recruited 402 women aged 18 years or older, residing in Fortaleza, state of Ceará, Brazil, who reported having had sexual intercourse in exchange for money in last four months. The sample was recruited using Respondent Driven Sampling, between August and November 2010. RESULTS: The 84.1% of the sample tested and the estimated prevalence of HIV infection was 3.8%. The sample was young (25 to 39 years ), single (80.0%), with one to three children (83.6%), had eight or more years of schooling (65.7%), and belonged to social classes D/E (53.1%). The majority worked in fixed locations (bars, motels, hotels, sauna - 88.9%), and prostitution was their only source of income (54.1%). About 25% of the sample did not know where to test in the public health sector and 51.8% either never tested or hadn't tested for over a year or more. The main reported barriers to testing were the perceptions that there was no risk of becoming infected (24.1%), and, alternatively, fear of discrimination if the test was positive (20.5%). Incentives for testing were the greater availability of testing sites (57.0%) and health facilities with alternative schedules (44.2%). CONCLUSIONS: Prevalence for HIV was similar to that found in other Brazilian cities in different regions of the country, although higher than the general female population. Non-traditional venues not associated with the health system and availability of testing in health units during non-commercial hours are factors that encourage testing. Not considering oneself to be at risk, fear of being discriminated against and not knowing testing locations are barriers.

Incentives and barriers to HIV testing among female sex workers in Ceará / Incentivos e barreiras ao teste de HIV entre mulheres profissionais do sexo no Ceará

ABSTRACT OBJECTIVE Estimating HIV prevalence and describing the incentives and barriers for HIV testing among female sex workers. METHODS This cross-sectional study recruited 402 women aged 18 years or older, residing in Fortaleza, state of Ceará, Brazil, who reported having had sexual intercourse in exchange for money in last four months. The sample was recruited using Respondent Driven Sampling, between August and November 2010. RESULTS The 84.1% of the sample tested and the estimated prevalence of HIV infection was 3.8%. The sample was young (25 to 39 years ), single (80.0%), with one to three children (83.6%), had eight or more years of schooling (65.7%), and belonged to social classes D/E (53.1%). The majority worked in fixed locations (bars, motels, hotels, sauna - 88.9%), and prostitution was their only source of income (54.1%). About 25% of the sample did not know where to test in the public health sector and 51.8% either never tested or hadn't tested for over a year or more. The main reported barriers to testing were the perceptions that there was no risk of becoming infected (24.1%), and, alternatively, fear of discrimination if the test was positive (20.5%). Incentives for testing were the greater availability of testing sites (57.0%) and health facilities with alternative schedules (44.2%). CONCLUSIONS Prevalence for HIV was similar to that found in other Brazilian cities in different regions of the country, although higher than the general female population. Non-traditional venues not associated with the health system and availability of testing in health units during non-commercial hours are factors that encourage testing. Not considering oneself to be at risk, fear of being discriminated against and not knowing testing locations are barriers.

RESUMO OBJETIVO Estimar a prevalência do HIV e descrever os incentivos e barreiras à realização do teste para o HIV entre mulheres profissionais do sexo. MÉTODOS Este estudo transversal recrutou 402 mulheres de 18 anos ou mais, residentes em Fortaleza, CE, que informaram ter tido relação sexual em troca de dinheiro nos últimos quatro meses. A amostra foi recrutada por meio da técnica Respondent Driven Sampling, entre agosto e novembro de 2010. RESULTADOS A adesão ao teste de HIV foi de 84,1% e a prevalência estimada da infecção pelo HIV foi de 3,8%. A amostra era jovem (25 a 39 anos), solteira (80,0%), com um a três filhos (83,6 %), tinham oito anos ou mais de estudo (65,7%) e pertencia às classes sociais D/E (53,1%). A maioria exercia a profissão em locais fechados (bares, motéis, hotéis, sauna - 88,9%), e a prostituição era a única fonte de renda (54,1%). Cerca de 25% da amostra desconhecia onde o teste de HIV era realizado na rede pública e 51,8% nunca fez o teste ou se testou há um ano ou mais. As principais barreiras ao teste foram acreditar que não corre risco de se infectar (24,1%) e o medo da discriminação caso o teste fosse reagente (20,5%). Os incentivos foram relacionados à maior oferta de locais para o teste (57,0%) e de unidades de saúde com horários alternativos (44,2%). CONCLUSÕES A prevalência foi semelhante à encontrada em outras cidades brasileiras de diferentes regiões do país, apesar de superiores a de mulheres não profissionais do sexo. A disponibilidade do teste em locais não relacionados à saúde e a oferta nas unidades básicas em horário não comercial são fatores que incentivam a realização do teste. Não se considerar sob-risco, medo de ser discriminada e desconhecimento dos locais onde o teste é realizado podem ser uma barreira para a realização do exame.

Incentives and barriers to HIV testing in men who have sex with men in a metropolitan area in Brazil.

This study aimed to identify incentives and barriers to HIV testing in men who have sex with men (MSM). This was a cross-sectional study of MSM who had lived at least three months in greater metropolitan Fortaleza, Ceará State, Brazil, 2010. The study recruited 391 men ≥ 18 years of age who reported sexual relations with men in the previous six months, using Respondent Driven Sampling. Personal network and socio-demographic data were collected and HIV testing was offered, analyzed with RDSAT 6.0 and Stata 11.0. The majority were young (40.3%), had 5 to 11 years of schooling (57.3%), were single (85.1%), had low income (37.6%), and 58.1% had tested for HIV some time in life. Incentive to test: certainty of not being infected (34.1%) and the exposure to national campaign Fique Sabendo [Know your Status] (34%). Barriers: trust in partner(s) (21%) and fear of discrimination if tested positive (20.3%). Policies should be developed to ensure test confidentiality and communication campaigns focusing on information gaps and encouragement for testing.

Incentives and barriers to HIV testing in men who have sex with men in a metropolitan area in Brazil / Incentivos e barreiras para testagem do HIV em homens que fazem sexo com homens em região metropolitana do Brasil / Incentivos y barreras para el test del VIH en hombres que practican sexo con hombres en una región metropolitana de Brasil

Abstract: This study aimed to identify incentives and barriers to HIV testing in men who have sex with men (MSM). This was a cross-sectional study of MSM who had lived at least three months in greater metropolitan Fortaleza, Ceará State, Brazil, 2010. The study recruited 391 men ≥ 18 years of age who reported sexual relations with men in the previous six months, using Respondent Driven Sampling. Personal network and socio-demographic data were collected and HIV testing was offered, analyzed with RDSAT 6.0 and Stata 11.0. The majority were young (40.3%), had 5 to 11 years of schooling (57.3%), were single (85.1%), had low income (37.6%), and 58.1% had tested for HIV some time in life. Incentive to test: certainty of not being infected (34.1%) and the exposure to national campaign Fique Sabendo [Know your Status] (34%). Barriers: trust in partner(s) (21%) and fear of discrimination if tested positive (20.3%). Policies should be developed to ensure test confidentiality and communication campaigns focusing on information gaps and encouragement for testing.

Resumo: Identificar os incentivos e as barreiras aos testes de HIV entre homens que fazem sexo com homens (HSH). Estudo transversal entre HSH que residiram pelo menos três meses na região metropolitana de Fortaleza, Ceará, Brasil, em 2010. Foram recrutados 391 homens, ≥ 18 anos, que relataram sexo com homens nos últimos seis meses, utilizando Respondent Driven Sampling. Coletados os dados: rede social, sociodemográficos e oferecido o teste de HIV e analisados pelo RDSAT 6.0 e Stata 11.0. A maioria era jovem (40,3%), de 5 a 11 anos de escolaridade (57,3%), solteira (85,1%), baixa renda (37,6%), 58,1% testaram para o HIV alguma vez na vida. Incentivos ao teste: certeza de não estar infectado (34,1%) e campanha nacional Fique Sabendo (34%). Barreiras: confiar no(s) parceiro(s) (21%) e medo de discriminação se o resultado for positivo (20,3%). Políticas que assegurem a confidencialidade dos testes e campanhas de comunicação voltadas às lacunas de informação e incentivo ao teste devem ser desenvolvidas.

Resumen: Identificar los incentivos y las barreras a los test de VIH entre hombres que practican sexo con hombres (HSH). Estudio transversal entre HSH que residieron por lo menos tres meses en la región metropolitana de Fortaleza, Ceará, Brasil, en 2010. Fueron reclutados 391 hombres, ≥ 18 años, que relataron sexo con hombres en los últimos seis meses, utilizando Respondent Driven Sampling. Datos recogidos: red social, sociodemográficos y ofrecido el test de VIH y analizados por el RDSAT 6.0 y Stata 11.0. La mayoría era joven (40,3%), de 5 a 11 años de escolaridad (57,3%), soltero (85,1%), baja renta (37,6%), 58,1% se hicieron pruebas del VIH alguna vez en la vida. Incentivos al test: certeza de no estar infectado (34,1%) y campaña nacional Fique Sabendo (34%). Barreras: confiar en el compañero (s) (21%) y miedo a la discriminación si el resultado fuera positivo (20,3%). Se deben desarrollar políticas que aseguren la confidencialidad de los test, así como campañas de comunicación, dirigidas a las lagunas de información sobre este asunto, además de incentivos a la realización del test.

Sexual Violence Against Men Who Have Sex with Men in Brazil: A Respondent-Driven Sampling Survey.

We estimated the prevalence of sexual violence (SV) experience among men who have sex with men (MSM) in Brazil and identified its associated risk factors. We recruited 3859 MSM through respondent driven sampling. A multivariable hierarchical analysis was performed using an ecological model. The prevalence of having ever experienced SV was 15.9 % (95 % confidence interval [CI] 14.7-17.1). SV experience was independently associated with discrimination due to sexual orientation (odds ratio [OR] 3.05; 95 % CI 2.10-4.42), prior HIV testing (OR 1.81; 95 % CI 1.25-2.63), ≤14 years at first sex (OR 1.86; 95 % CI 1.28-2.71), first sex with a man (OR 1.89; 95 % CI 1.28-2.79), presenting STI symptoms (last year) (OR 1.66; 95 % CI 1.12-2.47), and having suicidal ideas (last 6 months) (OR 2.08; 95 % CI 1.30-3.35). The high levels of SV against MSM in Brazil place them at a markedly higher risk of SV than the general population. Homophobic prejudice is the strongest determinant of SV and urgently needs to be included at the forefront of the national response to SV.

Factors associated with pulmonary tuberculosis among patients seeking medical attention at referral clinics for tuberculosis.

OBJECTIVE: The identification of behavioral and clinical factors that are associated with pulmonary tuberculosis might improve the detection and treatment of the disease, thereby reducing its duration and transmission. Our objective was to identify sociodemographic, clinical, and behavioral factors that are associated with the diagnosis of pulmonary tuberculosis. METHODS: This was a cross-sectional study conducted between April of 2008 and March of 2009 at three health care clinics in the city of Fortaleza, Brazil. We selected 233 patients older than 14 years of age who spontaneously sought medical attention and presented with cough for > 2 weeks. Sociodemographic, clinical, and behavioral data were collected. Sputum smear microscopy for AFB and mycobacterial culture were also carried out, as were tuberculin skin tests and chest X-rays. The patients were divided into two groups (with and without pulmonary tuberculosis). The categorical variables were compared by the chi-square test, followed by logistic regression analysis when the variables were considered significant. RESULTS: The prevalence of pulmonary tuberculosis was 41.2%. The unadjusted OR showed that the following variables were statistically significant risk factors for pulmonary tuberculosis: fever (OR = 2.39; 95% CI, 1.34-4.30), anorexia (OR = 3.69; 95% CI, 2.03-6.75), and weight loss (OR = 3.37; 95% CI, 1.76-6.62). In the multivariate analysis, only weight loss (OR = 3.31; 95% CI, 1.78-6.14) was significantly associated with pulmonary tuberculosis. CONCLUSIONS: In areas with a high prevalence of tuberculosis, weight loss could be used as an indicator of pulmonary tuberculosis in patients with chronic cough for > 2 weeks.

Fatores associados à tuberculose pulmonar em pacientes que procuraram serviços de saúde de referência para tuberculose / Factors associated with pulmonary tuberculosis among patients seeking medical attention at referral clinics for tuberculosis

OBJETIVO: A identificação de fatores comportamentais e clínicos associados à tuberculose pulmonar pode melhorar a detecção e o tratamento dessa doença, consequentemente reduzindo sua duração e transmissão. Nosso objetivo foi identificar fatores sociodemográficos, clínicos e comportamentais associados à tuberculose pulmonar. MÉTODOS: Estudo transversal realizado entre abril de 2008 e março de 2009 em três unidades de saúde na cidade de Fortaleza (CE). Foram selecionados 233 pacientes maiores de 14 anos que procuraram atendimento médico espontaneamente e que apresentavam tosse por > 2 semanas. Foram coletados dados sociodemográficos, clínicos e comportamentais. Foram realizadas baciloscopia direta para BAAR e cultura de micobactérias, bem como testes tuberculínicos e radiografias de tórax. Os pacientes foram divididos em dois grupos (com e sem tuberculose pulmonar). As variáveis categóricas foram comparadas com o teste do qui-quadrado, seguido de análise de regressão logística quando as variáveis foram consideradas significativas. RESULTADOS: A prevalência de tuberculose pulmonar foi 41,2%. As OR não ajustadas indicaram que as seguintes variáveis foram fatores de risco significativos para tuberculose pulmonar: febre (OR = 2,39; IC95%: 1,34-4,30), anorexia (OR = 3,69; IC95%: 2,03-6,75) e perda de peso (OR = 3,37; IC95%: 1,76-6,62). Na análise multivariada, apenas perda de peso (OR = 3,31; IC95%: 1,78-6,14) associou-se significativamente com tuberculose pulmonar. CONCLUSÕES: Em áreas com elevada prevalência de tuberculose, a perda de peso poderia ser utilizada como um indicador de tuberculose pulmonar em pacientes com tosse crônica por > 2 semanas.

OBJECTIVE: The identification of behavioral and clinical factors that are associated with pulmonary tuberculosis might improve the detection and treatment of the disease, thereby reducing its duration and transmission. Our objective was to identify sociodemographic, clinical, and behavioral factors that are associated with the diagnosis of pulmonary tuberculosis. METHODS: This was a cross-sectional study conducted between April of 2008 and March of 2009 at three health care clinics in the city of Fortaleza, Brazil. We selected 233 patients older than 14 years of age who spontaneously sought medical attention and presented with cough for > 2 weeks. Sociodemographic, clinical, and behavioral data were collected. Sputum smear microscopy for AFB and mycobacterial culture were also carried out, as were tuberculin skin tests and chest X-rays. The patients were divided into two groups (with and without pulmonary tuberculosis). The categorical variables were compared by the chi-square test, followed by logistic regression analysis when the variables were considered significant. RESULTS: The prevalence of pulmonary tuberculosis was 41.2%. The unadjusted OR showed that the following variables were statistically significant risk factors for pulmonary tuberculosis: fever (OR = 2.39; 95% CI, 1.34-4.30), anorexia (OR = 3.69; 95% CI, 2.03-6.75), and weight loss (OR = 3.37; 95% CI, 1.76-6.62). In the multivariate analysis, only weight loss (OR = 3.31; 95% CI, 1.78-6.14) was significantly associated with pulmonary tuberculosis. CONCLUSIONS: In areas with a high prevalence of tuberculosis, weight loss could be used as an indicator of pulmonary tuberculosis in patients with chronic cough for > 2 weeks.

A comparative analysis of pre- and post-dialysis albumin as indicators of nutritional and morbi-mortality risks in haemodialysis patients.

INTRODUCTION: Pre-dialysis albumin is likely to be falsely low due to a dilution effect, making its usefulness in assessing protein status questionable. OBJEVTIVES: The purpose of this study was to assess whether post-dialysis albumin would be a better marker of malnutrition and risk of mortality, when compared to pre-dialysis albumin. METHODS: We evaluated the correlation between pre- and post-dialysis albumin and the following parameters: body mass index (BMI), adequacy of muscle arm circumference (MAC) and tricipital skinfold (TS) to the 50th percentile (P50), C-reactive protein (CRP), phase angle (PA), protein equivalent of nitrogen appearance (PNA), the Kt/V index of dialysis adequacy, and the hydration status (Pearson's correlation coefficient). Agreement in the nutritional status according to pre- and post-dialysis (post-HD) albumin and PA was estimated according to the Kappa (K) coefficient (Bland-Altman). RESULTS: A total of 58 haemodialysis (HD) patients were included in this study (30 female; mean age: 49 years). BMI, PA and CRP had a significant correlation with pre- and post-HD albumin, while MAC and PNA correlated only with post-HD albumin. Agreement in the diagnosis of malnutrition according to PA < 5 and pre- and post-HD albumin < 3.2 g/dL was regular (K = 0.432). When using an albumin cut-off value of 3.7 g/dL for malnutrition (mild malnutrition or risk of malnutrition), the diagnosis was concordant only in the post-HD period (K = 0.544). CONCLUSIONS: Post-dialysis albumin levels may be a better marker of protein status and mortality risk in cases of mild malnutrition or risk of malnutrition and in patients with low/medium mortality risk. Pre-dialysis fluid overload may be a confounding factor when evaluating albumin levels.

Análise comparativa entre a albumina pré- e pós-dialise como indicadores do risco nutricional e de morbimortalidade em hemodiálise / A comparative analysis of pre- and post-dialysis albumin as indicators of nutritional and morbi-mortality risks in haemodialysis patients

INTRODUÇÃO: A albumina pré-diálise pode ter sua utilidade questionada na avaliação do estado proteico devido ao efeito dilucional nesse período. OBJETIVOS: Avaliar se a albumina sérica dosada no período pós-diálise (pós-HD) seria um melhor marcador do estado nutricional e do risco de mortalidade, comparada à albumina pré-diálise. MÉTODOS: Investigou-se a correlação entre a albumina pré- e pós-HD e: o índice de massa corpórea (IMC), a adequação da circunferência muscular do braço (CMB) e da prega tricipital (PCT) ao percentil 50 (P50), proteína C-reativa ultrassensível (hs-PCR), o ângulo de fase (PA), o PNA (equivalente proteico do aparecimento de nitrogênio), o índice de adequação da diálise (Kt/V) e o estado de hidratação (correlação de Pearson). A concordância no diagnóstico do estado nutricional segundo a albumina pré- e pós-HD e o PA foi testada pelo coeficiente Kappa (K) (Bland-Altman). RESULTADOS: Foram incluídos 58 pacientes em hemodiálise (HD) (30 do sexo feminino, com idade média de 49 anos). O IMC, o PA e a hs-PCR apresentaram correlação significativa com a albumina pré- e pós-HD, enquanto a adequação da CMB ao P50 e o PNA o fizeram apenas com a albumina pós-HD. A concordância no diagnóstico de desnutrição, segundo o PA < 5 e albumina pré- e pós-HD < 3,2 g/dL foi regular (K = 0,432). Quando o ponto de corte da albumina para desnutrição foi de 3,7 g/dL (desnutrição leve ou risco de desnutrição), os diagnósticos foram concordantes somente no período pós-HD (K = 0,544). CONCLUSÃO: A albumina pós-diálise parece ser um melhor marcador do estado nutricional e de risco de mortalidade nos casos de desnutrição leve ou risco de desnutrição e nas situações de médio a baixo risco de mortalidade. O estado de hiper-hidratação pré-diálise pode representar um fator de confusão na interpretação clínica da albumina.

INTRODUCTION: Pre-dialysis albumin is likely to be falsely low due to a dilution effect, making its usefulness in assessing protein status questionable. OBJEVTIVES: The purpose of this study was to assess whether post-dialysis albumin would be a better marker of malnutrition and risk of mortality, when compared to pre-dialysis albumin. METHODS: We evaluated the correlation between pre- and post-dialysis albumin and the following parameters: body mass index (BMI), adequacy of muscle arm circumference (MAC) and tricipital skinfold (TS) to the 50th percentile (P50), C-reactive protein (CRP), phase angle (PA), protein equivalent of nitrogen appearance (PNA), the Kt/V index of dialysis adequacy, and the hydration status (Pearson's correlation coefficient). Agreement in the nutritional status according to pre- and post-dialysis (post-HD) albumin and PA was estimated according to the Kappa (K) coefficient (Bland-Altman). RESULTS: A total of 58 haemodialysis (HD) patients were included in this study (30 female; mean age: 49 years). BMI, PA and CRP had a significant correlation with pre- and post-HD albumin, while MAC and PNA correlated only with post-HD albumin. Agreement in the diagnosis of malnutrition according to PA < 5 and pre- and post-HD albumin < 3.2 g/dL was regular (K = 0.432). When using an albumin cut-off value of 3.7 g/dL for malnutrition (mild malnutrition or risk of malnutrition), the diagnosis was concordant only in the post-HD period (K = 0.544). CONCLUSIONS: Post-dialysis albumin levels may be a better marker of protein status and mortality risk in cases of mild malnutrition or risk of malnutrition and in patients with low/medium mortality risk. Pre-dialysis fluid overload may be a confounding factor when evaluating albumin levels.

Adductor pollicis muscle thickness: a promising anthropometric parameter for patients with chronic renal failure.

INTRODUCTION: Protein-calorie malnutrition is a prevalent disorder in chronic renal failure (CRF) and a major risk factor for increased mortality in hemodialysis (HD) patients. Although many methods have been used to assess malnutrition in CRF, the role of adductor pollicis muscle thickness (APMt) is not established yet. AIMS: This study aimed to analyze the APMt in HD patients and to investigate the correlation between APMt and conventional anthropometric, laboratory, and bioelectrical impedance markers, as well as its association with mortality/morbidity in a period of 12 months of follow-up. SUBJECTS AND METHODS: The study included 143 HD patients from a single facility. After dialysis, the dry weight, height, mid-arm circumference, triceps skinfold thickness, and APMt were measured. Subsequently, the body mass index, percentage of standard body weight, the mid-arm muscle circumference, and the mid-arm muscle area were calculated. Blood counts were performed for hemoglobin, creatinine, and albumin. Patients were also submitted to a single-frequency tetrapolar bioimpedance test for measuring resistance, reactance, phase angle, and percentage of body cell mass. The correlation between APMt and anthropometric, laboratory, and bioelectrical impedance parameters was calculated using Pearson's linear correlation. Multiple linear regression analysis was used to select independent risk factors to death and hospitalizations in 6 and 12 months of follow-up, among parameters selected by univariate analysis. RESULTS: Patients were aged 52.2 ± 16.6 years (20 to 83 years) on average, 58% were men, and mean dialysis vintage was 5.27 ± 5.12 years. APMt was 11.85 ± 1.63 mm (men, 12.34 ± 1.53; women, 11.19 ± 1.51; P < .0001). APMt was positively correlated with body mass index (r = 0.37; P < .0001), mid-arm circumference (r = 0.437; P < .0001), mid-arm muscle circumference (r = 0.494; P < .0001), mid-arm muscle area (r = 0.449; P < .0001), percentage of standard body weight (r = 0.355; P = .000), creatinine (r = 0.230; P = .006), albumin (r = 0.207; P = .013), percentage of body cell mass (r = 0.293; P = .000), and phase angle (r = 0.402; P < .0001), and negatively correlated with resistance (r = -0.403; P < .0001). The APMt ≤10.6 mm was associated with a 3.3 times greater risk of hospitalization within 6 months of follow-up (OR = 3.3, 95% CI: 1.13 to 9.66; P = .029) compared with patients with an APMt >10.6 mm. The APMt was not associated with risk of death at 6 and 12 months or hospitalization within 12 months of follow-up. CONCLUSION: This is the first study testing APMt as an anthropometric marker in HD patients. The parameter is easy to measure and does not seem to be significantly affected by variations in hydration status. The parameter was significantly correlated with markers reflecting the condition of the muscle compartment, but not with parameters estimating the fat mass. The determination of an APMt cutoff point for malnutrition in patients with CRF and its correlation with morbidity and mortality will require further investigation in clinical studies.

Antiretroviral drug resistance in a respondent-driven sample of HIV-infected men who have sex with men in Brazil.

BACKGROUND: : There are few studies on HIV subtypes and primary and secondary antiretroviral drug resistance (ADR) in community-recruited samples in Brazil. We analyzed HIV clade diversity and prevalence of mutations associated with ADR in men who have sex with men in all five regions of Brazil. METHODS: : Using respondent-driven sampling, we recruited 3515 men who have sex with men in nine cities: 299 (9.5%) were HIV-positive; 143 subjects had adequate genotyping and epidemiologic data. Forty-four (30.8%) subjects were antiretroviral therapy-experienced (AE) and 99 (69.2%) antiretroviral therapy-naïve (AN). We sequenced the reverse transcriptase and protease regions of the virus and analyzed them for drug resistant mutations using World Health Organization guidelines. RESULTS: : The most common subtypes were B (81.8%), C (7.7%), and recombinant forms (6.9%). The overall prevalence of primary ADR resistance was 21.4% (i.e. among the AN) and secondary ADR was 35.8% (i.e. among the AE). The prevalence of resistance to protease inhibitors was 3.9% (AN) and 4.4% (AE); to nucleoside reverse transcriptase inhibitors 15.0% (AN) and 31.0% (AE) and to nonnucleoside reverse transcriptase inhibitors 5.5% (AN) and 13.2% (AE). The most common resistance mutation for nucleoside reverse transcriptase inhibitors was 184V (17 cases) and for nonnucleoside reverse transcriptase inhibitors 103N (16 cases). CONCLUSIONS: : Our data suggest a high level of both primary and secondary ADR in men who have sex with men in Brazil. Additional studies are needed to identify the correlates and causes of antiretroviral therapy resistance to limit the development of resistance among those in care and the transmission of resistant strains in the wider epidemic.

Desnutrição na insuficiência renal crônica: qual o melhor método diagnóstico na prática clínica? / Malnutrition in chronic renal failure: what is the best diagnostic method to assess?

Introdução: A desnutrição protéico-calórica, o processo inflamatório sistêmico e os distúrbios mestabólicos são frequentes em pacientes com insuficiência renal crônica em terapia dialítica, contribuindo para sua morbimortalidade. Material e Métodos: No presente estudo, a prevalência de desnutrição em pacientes renais crônicos em hemodiálise em um único centro do Nordeste do Brasil foi avaliada segundo três diferentes técnicas de avaliação subjetiva global (ASG), o índice de massa corporal (IMC), o percentual de peso atual em relação ao ideal, a adequação a o percentil 50 da prega cutânea triciptal (PCT), da circunferência do braço (CB), da circunferência muscular do braço (CMB), a albumina pré-diálise, o ângulo de fase e o percentual de massa celular corporal (MCC). A correlação do diagnóstico nutricional realizado através da ASG com as medidas antropométricas, bioquímicas e bioimpedância elétrica foi pesquisada. Resultados: Foram avaliados 58 pacientes, sendo 30 do sexo feminino (51,7%), com idade média de 49 anos. A prevalência de desnutrição segundo os diferentes métodos variou entre 12,1% a 94,8%. A ASG clássica teve uma concordância moderada no diagnóstico nutricional com a ASG gerada pelo paciente, IMC com ponto de corte em 22,0 kg/m² e CMB; regular com o IMC com ponto de corte em 18,5 kg/m², adequação do peso atual em relação ao ideal, CB e ângulo de fase ruim com a ASG adaptada ao renal, PCT e percentual de MCC. Conclusões: Os métodos de avaliação nutricional comumente utilizados na pr´tica clínica têm restrições na população em diálise, tendo em vista os diferentes percentuais obtidos com os diferentes métodos. Estudos longitudinais, prospectivos, pesquisando a associação dos marcadores nutricionais com eventos adversos como hospitalização e mortilidade, devem continuar sendo realizados para maior esclarecimento do problema.

Introduction: Protein-energy malnutrition, the systemic inflammatory process mestabólicos and disturbances are common in patients with chronic renal failure undergoing dialysis therapy, contributing to morbidity and mortality. Methods: In this study, the prevalence of malnutrition in patients on hemodialysis in a single center in northeastern Brazil was assessed by three different techniques of subjective global assessment (SGA), body mass index (BMI), the percentage of current weight in relation to the ideal, the suitability to the 50th percentile of triceps skinfold thickness (TSF), arm circumference (AC), arm muscle circumference (MAMC), albumin pre-dialysis, the phase angle and percentage of body cell mass (CCM). The correlation of nutritional diagnosis achieved by the ASG to the anthropometric measurements, biochemical and bioelectrical impedance was investigated. Results: We studied 58 patients, 30 females (51.7%), mean age 49 years. The prevalence of malnutrition according to the different methods ranged from 12.1% to 94.8%. The ASG had a classic moderate agreement in the nutritional diagnosis with ASG generated by the patient, with BMI cutoff of 22.0 kg / m² and CMB; regular with BMI cutoff of 18.5 kg / m², adequacy of current weight in relation to the ideal, CB and phase angle with bad ASG adapted to renal PCT and percentage of MCC. Conclusions: The nutritional assessment methods commonly used in clinical pr'tica have restrictions on the population on dialysis, in view of the different percentages obtained with different methods. Longitudinal, prospective, researching the association of nutritional markers with adverse events such as hospitalization and mortilidade should continue being carried out to further clarify the problem.

[Malnutrition in chronic kidney failure: what is the best diagnostic method to assess?].

INTRODUCTION: Protein-energy malnutrition, systemic inflammation, and metabolic disorders are frequent among patients with chronic kidney failure undergoing dialysis, contributing to their morbidity and mortality. MATERIAL AND METHODS: In the present study, the prevalence of malnutrition in chronic renal patients undergoing hemodialysis in one single center in the Northeastern region of Brazil was assessed according to the following: three different methods of subjective global assessment (SGA); body mass index (BMI); percent of standard body weight; adequacy to the 50th percentile of triceps skinfold (TSF) and arm muscle circumference (AMC) thicknesses; pre-dialysis albumin; phase angle; and percentage of body cell mass (%BCM). Agreement of the nutritional status diagnosis performed through SGA with anthropometric, biochemical, and bioelectrical impedance measures was assessed. RESULTS: The study assessed 58 patients [females, 30 (51.7%); mean age = 49 years]. The prevalence of malnutrition according to the different methods ranged from 12.1% to 94.8%. Conventional SGA showed a moderate agreement with patient-generated SGA (PG-SGA), BMI (cutoff point, 22.0 kg/m²), and AMC; a fair agreement with BMI (cutoff point, 18.5 kg/m²), percent of standard body weight, AC, and phase angle; and a poor agreement with SGA adapted to the renal patient, TSF, and %BCM. CONCLUSIONS: The nutritional assessment methods commonly used in clinical practice are subject to restrictions when applied to the dialysis population, considering the different percentages obtained with the different methods. Longitudinal, prospective studies on the association of nutritional markers with adverse events, such as hospitalization and mortality, should be carried out to clarify remaining issues.

Prevalence and staging of chronic kidney disease in renal transplant recipients.

INTRODUCTION: Diagnosis and staging of chronic kidney disease (CKD) is important for management and prevention of renal disease progression. It is unclear whether K/DOQI guidelines of the National Kidney Foundation are applicable to diagnosis of CKD in renal transplant recipients (RTRs) and which method is most appropriate for estimating glomerular filtration. OBJECTIVES: To determine the prevalence and staging of CKD in RTRs, according to K/DOQI guidelines, and the prevalence of complications of CKD. SUBJECTS AND METHODS: This cross-sectional study included RTRs at least six months post-transplantation followed at a single out-patient service. The glomerular filtration rate (GFR) was estimated with two different equations: the MDRD equation (Modification of Diet in Renal Disease) with four variables (age, creatinine level, gender, and race) and the Cockcroft-Gault (CG) formula. Patients with GFR more than 60 mL/min/1.73 m2 were diagnosed with CKD only in the presence of renal damage (hematuria, proteinuria, or evidence of injury in renal biopsy). CKD staging was compared to the two equations and the prevalence of complications was determined. RESULTS: The study evaluated 241 RTRs (average age: 40.6 +/- 12.5 yr, 62.2% male; 4.5% black, 50.6% from cadaveric donors). Average follow-up time was 6.8 +/- 6.1 yr and the average baseline creatinine level was 1.48 +/- 0.72 mg/dL. CKD was diagnosed in 70.5% of RTRs, of whom 52.9% (MDRD)/47.6% (CG) were classified as Stage III (GFR: 30-59 mL/min/1.73 m2). The agreement between the two methods was very close with regard to CKD diagnosis (kappa = 0.92) and close for stage-dependent prevalence (kappa = 0.68). The prevalence of anemia, hypocalcemia, hyperphosphatemia (HF), hyperuricemia (HU), and systemic arterial hypertension (SAH) was 10.6%, 7.6%, 10.3%, 54%, and 73.4% for patients with CKD. Significant differences were observed for HU, HF and SAH in patients without CKD. Anemia, HU and SAH were associated with CKD stage (p < 0.001). CONCLUSION: The prevalence of CKD in the study population was high (70.5%). The two equations tested correlated closely when used for GFR estimation. Routine CKD staging in RTRs would provide patients with safer and more appropriate management.