Carla Vitola Gonçalves

Infecção urinária na gravidez: análise dos métodos para diagnóstico e do tratamento

Objetivos: avaliar os aspectos diagnosticos, terapeuticos e as complicacoes dos casos de infeccao do trato urinario (ITU) sintomatica durante a gestacao, que necessitaram de internacao hospitalar. Metodos: foram incluidas 136 gravidas com diagnostico clinico de pielonefrite. Foram avaliados: a idade e paridade da paciente, idade gestacional em que foi feito o diagnostico, antecedentes de importância epidemiologica, propedeutica laboratorial para avaliacao da infeccao urinaria, tratamento e evolucao clinica, antimicrobianoprofilaxia e complicacoes. Resultados: pielonefrite foi diagnosticada, nas mesmas proporcoes, em todas as idades gestacionais. Houve maior incidencia de ITU entre as primigestas. Apenas 29,3% das gestantes apresentaram historia previa de ITU. Observou-se que 57,0% das pacientes apresentaram anemia e 93,0% mostraram analise urinaria alterada. A Escherichia coli foi o uropatogeno mais prevalente (75,8% dos casos), com baixos percentuais de sensibilidade a ampicilina (60,6%) e a cefalotina (63,6%) e altos percentuais de sensibilidade a cefuroxima (95,5%). A maior taxa de melhora clinica foi obtida entre as gestantes tratadas com cefuroxima (95,7%). A antimicrobianoprofilaxia foi necessaria em 11,0% das pacientes. O trabalho de parto pre-termo ocorreu em 33,3% das gestantes que deram a luz em nosso servico, e o parto pre-termo em 18,9%. Conclusoes: esses resultados reforcam a necessidade do diagnostico precoce e tratamento efetivo da ITU em gestantes, a fim de evitar a ocorrencia frequente de complicacoes perinatais, como o trabalho de parto e o parto pre-termo. Destaca-se a necessidade de avaliacao periodica do padrao de sensibilidade dos agentes etiologicos prevalentes aos antimicrobianos de uso permitido durante a gestacao, adotando-se a cefuroxima como o antimicrobiano de escolha para o tratamento das ITU na gestacao.Purpose: to assess the diagnostic and therapeutic aspects and the complications of symptomatic urinary tract infections (UTI) during pregnancy of patients who were hospitalized. Methods: a total of 136 pregnant women with a clinical diagnosis of pyelonephritis were studied. The studied parameters were: age and parity of patients, gestational age of diagnosis, epidemiologic aspects, laboratory evaluation for UTI, treatment and clinic evolution, prophylaxis and complications. Results: pyelonephritis was diagnosed at the same proportions at all gestational ages. The incidence of UTI was higher among primigravidae. Only 29.3% of the pregnant women had a previous history of UTI; 57.0% were anemic and 93.0% had altered urinalysis. Escherichia coli was the most prevalent uropathogen (75.8% of cases), with low percentages of sensitivity to ampicillin (60.6%) and high percentages of sensitivity to cefuroxime (95,5%). The highest rate of clinical improvement was obtained for the pregnant women treated with cefuroxime (95.7%). Prophylaxis was needed in 11.0% of the patients. Preterm labor occurred in 33.3% of the pregnant women who delivered in our service and preterm delivery occurred in 18.9%. Conclusions: the present results support the need for an early diagnosis and effective treatment of UTI in pregnant women in order to prevent the frequent occurrence of perinatal complications such as premature labor and delivery. We emphasize the need of a periodical evaluation of the pattern of sensitivity of the etiologic agents to the antimicrobials allowed for use during pregnancy, with cefuroxime being adopted as the antibiotic of choice for the treatment of UTI during pregnancy.

Teste rápido para detecção da infecção pelo HIV-1 em gestantes

Purpose: to evaluate the results of a rapid diagnostic test for HIV-1 infection made available by the Health Ministry for the identification of pregnant women contaminated by this virus. Methods: we evaluated prospectively 443 pregnant women with no prenatal serologic anti-HIV test seen at the Department of Gynecology and Obstetrics of the Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, from February to June, 2000. Samples from these patients were submitted to the rapid immunochromatographic test, which was compared with ELISA and submitted to a confirmatory agglutination test. Results: among the 443 pregnant women submitted to the rapid test (20.1% of the deliveries performed during the study period), 16 showed positive results (3.6%). No sample with a negative result by the rapid test was positive by ELISA. However, of the 16 samples that were positive by the rapid test, two were negative by the confirmatory tests. Thus, the rapid test showed 100.0% sensitivity, 99.5% specificity, 87.5% positive predictive value, and 100.0% negative predictive value. Conclusions: the results obtained by evaluation of the test for a rapid diagnosis of HIV-1 infection in pregnant women revealed sensitivity, specificity and predictive values that qualify it as an extremely important resource for the indication of measures that will reduce perinatal transmission of this virus.

Late response to anti-TNF-α therapy in refractory mucocutaneous lesions of Behçet’s disease

Behçet’s disease (BD) is a multisystem chronic inflammatory disorder characterized by oral and genital ulceration and ocular involvement. Recurrent oral and genital ulcers are the most common symptoms of BD and occur in more than 80% of patients. The treatments of these disease manifestations include colchicine, corticosteroids and immunosuppressive drugs in severe cases. Anti-TNF-α therapy may be useful in refractory severe BD, particularly for ocular, central nervous system, gastrointestinal and refractory mucocutaneous lesions. During a 2-year period, 280 patients suffering from rheumatic diseases received anti-TNF-α agents at the infusion center of our University Hospital. Two patients (0.7%) presented BD; one of them had celiac disease as well, with recalcitrant mucocutaneous lesions that were not responsive to immunosuppressive drugs. We reported those patients who were successfully treated with infliximab and adalimumab, despite their late response.

Exame clínico das mamas em consultas de pré-natal: análise da cobertura e de fatores associados em município do Rio Grande do Sul, Brasil

The Brazilian Ministry of Health recommends that breast examination be performed along with breastfeeding orientation during the first prenatal visit. The aims of the current study were to analyze breast examination during prenatal care and describe the factors associated with insufficient coverage. A cross-sectional study was performed in Rio Grande, Rio Grande do Sul State, Brazil, from May to July 2007. Data for women who had just given birth were recorded on a standardized questionnaire. Of 445 women, 266 (59.8%) had not undergone breast examination during prenatal care. Non-white women and those with a monthly income below the minimum wage (BRL 380.00) or with prenatal care and delivery in the public health system showed the highest probability of not having a breast examination during prenatal care. The results show the low prevalence of breast examination during prenatal care and indicate serious problems related to quality of prenatal care, besides unequal access for poor women.

Antineutrophil cytoplasmic antibodies in chronic rhinosinusitis may be a marker of undisclosed vasculitis.

Background Upper airway manifestations are common features of antineutrophil cytoplasmic antibody (ANCA)–related vasculitis. Determining the presence of this antibody in patients with chronic rhinosinusitis (CRS) may allow early identification and treatment of underlying vasculitis. Methods Forty-nine consecutive CRS patients and 165 age- and sex-matched healthy controls were evaluated for vasculitis complaints. ANCA were detected by indirect immunofluorescence, and antibodies to proteinase 3 (PR3) and myeloperoxidase were determined by ELISA. Results Patients and controls were comparable concerning the mean age (47.2 ± 15 years versus 45 ± 12.5 years; p = 0.303) and female predominance (73.5% versus 60%; p = 0.502). Vasculitis-associated complaints were reported in 8/49 (16.3%) patients: 7 patients reported a 10-year history of asthma and 1 patient had red/painful eyes associated with epistaxis. ANCA was positive in 5/49 (10%) patients and absent in controls (p < 0.0001). One patient had high titer cytoplasmic ANCA/PR3 and during the investigation developed clinical features of Wegeners granulomatosis. The other four patients had perinuclear ANCA, of whom three were asymptomatic and one is currently under surveillance for Churg-Strauss syndrome. Sinus computed tomography scan revealed that patients who were ANCA+ had more extensive disease involvement than ANCA- patients (Lund-Mackay score median value, 21 versus 13; p = 0.008). Conclusion ANCA may identify a subset of difficult to treat CRS patients with underlying vasculitis and may be useful for establishing an early diagnosis of vasculitis in CRS.

Avaliação longitudinal da infecção por parvovírus B19 entre grávidas em Ribeirão Preto, SP, Brasil

PURPOSE: to evaluate the rate of seropositivity for parvovirus B19 (PB19) among pregnant women and the rate of seroconversion against this infection during pregnancy. METHODS: prospective study carried out in the Hospital of the Medical School of Ribeirao Preto, University of Sao Paulo. In the first stage of the present study, we evaluated 245 pregnant women with gestational age less than 16 weeks to determine the seroprevalence of PB19 infection by ELISA. According to the serological results we determined if the PB19 infection was an acute infection (IgM positive and IgG negative or positive), or a former infection (IgM negative and IgG positive). In the second stage of this study, 73 previously seronegative pregnant women were tested again when they came to the hospital for delivery (IgM and IgG), to detect the seroconversion rate during pregnancy. RESULTS: the seroprevalence of the PB19 infection until 16 weeks of gestation was 62.9% (95% IC: 56.8-68.9), divided into acute infection (8.1%), or former infection (54.8%). Of the 73 patients, seronegative in the first stage of this investigation, seven (9.6%) showed seroconversion during pregnancy (95% IC: 2.8-16.3), two (2.7%) showed acute serological infection and five (6.9%) presented markers of past infection. The final seroprevalence of PB19 infection during pregnancy was 72.5%. CONCLUSIONS: considering that only the acute PB19 infection is associated with risk for vertical transmission, the high seroprevalence of this infection observed in this study would be protecting these fetuses against this form of infection. Despite the relatively high rate of seroconversion against PB19 infection during the pregnancy period, we did not observe any symptomatic neonate in this group.

Longitudinal Reference Values for Ductus Venosus Doppler in Low-Risk Pregnancies

The aim of this study was to establish normal ranges of blood flow velocities and indices in the fetal ductus venosus (DV) during the second half of normal pregnancy. A Doppler study of 60 healthy pregnant women without fetal pathologies was performed during the second half of pregnancy. The peak systolic velocity (PSV), peak diastolic velocity (PDV), maximum velocity during atrial contraction (VAC), peak systolic velocity/maximum velocity during atrial contraction (S/A ratio), pulsatility index for the vein (PIV), preload index (PLI) and velocity index for the vein (VIV) were calculated from the DV at 4-week intervals. A significant increase in PSV, PDV and VAC was observed from the 20-23(6/7) to the 28-31(6/7) weeks, with stabilization of values until the end of the pregnancy. On the other hand, the study showed a significant decrease for the S/A ratio, PIV, PLI and VIV from the 20-23(6/7) to the 28-31(6/7) weeks and remaining stable from then until term.

Frequency of antibodies against the etiologic agents of acquired imunodeficiency syndrome, syphilis, hepatitis B and C, and Chagas' disease in patients with rheumatic diseases treated with anti-tumor necrosis factor

INTRODUCAO: Os pacientes reumatologicos em terapia com antifator de necrose tumoral (anti-TNF, Tumor Necrosis Factor) sao considerados imunodeprimidos. Neste sentido, a pesquisa de doencas infecciosas nesta populacao e imperiosa devido a alta morbidade e, por vezes, mortalidade associada a este quadro. OBJETIVOS: O presente trabalho teve por objetivo avaliar a frequencia de soropositividade para os seguintes agentes infecciosos: Treponema pallidum (sifilis), Trypanosoma cruzii (doenca de Chagas), virus da imunodeficiencia humana adquirida (Human imunnodeficiency Virus - HIV) e hepatites B e C (HBV e HCV, respectivamente) em pacientes recebendo terapia anti-TNF. PACIENTES E METODOS: Foram avaliados 143 pacientes reumatologicos em um estudo observacional, com artrite reumatoide, espondilite anquilosante, artrite psoriasica e outras doencas, em uso de terapia anti-TNF (adalimumabe, etanercepte e infliximabe) no periodo de setembro de 2007 a novembro de 2008. Foram coletados dados clinicos e demograficos, bem como uma amostra de sangue para a analise da presenca de anticorpos contra os agentes infecciosos HIV (Aids), HBV e HCV (hepatites B e C, respectivamente), Treponema pallidum (sifilis) e Trypanosoma cruzii (doenca de Chagas). RESULTADOS: A media de idade da populacao estudada foi de 45,78 ± 12,7 anos, sendo 60,1% do sexo feminino e 76,9% de cor branca. Treze (9%) dos pacientes apresentaram pelo menos uma sorologia positiva. Nenhum dos pacientes apresentou sorologia positiva para o Trypanosoma cruzii (doenca de Chagas), bem como para HIV. Somente dois (1,4%) individuos apresentaram positividade para o Treponema pallidum (sifilis) (ELISA positivo e VDRL negativo). A frequencia de anti-HBc total foi de 5% (7/140), sendo que todos estes foram positivos tambem para anti-HBs. O HBsAg foi negativo em todos os pacientes. Quatro pacientes tiveram HCV positivo, sendo que dois deles tinham PCR negativo para o virus e os outros dois foram positivos e estavam estaveis. CONCLUSAO: A frequencia de soropositividade para certas doencas infecciosas em pacientes em terapia com anti-TNF e baixa. Os individuos que merecem maior atencao sao aqueles com sorologia positiva para o HCV.