Marcelo Barreto Lopes

Penicillin at the late stage of leptospirosis: a randomized controlled trial.

There is evidence that an early start of penicillin reduces the case-fatality rate of leptospirosis and that chemoprophylaxis is efficacious in persons exposed to the sources of leptospira. The existent data, however, are inconsistent regarding the benefit of introducing penicillin at a late stage of leptospirosis. The present study was developed to assess whether the introduction of penicillin after more than four days of symptoms reduces the in-hospital case-fatality rate of leptospirosis. A total of 253 patients aged 15 to 76 years with advanced leptospirosis, i.e., more than four days of symptoms, admitted to an infectious disease hospital located in Salvador, Brazil, were selected for the study. The patients were randomized to one of two treatment groups: with intravenous penicillin, 6 million units day (one million unit every four hours) for seven days (n = 125) and without (n = 128) penicillin. The main outcome was death during hospitalization. The case-fatality rate was approximately twice as high in the group treated with penicillin (12%; 15/125) than in the comparison group (6.3%; 8/128). This difference pointed in the opposite direction of the study hypothesis, but was not statistically significant (p = 0.112). Length of hospital stay was similar between the treatment groups. According to the results of the present randomized clinical trial initiation of penicillin in patients with severe forms of leptospirosis after at least four days of symptomatic leptospirosis is not beneficial. Therefore, more attention should be directed to prevention and earlier initiation of the treatment of leptospirosis.

Comparative study of the in-hospital case-fatality rate of leptospirosis between pediatric and adult patients of different age groups

The main objective was to compare the in-hospital case-fatality rate of leptospirosis between pediatric (< 19 years) and adult (>19 years) patients, taking into account gender, renal function, duration of symptoms and jaundice. Medical records of 1016 patients were reviewed. Comparative analysis was restricted to 840 patients (100 pediatric, 740 adults) with recorded information on the variables included in the analysis. Among these patients 81.7% were male and 91.5% were icteric. The case-fatality rate of leptospirosis was 14.4%. The odds of death adjusted for gender, jaundice, duration of symptoms, serum urea and serum creatinine were almost four times higher for the adult than for the pediatric group (odds ratio (OR) = 3.94; 95% confidence interval = 1.19-13.03, p = 0.029). Among adults, increased age was also significantly and independently associated with increased risk of death (p < 0.01). Older patients were also more often treated by dialysis. In conclusion, the data suggest that the in-hospital case fatality rate of leptospirosis is higher for adults than for children and adolescents, even after taking into account the effects of several potential risk factors of death. Among adults, older age was also strongly and independently associated with higher risk of death.

Raça e lesão de órgãos-alvo da hipertensão arterial em pacientes atendidos em um ambulatório universitário de referência na cidade de Salvador

OBJECTIVE To assess whether a patients race is associated with the presence of left ventricular hypertrophy, stroke, and renal failure in hypertensive patients from an outpatient care referral clinic in the city of Salvador in the state of Bahia. METHODS We assessed the data of 622 patients collected during their first visit to the hypertension outpatient care clinic between 1982 and 1986, identifying those with a previous history or sequela of stroke, left ventricular hypertrophy, or renal failure (serum creatinine > 1.4 mg/dL). Logistic regression models were used to estimate the odds ratio (OR) of the association between race (mulattos or black vs white individuals) and hypertensive target-organ damage adjusted for sex and age. RESULTS The mean age of the patients was 53.8+/-14.3 years, and 74.1% were women. In regard to race, 15.1% were white, 65.9% mulatto, and 19.0% black. Stroke was significantly more frequent in blacks or mulattos than in white individuals [adjusted odds ratio (aOR) = 3.44; 95% confidence interval (CI) = (1.23-9.67). In regard to the associations involving race and the events of left ventricular hypertrophy and renal failure, the aORs were not statistically significant but were consistent with a greater prevalence of left ventricular hypertrophy and renal failure in blacks and mulattos. CONCLUSION Hypertensive mulattos and blacks have a greater risk of target-organ damage than white individuals do, with a greater racial difference for nonfatal stroke. Whether racial differences in mortality related to hypertensive complications influence the associations observed between race and target-organ damage should be assessed.

Complicações da hipertensão arterial em homens e mulheres atendidos em um ambulatório de referência

OBJECTIVE To assess the association between sex and left ventricular hypertrophy, stroke, and renal failure in hypertensive patients in a referral outpatient care unit. METHODS This study assessed 622 hypertensive patients diagnosed with left ventricular hypertrophy based on electrocardiography, renal failure based on serum creatinine level > or = 1.4 mg/dL, and stroke based on a previous history and physical examination. Logistic regression was used to estimate the odds ratio of the association between sex and target-organ lesions in hypertension adjusted for race, age, and duration of the disease. RESULTS The mean age of the patients was 48.4 +/- 13.8 years; 74.1% were women, and 84.9% were mulattos or blacks. Almost half of the men and more than 40% of the women had had at least 1 definite event involving a target-organ lesion. The incidence of renal failure was greater among men [adjusted OR (ORa) = 2.73, P= 0.002]. In white patients, the incidence of stroke was significantly (P= 0.017) greater among men (4/33) than among women (0/56), and, in the age group > or = 49 years, the prevalence of left ventricular hypertrophy was significantly greater among men (ORa = 1.99, P= 0.024). CONCLUSION The data obtained suggest a greater prevalence of renal failure in men than in women, of stroke in white men than in white women, and of left ventricular hypertrophy in men than in women aged 49 years and above.

Chest Radiograph Abnormalities in Patients Hospitalized with Leptospirosis in the City of Salvador, Bahia, Brazil

This study was designed to estimate the prevalence of pulmonary radiograph abnormalities and describe the distribution of the patterns of radiographic alterations among patients hospitalized with leptospirosis. Chest radiographs of 139 patients hospitalized with leptospirosis in Couto Maia Hospital, in Salvador, Bahia, Brazil, between July, 1997, and July, 1999, were analyzed. The radiographs were requested soon after hospital admission, independent of the clinical manifestations of the patients. Only the first radiograph was considered. Pulmonary radiograph alterations were recorded in 35/139 patients (25.2%); 95% mid-point confidence interval = 18.5% to 32.9%. Among the patients with radiograph alterations, alveolar infiltrate was seen in 26/35 (74.3%). The lesions were bilateral in 54.3% and located in the inferior lobes in 45.5%. Pleural effusion, represented by blunting of the costo-phrenic angle, was detected in 8.6% of the patients. The pattern of the pulmonary alterations, predominantly bilateral alveolar infiltrates, is consistent with the evidence that the basic pulmonary alteration in leptospirosis is a generalized capillaritis.

Existe evidência para tratar insuficiência cardíaca baseada na raça ou etnia

OBJECTIVE To assess if there is evidence to support different interventions for treatment of heart failure based upon race/ethnicity. METHODS Systematic review of randomized clinical trials permitted comparisons between blacks and whites with systolic heart failure concerning the efficacy of angiotensin converting enzyme (ACE) inhibitors, beta blockers and a combination of hydralazine/ nitrate to reduce the risks of death and hospitalization. The literature search was based on articles published between 1980 and December 2006 cited in MEDLINE or LILACS. RESULTS Three studies fulfilled the criteria of the reiew. In SOLVD, enalapril was efficient in reducing the risks of death or hospitalization similarly in whites (relative risk reduction (RRR) =18%) and blacks (RRR=17%). In US Carvedilol, carvediol was also associated with significant reduction in the risk of death or hospitalization both in whites (RRR=49%) and blacks (RRR=43%). In V-HeFT II, enalapril was superior to the combination hydralazine with nitrate in reducing the death risk only in whites. CONCLUSION According to the data ACE inhibitors and beta blockers should be considered as the essential drugs to improve the prognosis of heart failure both in blacks and whites. The A-HeFT study was not included in the review because it was restricted to blacks; however, it should be viewed as evidence that the combination hydralazine/nitrate is beneficial to improve survival in patients with advanced heart failure. Data support development of a clinical trial especially designed to assess if the combination hydralazine/nitrate is also efficient in patients not classified as blacks, with advanced heart failure.OBJECTIVE: To assess if there is evidence to support different interventions for treatment of heart failure based upon race/ethnicity. METHODS: Systematic review of randomized clinical trials permitted comparisons between blacks and whites with systolic heart failure concerning the efficacy of angiotensin converting enzyme (ACE) inhibitors, beta blockers and a combination of hydralazine/ nitrate to reduce the risks of death and hospitalization. The literature search was based on articles published between 1980 and December 2006 cited in MEDLINE or LILACS. RESULTS: Three studies fulfilled the criteria of the reiew. In SOLVD, enalapril was efficient in reducing the risks of death or hospitalization similarly in whites (relative risk reduction (RRR) =18%) and blacks (RRR=17%). In US Carvedilol, carvediol was also associated with significant reduction in the risk of death or hospitalization both in whites (RRR=49%) and blacks (RRR=43%). In V-HeFT II, enalapril was superior to the combination hydralazine with nitrate in reducing the death risk only in whites. CONCLUSION: According to the data ACE inhibitors and beta blockers should be considered as the essential drugs to improve the prognosis of heart failure both in blacks and whites. The A-HeFT study was not included in the review because it was restricted to blacks; however, it should be viewed as evidence that the combination hydralazine/nitrate is beneficial to improve survival in patients with advanced heart failure. Data support development of a clinical trial especially designed to assess if the combination hydralazine/nitrate is also efficient in patients not classified as blacks, with advanced heart failure.

Sex-age-specific handgrip strength and mortality in an incident hemodialysis cohort: The risk explained by nutrition and comorbidities

Objective: To investigate associations of sex-age-specific handgrip strength by a dynamometer with all-cause mortality and the percent excess risk explained (%ERE) by comorbidities and nutritional indicators in incident maintenance hemodialysis patients. Methods: Prospective cohort of 413 adult patients (165 women, 248 men, 299 <60 years and 114 ⩾60 years) with <6 months (82% <3 months) on dialysis enrolled in PROHEMO in Salvador, Brazil. Low and high handgrip strength groups were based on sex-age-specific cutoffs (17.8 kg for women <60 years, 13.8 kg for women ⩾60 years, 29.5 kg for men <60 years, and 21.9 kg for men ⩾60 years). We used Cox regression to estimate the mortality hazard ratio. The %ERE was determined by the equation (HR1 – HR2)/(HR1 – 1) × 100, in which HR1 represented the hazard ratio in a model with a smaller number of covariates and HR2 represented the hazard ratio in a subsequent model with the inclusion of new covariates plus the variables included in the previous model. Results: The mortality hazard ratio comparing low and high handgrip strength was 2.58 (95% confidence interval: 1.73, 3.85) in the model with sociodemographic factors and vintage and 2.25 (95% confidence interval: 1.49, 3.43) with addition of comorbidities, corresponding to a %ERE of 21%. The hazard ratio was 1.98 (95% confidence interval: 1.29, 3.06) after addition of nutritional indicators corresponding to %ERE of 38%. Results stratified by age and gender followed similar patterns. Conclusion: These results provide support for the assessment of handgrip strength in all maintenance hemodialysis patients for early identification of those who may require special care to improve nutritional status and survival.

A 3-day diary of dietary protein and calorie intake by serum phosphate concentration and binder use in hemodialysis patients

Introduction: The use of phosphate binders to control hyperphosphatemia may allow diets less restricted in protein and calories for maintenance hemodialysis (MHD) patients. The study compared intakes of protein, calorie and phosphate among MHD patients with different serum phosphate concentrations, taking into account binder use. The hypothesis was that low serum phosphate would be associated with low intakes of protein and calories only in patients not on binders. Methods: A cross-sectional study of 443 patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, Brazil, with stratified sampling on serum phosphate: ≤3.0 (n = 41), 3.5-5.5 (n = 328) and ≥7.0 mg/dL (n = 74). A 3-day diet diary was used to determine dietary intakes. Results: Approximately 49.0% confirmed binder use. Covariate-adjusted linear regression showed that associations between dietary intakes and serum phosphate were modified by the binder use. In patients not on binders, protein intake was >20% lower for serum phosphate ≤3.0 mg/dL compared to higher concentrations. Also in those not on binders, calorie intake was >30% lower for serum phosphate ≤3.0 mg/dL compared to ≥7.0 mg/dL. Differences in dietary intakes by serum phosphate were virtually absent in patients on binders. Conclusions: The results are consistent with the hypothesis that low serum phosphate is associated with low protein and calorie intake only among MHD patients not on binders. This study supports recommendations to prevent hyperphosphatemia in MHD patients by adequate combination of binder use and selection of foods restricted in phosphors but not severely restricted in protein and calories.

Associations of physical activity energy expenditure with nutritional-inflammatory markers in hemodialysis patients

Background Sedentariness, high inflammation status and malnutrition are highly prevalent in end-stage kidney disease patients on maintenance hemodialysis (MHD). This study investigated associations of weekly physical activity energy expenditure (PAEE) with clinical and anthropometric markers of nutrition and inflammation. Methods The analysis was performed using baseline cross-sectional data of 640 patients enrolled in the prospective cohort “The Prospective Study of the Prognosis of Patients Treated Chronically by Hemodialysis” (PROHEMO) developed in Salvador, BA, Brazil. The long version of the International Physical Activity Questionnaire was used to determine a summary measure of PAEE, the metabolic equivalent of task (MET), taking into account physical activities related to occupation, recreation, travel, sports, and housework. PAEE was the predictor variable. To assess associations of PAEE with outcomes, the sex-age-specific median MET was used. The malnutrition-inflammation score (MIS) with range of 0 to 30 (higher is worse), conicity index as indicator of abdominal adiposity and C-reactive protein (CRP) were the nutritional-inflammatory outcomes. Results The mean age of the patients was 48.9 ± 13.8 y, 60.3% were males, 16.7% diabetic, 88.1% nonwhite. In multivariable logistic regression models with adjustments for sociodemographic variables and comorbidities, PAEE ≤median was associated with MIS ≥6 (odds ratio [OR] = 1.57; 95% confidence interval [CI] = 1.08, 2.29), conicity index ≥1.3 (OR = 1.52, 95% CI = 1.03, 2.23) and CRP >1.30 mg/dL (OR = 1.69, 95% CI = 1.08, 2.84). Conclusions Greater physical activity assessed by PAEE was associated with indicators of better nutritional and inflammation status. These results indicate opportunities for improving outcomes in MHD patients by counseling and treatment intervention.