Monica Maria Ferreira Magnanini

Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users : a systematic review

AIMS Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. OBJECTIVE To conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU) and identify factors associated with non-adherence to HIV treatment. DATA SOURCES Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. STUDY SELECTION AND DATA ABSTRACTION Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on DU. Findings on adherence were extracted and summarized. DATA SYNTHESIS Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive DU (n = 11 628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patents receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). CONCLUSION While lower than other populations-especially among users of stimulants, incarcerated DU and patients with psychiatric comorbidities-adherence to HAART among HIV-positive DU can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support.

Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis

We conducted a meta-analysis of studies assessing adherence to highly active antiretroviral therapy (HAART) and a qualitative systematic review of factors associated with better HAART outcomes among HIV+ drug users (DU). Thirty-eight studies were considered, which analyzed 14,960 patients (11,394 HIV+ DU, 76.2%). Overall adherence (pooled percent of DU classified as adherent in each study) was 0.60 (95% CI: 0.52–0.68), similar to levels identified by studies conducted with HIV+ patients who are not drug users. Time frame used to measure adherence was an independent predictor of inter-study heterogeneity. The systematic review identified better HAART outcomes among former DU, those with less severe psychiatric conditions, those receiving opioid substitution therapy and/or psychosocial support. Patients initiating HAART with lower viral load and higher CD4 counts, and those without co-infections also had better treatment outcomes. Our findings suggest that HIV+ DU tend to be inappropriately assumed to be less adherent and unlikely to achieve desirable treatment outcomes, when compared to their non-DU cohort.

Iniciativa STROBE: subsídios para a comunicação de estudos observacionais

Reporting of observational studies is often inadequate, hampering the assessment of their strengths and weaknesses and, consequently, the generalization of study results. The initiative named Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) developed a checklist of 22 items, the STROBE Statement, with recommendations about what should be included in a more accurate and complete description of observational studies. Between June and December 2008, a group of Brazilian researchers was dedicated to the translation and adaptation of the STROBE Statement into Portuguese. The present study aimed to show the translation into Portuguese, introduce the discussion on the context of use, the potential and limitations of the STROBE initiative.El objetivo del articulo fue estimar la prevalencia de extremos antropometricos indicativos del estado nutricional de ninos. Se realizo estudio transversal con muestra probabilistica de 1.386 ninos menores de cinco anos del estado de Alagoas. Las prevalencias de deficit (z< -2; patron de la Organizacion Mundial de Salud - 2006) para los indices peso-para-edad (bajo peso), peso-para-altura (flacura) y altura-para-edad (deficit estatural) fueron, respectivamente, 2,9% (n=40), 1,2% (n=17) y 10,3% (n=144). El exceso de peso-para-altura (sobrepeso) acometio 135 ninos (9,7%). Se concluyo que las prevalencias de bajo peso y flacura son epidemiologicamente irrelevantes y que el deficit estatural y el sobrepeso prevalecen con identica magnitud.

Prevalence of human immunodeficiency virus drug resistance mutations and subtypes in drug-naive, infected individuals in the army health service of Rio de Janeiro, Brazil.

ABSTRACT The prevalence of mutations that confer resistance to antiretroviral drugs was examined in 56 drug-naive, human immunodeficiency virus type 1 (HIV-1)-infected individuals from the Army Health Service in Rio de Janeiro, Brazil. No primary protease inhibitor mutations were found, but secondary mutations were observed in 51.2% of the samples. Fourteen percent of the viruses had reverse transcriptase inhibitor-associated mutations. Comparative analysis of protease secondary mutations from four different time periods in drug-naive patients in the city of Rio de Janeiro has indicated constant rates for particular mutations. Changes in CD4 cell counts and HIV viral load over time in subtype B- and non-B-infected drug-naive patients were not significantly different.

Drug and Multidrug Resistance among Mycobacterium leprae Isolates from Brazilian Relapsed Leprosy Patients

ABSTRACT Skin biopsy samples from 145 relapse leprosy cases and from five different regions in Brazil were submitted for sequence analysis of part of the genes associated with Mycobacterium leprae drug resistance. Single nucleotide polymorphisms (SNPs) in these genes were observed in M. leprae from 4 out of 92 cases with positive amplification (4.3%) and included a case with a mutation in rpoB only, another sample with SNPs in both folP1 and rpoB, and two cases showing mutations in folP1, rpoB, and gyrA, suggesting the existence of multidrug resistance (MDR). The nature of the mutations was as reported in earlier studies, being CCC to CGC in codon 55 in folP (Pro to Arg), while in the case of rpoB, all mutations occurred at codon 531, with two being a transition of TCG to ATG (Ser to Met), one TCG to TTC (Ser to Phe), and one TCG to TTG (Ser to Leu). The two cases with mutations in gyrA changed from GCA to GTA (Ala to Val) in codon 91. The median time from cure to relapse diagnosis was 9.45 years but was significantly shorter in patients with mutations (3.26 years; P = 0.0038). More than 70% of the relapses were multibacillary, including three of the mutation-carrying cases; one MDR relapse patient was paucibacillary.

Heterogeneous resistance to vancomycin and teicoplanin among Staphylococcus spp. isolated from bacteremia

This study evaluated the BHIA screening method with 4 or 6 mug/mL of vancomycin to detect glycopeptides heteroresistant staphylococci strains isolated from bacteremia. A total of 213 staphylococci strains were isolated from 106 patients between October/2001 and November/2002 in a tertiary hospital in Rio de Janeiro city. Fifty-seven (53.8%) patients presented Staphylococcus aureus, while coagulase-negative staphylococci (CNS) were isolated from 49 (46.2%). Resistance rates for oxacillin of 26.3% and 81.6% were found for the staphylococci isolates, respectively. Thirteen CNS isolated from nine (8.5%) patients grew on agar screening with 4 mug/mL of vancomycin and showed heterogeneous profiles of resistance for vancomycin and teicoplanin by the population analysis profile method. Only 30.8% of them grew at the concentration 6 mug/mL. Bacterial infection and use of antimicrobial therapy were common among these patients. Alert about the emergence of oxacillin-resistant staphylococci presenting heteroresistance to glycopeptides is important in order to achieve judicious use of antimicrobials. Vancomycin agar screening test could help to confirm the presence of these isolates in hospitals.

Epidemiologic study of 107 cases of families with leprosy in Duque de Caxias, Rio de Janeiro, Brazil

BACKGROUNDS ultibacillary patients are the major source of infection in leprosy. Nevertheless, the risk is higher in household contacts between multibacillary patients than paucibacillary patients and in the general population. Household contacts are in close genetic relationship with the index case-patient. OBJECTIVE To evaluate epidemiological data of the following variables: age, gender, education level, genetic proximity, and type of contact with the index case-patient (household or not) in 107 families with leprosy. METHODS Home visits were conducted to clinically examine family members. The medical charts of index case-patients and co-prevalent cases were reviewed. RESULTS The controlled analysis of variables such as type of contact and genetic proximity revealed that household contacts and first-degree kinship are independently associated with a higher chance of contracting the disease. CONCLUSION Household contacts are often genetically closer to the index case-patient. To investigate the independent relevance of these risks in leprosy surveillance contact studies has been a challenge. Our results confirm literature data that show the influence of genetics in the susceptibility to leprosy per se.

Intraobserver and interobserver agreement of Goutallier classification applied to magnetic resonance images

BACKGROUND Fatty infiltration of the muscle bellies is an important prognostic factor in rotator cuff tears. It was described initially in computed tomography examinations, and there is an ongoing debate about whether magnetic resonance (MR) is a reliable method for staging fatty infiltration. This study sought to determine intraobserver and interobserver agreement for Goutalliers classification of fatty infiltration of the rotator cuff as evaluated through MR imaging. MATERIALS AND METHODS Twenty MR examinations of the shoulder showing full-thickness tear of the supraspinatus tendon, with or without associated lesions, were evaluated by 3 radiologists with experience in musculoskeletal system imaging and 3 fellowship-trained shoulder surgeons. The evaluators classified the fatty infiltration of the supraspinatus muscle according to the guidelines proposed by Goutallier et al. After 8 weeks, they re-evaluated the examinations, without access to their previous reports. Weighted κ index values were determined for intraobserver and interobserver agreement analyses, and intraobserver agreement κ values are reported with 95% confidence intervals (CIs). RESULTS The mean intraobserver agreement was 0.832 among the orthopedists (CI > 95%) and 0.741 among the radiologists (CI > 95%). Interobserver agreement was 0.8214 (evaluation 1) and 0.7231 (evaluation 2) among the orthopedists (P < .0001) and 0.6627 (evaluation 1) and 0.6067 (evaluation 2) among the radiologists (P < .0001). Intraobserver agreement was not associated with length of experience or frequency of routine evaluations. CONCLUSIONS When it is applied to MR images of rotator cuff musculature, Goutalliers fatty infiltration staging rubric yielded highly significant intraobserver and interobserver agreement.

Ambulatory blood pressure monitoring and cardiovascular risk in resistant hypertensive women

FUNDAMENTO: Pocos estudios exploraron el valor pronostico del monitoreo ambulatorio de presion arterial (MAPA) en pacientes hipertensos resistentes, un grupo que presenta alto riesgo. OBJETIVO: Investigar el valor pronostico de la presion arterial (PA) diurna, en mujeres hipertensas resistentes. METODOS: Se siguieron por hasta 8,9 anos (promedio 3,9), a 382 mujeres hipertensas resistentes con edad entre 24 y 92 anos, atendidas en una unidad de hipertension de un hospital universitario. Se clasificaron a las pacientes como controladas (PA de consultorio>140/90 mmHg y PA diurna 140/90 mmHg y PA diurna>135/85 mmHg). Se analizo una combinacion de mortalidad cardiovascular, cardiopatia isquemica, accidente vascular encefalico y nefropatia. Se utilizo el modelo proporcional de Cox para estimarse el riesgo de eventos cardiovasculares ajustado para potenciales confundidores. RESULTADOS: La tasa total de eventos fue de 5,0 por 100 mujeres-ano. En el grupo de controladas ese valor fue de 3,7 y entre las no-controladas, de 5,8, con p=0.06. Los riesgos relativos asociados al aumento de 10 mmHg en la PA sistolica, ajustando para edad y tabaquismo actual, fueron mayores que los asociados a aumentos de 5 mmHg en la PA diastolica. Pacientes con descenso nocturno 10%, aunque esa asociacion no haya sido estadisticamente significante. La presion diurna no controlada (si/no) fue un fuerte factor de riesgo independiente, 1,67 (1,00-2,78). CONCLUSION: El aumento del 67% en el riesgo de evento cardiovascular cuando la PA diurna no estaba controlada es un indicador de que el empleo del MAPA es esencial en la evaluacion del control y como guia de las decisiones terapeuticas en la hipertension resistente.BACKGROUND Few studies have explored the prognostic value of ambulatory blood pressure (ABP) in resistant hypertensive patients, a high-risk group. OBJECTIVE To investigate the prognostic value of uncontrolled daytime ABP in resistant hypertensive women. METHODS We followed 382 resistant hypertensive women, aged 24-92 years, from a hypertension unit of a university hospital, for up to 8.9 years (mean 3.9). Patients were classified as controlled (office BP>140/90 mmHg and daytime ABP<135/85 mmHg) or uncontrolled (office BP>140/90 mmHg and daytime ABP >135/85 mmHg). We analyzed a combined endpoint, consisting of cardiovascular mortality, ischemic heart disease, stroke and nephropathy. Cox proportional hazard models were used to estimate the risk for cardiovascular events, adjusting for potential confounders. RESULTS The total event rate was 5.0 per 100 women-years. In the controlled and uncontrolled groups, the rates were 3.7 vs. 5.8 events respectively, p=0.06. The relative risks adjusted for age and current smoking status associated with a 10 mmHg increment in systolic ABP were greater than the ones associated with a 5 mmHg increment in diastolic ABP. Non-dipper patients had a higher risk for cardiovascular events than dipper patients (RR = 1.42 (0.87-2.32)), although this association had no statistical significance. Uncontrolled daytime blood pressure (yes/no) was a stronger independent risk factor, 1.67 (1.00-2.78). CONCLUSIONS There was a 67% increase in the risk of a cardiovascular event if daytime ambulatory blood pressure was uncontrolled in women with resistant hypertension. Therefore, it is mandatory to use ABP to evaluate control and to guide therapeutic strategies in resistant hypertensive patients.

Prognostic Value of Exercise-Induced Ventricular Arrhythmia in Chagas’ Heart Disease

Objective:  To determine the prevalence and the prognostic value of exercise‐induced ventricular arrhythmia (EIVA) in chronic Chagas’ heart disease.