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Introduction: Prisons context has the potential for the spread of infectious diseases, like HIV and tuberculosis, which prevalence is higher in the people deprived of liberty compared to the general population. Objective: to analyze which are the determinants of coinfection tuberculosis and HIV in prisons. Methodology: Case-control study conducted in the state of São Paulo, Brazil. New cases of tuberculosis in the population deprived of liberty in the period between 2015 and 2017 were considered. Data were obtained through the notification and monitoring system for tuberculosis cases in the state of São Paulo and included sociodemographic and clinical variables and diagnosis and treatment information. The data were analyzed through frequency distribution and bivariate analysis, testing the association of the dependent variable (tuberculosis/HIV coinfection vs. tuberculosis/HIV non-coinfection) with independent variables (sociodemographic, clinical and diagnostics variables) by calculating the odds ratio and p-value. Results: Among the determinants of tuberculosis/HIV coinfection in prisons, we identified: age between 26-35, 36-55 and 56-84 years, notification in hospitals, negative sputum smear microscopy and culture, X-ray suggestive of another pathology, extrapulmonary and mixed clinical form, and alcoholism. A high percentage of death was also identified among coinfected people. Conclusions: identifying the determinants of the tuberculosis/HIV coinfected individual can assist in the development and implementation of guidelines aimed at controlling both infections in the prison environment.

Tuberculosis (TB) is an infectious-contagious disease that affects mainly the lungs, ranking in the 10 main causes of death in the world. Non-adherence or non-treatment of TB may prolong transmissibility, increase the risk of drug resistance and lead to patient death. One step forward is the use of smartphones for monitoring the medication intake via video (VDOT). VDOT is a more acceptable and cost-effective option than the traditional DOT (in person). However, the VDOT system requires a professional (verifying agent) to check all medication intake daily. Based on an initiative that aims to replace the verifying agent with an artificial intelligence tool capable of validating it automatically through computer vision techniques (AI-based VDOT), the main goal of this work is to measure the acceptance and perception of Brazilian health professionals on the AI-Based VDOT before implementing this technology by using a quantitative questionnaire as instrument. To achieve this, we have developed a proposal of study protocol that describes the steps to create, apply and validate this research.

Tuberculosis (TB) is a curable disease, although it still kills thousands of people every year. There are several information systems and applications developed to assist the TB treatment, but many of these systems are isolated and are not able to exchange relevant information. In this way, a set of interoperable applications and decision support modules have been developed. A socio-technical approach was applied to incorporate key stakeholders in all development stages so that final tools fit the health service reality. A set of systems and applications, called the SISTB Ecosystem, has been designed to assist in the treatment of TB and to improve the routine of health professionals.

Tuberculosis is among the world leading causes of death, where over 0.9% of world tuberculosis cases are reported from Brazil. The World Health Organization have suggested the application of the Directly Observed Treatment Short-course, which have proved to reduced the number of deaths. However, over 4,500 deaths due to tuberculosis have been reported in Brazil during 2016. New methods that assist in the management and detection of tuberculosis could still be applied to further re-duce the number of deaths. This study evaluates the use of Charlson Comorbidity Index as predictor to detect deaths caused due to tuberculosis during the patient treatment. We compared the importance Charlson Comorbidity Index as predictor to different attributes that are collected through the patient treatment, and noticed that the Charlson Comorbidity Index have presented one of the highest scores of importance as predictor to detect cases of death due to tuberculosis. Therefore, al-lowing public health care system to focus on patients that have higher chances of death.

Summary Objectives The diagnosis of pediatric tuberculosis (TB) presents many challenges, and is further complicated in HIV-infected patients. While many diagnostic systems have been proposed, there is no pediatric TB diagnosis gold standard. The outcomes of four TB diagnostic systems in HIV-infected children were compared in this study. Methods A retrospective cohort study was conducted at a TB/HIV reference hospital in Rio de Janeiro. HIV-infected pediatric patients evaluated for TB from 1998 to 2010 were reassessed using four diagnostic systems: Kenneth Jones, 1969; Tidjani, 1986; Ben Marais, 2006; Brazilian Ministry of Health, 2010. Results were compared to standardized diagnoses made by an expert panel of physicians. Results Of the 121 patients in the study cohort, the expert panel diagnosed 64 as TB and 57 as not TB cases. The Tidjani system showed the highest diagnostic accuracy, with and without the inclusion of microbiological data. The Tidjani and Kenneth Jones systems produced fewer false-positives, and the Ben Marais and Ministry of Health fewer false-negatives. Across systems, there was little agreement between TB diagnoses. Conclusions In HIV-infected pediatric patients, the Ben Marais and Ministry of Health systems are useful for TB diagnostic screening, whereas the Tidjani and Kenneth Jones systems are best used in a reference center setting.

RESUMO: Introdução: Visando controlar a tuberculose, o Ministério da Saúde recomenda a descentralização das ações de controle para a Atenção Primária à Saúde, sendo escassos os estudos acerca do desempenho do Programa de Controle da Tuberculose em contextos descentralizados. Objetivo: Avaliar o desempenho dos serviços da Atenção Primária à Saúde no tratamento da tuberculose. Métodos: Estudo avaliativo, realizado de maneira transversal em 2011. Foram entrevistados 239 profissionais de saúde da Atenção Primária à Saúde utilizando um instrumento estruturado com base no referencial de avaliação da qualidade dos serviços de saúde (estrutura, processo e resultado). O desempenho de tais serviços foi analisado mediante técnicas de estatística descritiva, validação e construção de indicadores e cálculo da variável reduzida Z. Resultados: Os indicadores “participação de profissionais no atendimento aos pacientes com tuberculose” (estrutura) e “referência e contrarreferência” (processo) foram os melhores avaliados, enquanto “capacitação dos profissionais” (estrutura) e “ações externas para o controle da tuberculose” (processo) tiveram os piores resultados. Conclusão: A descentralização das ações de controle da tuberculose vem ocorrendo de maneira verticalizada na Atenção Primária à Saúde. O desafio de controlar a tuberculose perpassa pela superação de fragilidades relacionadas ao envolvimento, à capacitação e à rotatividade profissional, que é a articulação entre os pontos de atenção e monitoramento das ações de controle na Atenção Primária à Saúde.

Objectives: to analyze the care provided to individuals with Tuberculosis (TB)-HIV coinfection in prison units in the state of São Paulo, according to the regional coordination of prisons. Methods: cross-sectional study conducted between 2016 and 2018. A structured questionnaire was applied to 112 directors or health professionals from 168 prison units. Data were analyzed by frequency distribution and multiple correspondence analysis. Results: 92.9% of participants reported active search for respiratory symptoms, 89.3% offer the directly observed treatment (DOT) for all TB cases, 95.5% anti-HIV testing for all inmates, 92.9% offer HIV follow-up in specialized care services and 59.8% antiretroviral drugs for cases of coinfection. An association was identified between the Northwest and Central regional coordinations and deficient human resources and low performance of actions for the diagnosis and follow-up of cases. Conclusions: although most prison units perform planned actions for the care of coinfected persons, some places need support to guarantee access to these actions.

Objective: to analyze the factors associated to chronic kidney disease in people living with HIV (PLHIV). Method: a paired case-control study (4 controls for each case) carried out in a specialized care service in the Southeastern of Brazil, by analyzing PLHIV medical records. The sample consisted of 85 participants, corresponding to 17 cases and 68 controls. Pearson’s chi-square test (Χ2) and Fisher’s exact test, logistic regression, Odds Ratio (OR), 95% Confidence Interval (CI) and p

Introduction This study evaluates the performance of individual and combinations tests used for pediatric tuberculosis diagnosis at a reference center. Materials and Methods Diagnostic test outcomes from children with presumed pulmonary tuberculosis evaluated from January 2005 - July 2010 were compared to a standard diagnosis made by an expert panel of physicians. Results Presence of at least one sign/symptom, history of contact, or abnormal chest X-ray (aCXR) individually showed the highest sensitivity (85.7%). While the combination of history of contact, at least one sign/symptom, positive tuberculin skin test, and aCXR had low sensitivity of 20%, but the specificity and a positive predictive value were 100%, respectively. The combination of tests used in the International Union Against Tuberculosis and Lung Disease and the Brazilian Ministry of Health systems showed sensitivity of 28.6% and 71.4% and specificity of 95.8% and 97.0%, respectively. Conclusions In the absence of a gold standard, the combination of clinical history, tuberculin skin test, and aCXR, as well as the Brazilian scoring system serve as simple, low-cost approach that can be used for pediatric TB diagnosis by first-contact care providers.

Background Tuberculosis is the leading cause of infectious disease-related death, surpassing even the immunodeficiency virus. Treatment loss to follow up and irregular medication use contribute to persistent morbidity and mortality. This increases bacillus drug resistance and has a negative impact on disease control. Objective This study aims to develop a computational model that predicts the loss to follow up treatment in tuberculosis patients, thereby increasing treatment adherence and cure, reducing efforts regarding treatment relapses and decreasing disease spread. Methods This is a case-controlled study. Included in the data set were 103,846 tuberculosis cases from the state of Sao Paulo. They were collected using the TBWEB, an information system used as a tuberculosis treatment monitor, containing samples from 2006 to 2016. This set was later resampled into 6 segments with a 1-1 ratio. This ratio was used to avoid any bias during the model construction. Results The Classification and Regression Trees were used as the prediction model. Training and test sets accounted for 70% in the former and 30% in the latter of the tuberculosis cases. The model displayed an accuracy of 0.76, F-measure of 0.77, sensitivity of 0.80 and specificity of 0.71. The model emphasizes the relationship between several variables that had been identified in previous studies as related to patient cure or loss to follow up treatment in tuberculosis patients. Conclusion It was possible to construct a predictive model for loss to follow up treatment in tuberculosis patients using Classification and Regression Trees. Although the fact that the ideal predictive ability was not achieved, it seems reasonable to propose the use of Classification and Regression Trees models to predict likelihood of treatment follow up to support healthcare professionals in minimising the loss to follow up.

Introduction There are scarce data on the routine latent tuberculosis infection treatment (LTBIT) and factors associated with a non-completion in high tuberculosis burden countries. Therefore, in this study we aimed to evaluate the factors associated with non-completion of LTBIT. Materials and methods This was a non-matched case control study conducted at a University Hospital in Rio de Janeiro, Brazil. A total of 114 cases and 404 controls were enrolled between January/1999 and December/2009. Cases were close contacts who did not complete the LTBIT and controls were the contacts that completed it. Multivariate analysis was used to investigate risk factors associated with non-completion of LTBIT among contacts in two different periods of recruitment. Results Factors associated with non-completion LTBIT included: drug use (OR 23.33, 95% CI 1.83–296.1), TB treatment default by the index case (OR 16.97, 95% CI 3.63–79.24) and drug intolerance. TB disease rates after two years of follow up varied from 0.4% to 1.9%. The number necessary to treat to prevent one TB case among contacts was 116. Conclusions Non-completion treatment by the index case and illicit drug use were associated with not completing latent tuberculosis infection treatment and no tuberculosis disease was identified among those who completed latent tuberculosis infection treatment.

Objectives: to identify the association between HIV/AIDS hospitalizations and factors that integrate individual, social, and programmatic vulnerabilities. Methods: a case-control study conducted in 2014 in a municipality in the state of São Paulo. “Cases” included people living with HIV (PLHIV) hospitalized and “control” those who were outpatients. Interviews were conducted using a tool with sociodemographic variables, clinical characteristics and other vulnerabilities. Data were analyzed by conditional logistic regression. Results: fifty-six cases and 112 control participated. Risk factors for HIV hospitalization were: unemployed and retired individuals; homeless people; non-antiretroviral users; individuals who did not regularly attend returns. Access to social workers was a protective factor for hospitalization. Conclusions: this research contributed to measure the social, individual and programmatic vulnerabilities that interfere with HIV worsening and, consequently, unfavorable outcome such as hospitalization. RESUMEN Objetivos: identificar la asociación entre las hospitalizaciones por VIH/SIDA y los factores que integran las vulnerabilidades individuales, sociales y del programa. Métodos: estudio de casos y controles realizado en 2014 en un municipio del estado de São Paulo. Los “casos” incluyeron a personas que viven con VIH (PVVIH) hospitalizadas y “controla” a los pacientes ambulatorios. Las entrevistas se realizaron utilizando un instrumento con variables sociodemográficas, características clínicas y otras vulnerabilidades. Los datos fueron analizados por regresión logística condicional. Resultados: participaron 56 casos y 112 controles. Los factores de riesgo de hospitalización por VIH fueron: personas desempleadas y jubiladas; personas sin hogar; usuarios no antirretrovirales; individuos que no asistieron regularmente a las declaraciones. El acceso a los trabajadores sociales fue un factor protector para la hospitalización. Conclusiones: esta investigación contribuyó a medir las vulnerabilidades sociales, individuales y programáticas que interfieren con la agudización del VIH y, en consecuencia, el resultado desfavorable, como la hospitalización. RESUMO Objetivos: identificar a associação entre as internações por HIV/aids e os fatores que integram as vulnerabilidades individuais, sociais e programáticas. Métodos: estudo caso-controle realizado em 2014 em um município do estado de São Paulo. “Casos” compreenderam pessoas que viviam com HIV (PVHIV) internadas e “controles” aquelas que faziam acompanhamento ambulatorial. Foram realizadas entrevistas utilizando um instrumento com variáveis sociodemográficas, características clínicas e outras vulnerabilidades. Os dados foram analisados por meio de regressão logística condicional. Resultados: participaram 56 casos e 112 controles. Constituíram fatores de risco para internação hospitalar por HIV: indivíduos desempregados e aposentados/do lar; pessoas em situação de rua; não usuários de antirretroviral; indivíduos que não compareciam regularmente aos retornos. Acesso à assistente social constituiu-se um fator de proteção para internação. Conclus ões: esta investigação contribuiu para mensurar as vulnerabilidades sociais, individuais e programáticas que interferem na agudização do HIV e, consequentemente, no desfecho desfavorável, como a internação hospitalar.

Tuberculosis is the second leading responsible cause of death from infectious diseases. Tuberculosis effective control and related activities depends on the use of different systems that aim to assist and monitor patients through managing their health data, and facilitating the activities of several health professionals. However, we noticed disparities in the information provided by some systems, which can negatively impact planning and decision-making. The study is defined as a quantitative and descriptive study of patients’ data during the treatment of tuberculosis in two different ambulatories. The data was collected from four different sources, including three information systems and the local patient archive in the ambulatories. Collected data was cleansed and standardized for semantic and structure, which allowed data comparison and analysis for its reliability and completeness. Low reliability scores are due to the absence of a semantic standard and the careless validation on recording of data by the professionals. Therefore, this study was able to effectively detect inconsistencies between the different data sources, stressing the need of health standards for data consistency, interoperability, and promoting data quality.

Objective: to analyze the quality and management of care to tuberculosis/HIV coinfection in the state of São Paulo, Brazil. Methods: a descriptive study involving municipalities having at least five cases of tuberculosis/HIV coinfection in the Brazilian state of São Paulo notified in the tuberculosis notification system. To analyze the quality and management of care to tuberculosis/HIV coinfection, indicators were designed, based on tuberculosis evaluability assessment studies, and validated in Brazil. The municipalities were grouped according to their care quality and then submitted to multiple correspondence analysis. Results: the study formed a group with 18 municipalities (42.86%) with satisfactory care and management quality, and another group with 24 municipalities (57.14%) with a quality characterized as unsatisfactory. In the municipalities that showed a satisfactory result, the investigation identified a low proportion of tuberculosis/HIV coinfection, a low AIDS incidence rate, intermediate population size, and high coverage of the Community Health Workers’ Program and Family Health Strategy. The municipalities with unsatisfactory quality had a high proportion of tuberculosis/HIV coinfection and a high AIDS incidence rate. Conclusion: the study reveals the defining characteristics of quality and management of care to tuberculosis/HIV coinfection as chronic conditions, bringing relevant elements regarding the mobilization of resources and investments in the municipalities where these are necessary. Additionally, the investigation shows that health results are critical where care quality is unsatisfactory, pointing out the need for reorganizing care and the management of actions involving control of tuberculosis/HIV coinfection in these contexts. RESUMEN Objetivo: analizar la calidad y gestión en la atención de la coinfección tuberculosis y VIH en el estado de São Paulo. Método: estudio descriptivo, realizado en municipios donde residen al menos cinco casos de coinfección de tuberculosis y VIH en el estado de São Paulo, informados al sistema de notificaciones de tuberculosis. Para analizar la calidad de atención y gestión de la coinfección tuberculosis/VIH fueron elaborados indicadores basados en estudios evaluativos en tuberculosis validados en Brasil. Los municipios fueron agrupados según su calidad de atención, sometiéndoselos luego a análisis de correspondencia múltiple. Resultados: el estudio conformó un grupo con 18 municipios (42,86%) de calidad de atención y gestión satisfactorias, y otro con 24 (57,14%) municipios caracterizados como no satisfactorios. En los municipios con resultados satisfactorios se identificó baja proporción de coinfección tuberculosis y VIH, baja tasa de incidencia de SIDA, cantidad poblacional mediana, elevada cobertura de Agentes Comunitarios de Salud y Estrategia Salud de la Familia. En los municipios no satisfactorios se observó alta proporción de coinfección tuberculosis e VIH y tasa de incidencia de SIDA. Conclusión: el estudio evidencia las características que definen la calidad de atención y gestión de la coinfección tuberculosis y VIH como condiciones crónicas, destacando elementos relevantes respecto de movilización de recursos e inversión en los municipios donde eso resulta necesario. Además, muestra que los resultados sanitarios son críticos donde no hay calidad de atención satisfactoria, expresando necesidad de reorganización de la atención y gestión de las acciones que involucran al control de la coinfección tuberculosis y VIH en tales contextos. RESUMO Objetivo: analisar a qualidade e gestão da atenção à coinfecção tuberculose e HIV no estado de São Paulo. Método: estudo descritivo, realizado com municípios de residência de pelo menos cinco casos de coinfecção tuberculose e HIV no estado de São Paulo, notificados no sistema de notificações de tuberculose. Para análise da qualidade da atenção e gerenciamento da coinfecção tuberculose e HIV foram construídos indicadores, com base em estudos de avaliabilidade em tuberculose, validados no Brasil. Os municípios foram agrupados conforme sua qualidade da atenção e depois foram submetidos à análise de correspondência múltipla. Resultados: no estudo, formou-se um grupo com 18 municípios (42,86%) com satisfatória qualidade da atenção e gerenciamento, e outro grupo com 24 (57,14%) municípios caracterizados como não satisfatório. Nos municípios com resultado satisfatório, identificou-se baixa proporção de coinfecção tuberculose e HIV, baixa taxa de incidência de aids, porte populacional médio, elevada cobertura de Programas de Agentes Comunitários de Saúde e Estratégia Saúde da Família. Para os demais municípios com qualidade não satisfatória, observou-se alta proporção de coinfecção tuberculose /HIV e taxa de incidência de aids. Conclusão: o estudo evidencia as características definidoras da qualidade da atenção e gerenciamento da coinfecção tuberculose e HIV enquanto condições crônicas, trazendo elementos relevantes no que tange à mobilização de recursos e investimentos nos municípios onde isso se faz necessário. Além disso, mostra que os resultados sanitários são críticos onde não há satisfatória qualidade da atenção, mostrando a necessidade de reorganização da assistência e do gerenciamento das ações que envolvem o controle da coinfecção tuberculose e HIV nesses contextos.

Objective : to describe the body temperature profile (TC) and the outcome in patients with sepsis assisted in an intensive care unit (UCI). Methods : retrospective, descriptive and exploratory study. Patients over the age of 18 were included, diagnosed with severe sepsis or septic shock in the period from January to December 2012, assisted in an UCI of a public hospital. Sociodemographic, clinical and outcome variables were built. For the evaluation of the TC, all measures recorded during hospitalization were considered, taken in the axillary region by digital thermometer coupled to the multiparametric monitor. In addition, comparative scenarios were proposed between the number of episodes of fever or hypothermia in the 24 hours after internment and the number of these 24 hours prior to the outcome. The data were collected from physical and electronic medical records. Results : 105 patients were included, predominantly over 60 years old, male and white. Clinical outcome for 26 patients (24.8 %) was to be discharged, and for 79 (75.2 %) it was death. 8778 TC verifications were observed, being hypothermia the most frequent in the death group (p = 0.00). In the discharge group, measurements within normality were more frequent (p = 0.00). Among the proposed scenarios, there was statistically significant difference between the groups when two or more episodes of fever occurred in the 24 hours prior to the outcome. Conclusion : the description of the thermoregulation profile in septic patients showed that the TC is a complementary indicator capable of assisting the team in the clinical practice in order to promote better results.

BackgroundThe role of genetic polymorphisms in latent tuberculosis (TB) infection and progression to active TB is not fully understood.MethodsWe tested the single-nucleotide polymorphisms (SNPs) rs5743708 (TLR2), rs4986791 (TLR4), rs361525 (TNFA), rs2430561 (IFNG) rs1143627 (IL1B) as risk factors for tuberculin skin test (TST) conversion or development of active TB in contacts of active TB cases. Contacts of microbiologically confirmed pulmonary TB cases were initially screened for longitudinal evaluation up to 24 months, with clinical examination and serial TST, between 1998 and 2004 at a referral center in Brazil. Data and biospecimens were collected from 526 individuals who were contacts of 177 active TB index cases. TST conversion was defined as induration ≥5 mm after a negative TST result (0 mm) at baseline or month 4 visit. Independent associations were tested using logistic regression models.ResultsAmong the 526 contacts, 60 had TST conversion and 44 developed active TB during follow-up. Multivariable regression analysis demonstrated that male sex (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.1–4.6), as well as SNPs in TLR4 genes (OR: 62.8, 95% CI: 7.5–525.3) and TNFA (OR: 4.2, 95% CI: 1.9–9.5) were independently associated with TST conversion. Moreover, a positive TST at baseline (OR: 4.7, 95% CI: 2.3–9.7) and SNPs in TLR4 (OR: 6.5, 95% CI: 1.1–36.7) and TNFA (OR: 12.4, 95% CI:5.1–30.1) were independently associated with incident TB.ConclusionsSNPs in TLR4 and TNFA predicted both TST conversion and active TB among contacts of TB cases in Brazil.

Objective: To investigate early detection of amikacin-induced ototoxicity in a population treated for multidrug-resistant tuberculosis (MDR-TB), by means of three different tests: pure-tone audiometry (PTA); high-frequency audiometry (HFA); and distortion-product otoacoustic emission (DPOAE) testing. Methods: This was a longitudinal prospective cohort study involving patients aged 18-69 years with a diagnosis of MDR-TB who had to receive amikacin for six months as part of their antituberculosis drug regimen for the first time. Hearing was assessed before treatment initiation and at two and six months after treatment initiation. Sequential statistics were used to analyze the results. Results: We included 61 patients, but the final population consisted of 10 patients (7 men and 3 women) because of sequential analysis. Comparison of the test results obtained at two and six months after treatment initiation with those obtained at baseline revealed that HFA at two months and PTA at six months detected hearing threshold shifts consistent with ototoxicity. However, DPOAE testing did not detect such shifts. Conclusions: The statistical method used in this study makes it possible to conclude that, over the six-month period, amikacin-associated hearing threshold shifts were detected by HFA and PTA, and that DPOAE testing was not efficient in detecting such shifts. RESUMO Objetivo: Verificar a detecção precoce de ototoxicidade causada pelo uso de amicacina numa população tratada para tuberculose multirresistente (TBMR) por meio da realização de três testes distintos: audiometria tonal liminar (ATL), audiometria de altas frequências (AAF) e pesquisa de emissões otoacústicas por produto de distorção (EOAPD). Métodos: Estudo longitudinal de coorte prospectiva incluindo pacientes de ambos os sexos, com idade entre 18 e 69 anos, com diagnóstico de TBMR pulmonar e que necessitaram utilizar amicacina por seis meses em seu esquema medicamentoso antituberculose pela primeira vez. A avaliação auditiva foi realizada antes do início do tratamento e depois de dois e seis meses do início do tratamento. A análise dos resultados foi realizada por meio de análise estatística sequencial. Resultados: Foram incluídos 61 pacientes, mas a população final foi constituída de 10 pacientes (7 homens e 3 mulheres), em razão da análise sequencial. Ao se comparar os valores das respostas dos testes com aqueles encontrados na avaliação basal, foram verificadas mudanças nos limiares auditivos compatíveis com ototoxicidade após dois meses de tratamento através da AAF e após seis meses de tratamento através da ATL. Entretanto, essas mudanças não foram verificadas através da pesquisa de EOAPD. Conclusões: Ao se considerar o método estatístico utilizado nessa população, é possível concluir que mudanças nos limiares auditivos foram associadas ao uso da amicacina no período de seis meses por meio de AAF e ATL e que a pesquisa de EOAPD não se mostrou eficiente na identificação dessas mudanças.

RESUMO: Objetivo: Medir os atrasos na suspeita e no diagnóstico de tuberculose (TB) e identificar fatores relacionados. Métodos: O atraso na suspeita foi definido como o tempo entre a percepção, pelo doente, dos sintomas até a procura pelo primeiro atendimento e no diagnóstico, como o tempo entre o primeiro atendimento até a realização do diagnóstico. Foram entrevistados 100 doentes, diagnosticados e notificados em 2008 e 2009, atendidos em serviços de saúde (SSs) de São José do Rio Preto, para os quais foram quantificados os atrasos. As possíveis variáveis explicativas foram obtidas das entrevistas e de informações secundárias disponíveis no sistema de vigilância. Os endereços dos casos e dos serviços de saúde foram geocodificados. As variáveis foram analisadas por regressão linear múltipla e, quando da identificação de dependência espacial dos seus resíduos, por regressão espacial. Resultados: As medianas, tanto para o atraso na suspeita como no diagnóstico, foram 15 dias. O atraso na suspeita foi modelado por regressão linear e mostrou-se associado positivamente com as distâncias percorridas pelos doentes para obter o primeiro atendimento e negativamente com a religião (não cristã). O atraso no diagnóstico foi modelado por regressão espacial e mostrou-se associado positivamente com idade e número de vezes que o doente procurou o SS e negativamente com a classificação do caso (TB pulmonar). Conclusão: O estudo revelou lacunas nas ações de controle da TB relacionadas aos doentes e à organização dos serviços e mostrou a importância de se levar em conta a dependência espacial dos fenômenos analisados. ABSTRACT: Objective: To measure the delays in tuberculosis (TB) suspicion and diagnosis and to identify factors related. Methods: We defined the delay in TB suspicion as the time between the perception of the symptoms by the patient and the search for health-care service and the diagnosis, as the time between the first visit to the health-care service and the diagnosis. We interviewed 100 patients treated at the health services in São José do Rio Preto that were diagnosed and reported/notified in 2008 and 2009, and the delays were quantified. We obtained the possible explanatory variables from interviews and secondary information available in the surveillance system. The addresses of TB patients and health-care services were geocoded. Variables were assessed by multiple linear regression analysis and, when spatial dependency was detected, by spatial regression. Results: The median values for the delays in TB suspicion and diagnosis were both 15 days. The first was modeled by linear regression and a positive relationship was found with the distances covered by the patients in order to get primary health-care service. The last was modeled by spatial regression and a positive relationship was found with the age and the frequency with the patients sought health-care services and a negative relationship with the pulmonary clinical form. Conclusion: The study revealed the existence of gaps in TB control activities related to the patients and the organization of the health-care services and showed the importance of taking into account the spatial dependence of the phenomena analyzed.

Assessment of health information systems consider different aspects of the system itself. They focus or on the professional who will use the software or on its usability or on the software engineering metrics or on financial and managerial issues. The existent approaches are very resources consuming, disconnected, and not standardized. As the software becomes more critical in the health organizations and in patients, becoming used as a medical device or a medicine, there is an urgency to identify tools and methods that can be applied in the development process. The present work is one of the steps of a broader study to identify standardized protocols to evaluate the health information systems as medicines and medical devices are evaluated by clinical trials. The goal of the present work was to evaluate the effect of the introduction of an information system for monitoring tuberculosis treatment (SISTB) in a Brazilian municipality from the patients' perspective. The Patient Satisfaction Questionnaire and the Hospital Consumer Assessment of Healthcare Providers and Systems were answered by the patients before and after the SISTB introduction, for comparison. Patients from an outpatient clinic, formed the control group, that is, at this site was not implanted the SISTB. Descriptive statistics and mixed effects model were used for data analysis. Eighty-eight interviews were conducted in the study. The questionnaire's results presented better averages after the system introduction but were not considered statistically significant. Therefore, it was not possible to associate system implantation with improved patient satisfaction. The HIS evaluation need be complete, the technical and managerial evaluation, the safety, the impact on the professionals and direct and/or indirect impact on patients are important. Developing the right tools and methods that can evaluate the software in its entirety, from the beginning of the development cycle with a normalized scale, are needed.

Resumo O objetivo deste artigo é analisar fontes de registro da tuberculose (TB) antes e após a implantação do Sistema Informatizado para Registro da Assistência à TB em Ribeirão Preto (SP). Estudo epidemiológico descritivo-analítico, do tipo intervenção. Os dados foram coletados em fontes secundárias, a partir de um formulário estruturado, e analisados através de teste Qui-quadrado ou Exato de Fisher com nível de significância de 5%. Identificou-se associação entre o período anterior da implantação do sistema com o arquivamento da Ficha do Tratamento Diretamente Observado no prontuário e o registro de orientação de retorno às consultas pela equipe de enfermagem. O posterior esteve associado com o aumento do registro do contato telefônico e endereço do doente de TB, data de término do tratamento, situação de encerramento, resultado da baciloscopia de escarro para controle mensal, teste anti-HIV, consultas mensais e solicitação de exames realizados pelo médico, atendimento com assistente social, condições de vida do doente, controle de comunicantes, incentivos sociais e uso de álcool e drogas. A implantação do sistema possibilitou a melhora no registro de algumas variáveis, ainda que outras fontes de registro tenham permanecido que não fossem o próprio sistema.

Este estudo analisou a magnitude da tuberculose pulmonar no período de 2007 a 2010 em municípios sul-mato-grossenses fronteiriços ao Paraguai e à Bolívia. Na região de fronteira, as taxas de incidência (49,1/100 mil habitantes), de mortalidade (4,0/100 mil) e de abandono do tratamento (11,3%) foram 1,6, 1,8 e 1,5 vez maiores do que na região não fronteiriça. Entre indígenas da fronteira, as taxas de incidência (253,4/100 mil habitantes), mortalidade (11,6/100 mil) e coinfecção por HIV (1,9/100 mil) foram, respectivamente, 6,4, 3,2 vezes e 1,9 vez maiores do que entre os não indígenas nesta região. Estar na região de fronteira revelou-se fator de proteção contra coinfecção por HIV. Constatou-se associação entre ser indígena e não abandonar o tratamento. Conclui-se que a população residente nesses municípios de fronteira vivencia elevado risco de adoecimento, de morte e de abandono do tratamento de tuberculose pulmonar, o que requer ações diferenciadas de vigilância em saúde. This study analyzed the epidemiological profile of pulmonary tuberculosis from 2007 to 2010 in municipalities (counties) in Mato Grosso do Sul State, Brazil, that border on Paraguay and Bolivia. In the border region, the incidence rate (49.1/100,000 inhabitants), mortality rate (4.0/100,000 inhabitants), and treatment dropout rate (11.3%) were 1.6, 1.8, and 1.5 times higher than in the non-border region. Among indigenous individuals in the border region, the rates for incidence (253.4/100,000 inhabitants), mortality (11.6/100,000 inhabitants), and HIV/TB co-infection (1.9/100,000 inhabitants) were 6.4, 3.2, and 1.9 times higher than in non-indigenous individuals in this region. Living in the border regions was inversely associated with HIV/TB co-infection. Indigenous ethnicity was associated statistically with not abandoning TB treatment. The study concludes that the population residing in these municipalities along the border is exposed to high risk of pulmonary TB and TB mortality and treatment dropout, thus requiring special health surveillance interventions. Este estudio examinó la magnitud de la tuberculosis pulmonar del 2007 al 2010 en los municipios de Mato Grosso do Sul (Brasil) limítrofes con Paraguay y Bolivia. En la región fronteriza, las tasas de incidencia (49,1/100.000 habitantes), mortalidad (4,0/100.000) y abandono del tratamiento (11,3%) fueron 1,6, 1,8 y 1,5 veces más altas que en la región no fronteriza. En la región fronteriza, las tasas de incidencia (253,4/100.000 habitantes), mortalidad (11,6/100.000) y co-infección por el VIH (1,9/100.000) entre residentes indígenas fueron 6,4, 3,2 y 1,9 veces más altas que en la población no indígena. Vivir en la región fronteriza resultó ser un factor protector contra la co-infección por el VIH. Se identificó asociación entre ser indígena y no abandonar el tratamiento. Los resultados mostraron que la población de estos municipios fronterizos está sujeta a un alto riesgo de enfermedad, muerte y abandono del tratamiento de la tuberculosis pulmonar, lo que requiere acciones de vigilancia de la salud específicas para este contexto.

INTRODUCTION: AIDS epidemic has given visibility to the incidence of tuberculosis, for being the most frequent opportunistic infection. It is known that individuals who are socially vulnerable are more susceptible to HIV transmission and tuberculosis as well. OBJECTIVE: This study aims to conduct a geoepidemiological study on HIV/AIDS, AIDS-Tuberculosis co-infection and social vulnerability. METHOD: This is an ecological study using incidence rates and the human development index to produce thematic maps and a descriptive analysis of epidemiology. The records of reported cases of HIV/AIDS from 1982 to 2007 were used, considering as cases of AIDS-Tuberculosis those records that were positively diagnosed with tuberculosis and those records with unknown diagnosis of tuberculosis, but showing compatible signs and symptoms with tuberculosis (fever, cough, cachexia and asthenia). RESULTS: The maps allowed the identification of areas with social differences and different patterns of incidence of HIV/AIDS and AIDS-Tuberculosis; regional differences were similar to those found by Josué de Castro, in 1940; regions with higher human development index values also showed higher incidence HIV/AIDS and AIDS-Tuberculosis. CONCLUSION: The prevention of HIV infection must be geographically specific, given socioeconomic and cultural differences. Although official records show decline in AIDS-TB co-infection, treatment of cases of HIV/AIDS should observe the occurrence of opportunistic diseases, which should be notified and/or updated. INTRODUÇÃO: A epidemia de AIDS deu visibilidade à incidência de tuberculose, por ter sido a infecção oportunista mais frequente nesses casos. Sabe-se que os indivíduos socialmente vulneráveis são mais suscetíveis à transmissão do HIV e também à tuberculose. OBJETIVO: Realizar um estudo geoepidemiológico sobre HIV/AIDS, coinfecção AIDS-tuberculose e vulnerabilidade social. MÉTODO: Trata-se de estudo ecológico com uso de coeficientes de incidência e do índice de desenvolvimento humano para produzir mapas temáticos e uma análise de epidemiologia descritiva. Foram utilizados os registros de notificação de casos de HIV/AIDS de 1982 a 2007. Foram considerados casos de AIDS-tuberculose os registros que tinham o diagnóstico positivo para tuberculose e aqueles que tinham diagnóstico ignorado para tuberculose, mas apresentavam sinais e sintomas compatíveis com a doença (febre, tosse, caquexia e astenia). RESULTADOS: Os mapas permitiram identificar regiões com diferenças sociais e diferentes padrões de incidência de HIV/AIDS e de AIDS-tuberculose. As diferenças regionais assemelham-se às encontradas por Josué de Castro, em 1940. As regiões com índice de desenvolvimento humano alto apresentaram alta incidência de HIV/AIDS e de AIDS-tuberculose. CONCLUSÃO: A prevenção da infecção pelo HIV deve ser geograficamente específica, dadas as diferenças socioeconômicas e culturais. Apesar de os registros oficiais mostrarem declínio da coinfecção AIDS-tuberculose, o tratamento dos casos de HIV/AIDS deve constatar a ocorrência de doenças oportunistas, que deveriam ser notificadas e/ou atualizadas.

OBJECTIVE: The aim of this study was to analyze social characteristics and stress as correlates of cigarette smoking in adolescence. The main intent was to identify elements that distinguish adolescents who had experimented with smoking and did not progress to regular smoking from those who became current smokers. METHODS: Students at 10 high schools in the city of Ribeirão Preto, Brazil, completed a questionnaire based on an instrument employed in a similar large-scale study. The students were classified as never-smokers or experimenters. The experimenters were subcategorized as having become current smokers or nonprogressors. Analyses were performed using adjusted logistic models. RESULTS: A total of 2,014 students (mean age, 16.2 ± 1.1 years; females, 53%) completed the questionnaire. We categorized 1,283 students (63.7%) as never-smokers, 244 (12.1%) as current smokers, and 487 (24.2%) as nonprogressors. We found that experimentation with smoking was associated with being held back a grade in school (OR = 1.80), alcohol intake (low/occasional, OR = 8.92; high/regular, OR = 2.64), illicit drug use (OR = 9.32), having a sibling or cousin who smokes (OR = 1.39), having a friend who smokes (OR = 2.08), and high levels of stress (in females only, OR = 1.32). Factors associated with an increased risk of transitioning from experimenter to current smoker were alcohol intake (low/occasional, OR = 3.28; high/regular, OR = 2.16), illicit drug use (OR = 3.61), and having a friend who smokes (OR = 7.20). CONCLUSIONS: Current smoking was associated with a profile of socioeconomic correlates different from that associated with experimentation only. Our data (showing that current smoking was associated with having a friend who smokes, alcohol intake, and illicit drug use) suggest the need for comprehensive approaches to discourage substance use during adolescence. OBJETIVO: Analisar características sociais e estresse como correlatos de consumo de cigarros na adolescência. O principal objetivo foi identificar elementos que distingam adolescentes que experimentaram cigarros e não progrediram para o tabagismo regular daqueles que se tornaram fumantes correntes. MÉTODOS: Estudantes de 10 escolas do ensino médio de Ribeirão Preto responderam um questionário baseado em instrumento empregado em um estudo com escala semelhante. Os estudantes foram classificados em indivíduos que nunca fumaram (NF) e experimentadores de cigarros (E). O grupo E foi subcategorizado em fumantes atuais e indivíduos que não progrediram para tabagismo corrente. As análises foram realizadas usando modelos logísticos ajustados. RESULTADOS: Um total de 2.014 estudantes (16,2 ± 1,1 anos; mulheres, 53%) responderam o questionário. Categorizamos 1.283 alunos (63,7%) em nunca fumantes, 244 (12,1%) como fumantes atuais e 487 (24,2%) como não progressores. A experimentação de cigarros foi associada a repetição de anos na escola (OR = 1,80), consumo de álcool (baixo/ocasional, OR = 8,92; intenso/frequente, OR = 2,64), uso de drogas ilícitas (OR = 9,32), fumantes entre irmãos ou primos (OR = 1,39), fumantes entre amigos (OR = 2,08) e níveis elevados de estresse (apenas em mulheres, OR = 1,32). Fatores associados com um risco maior de passar de experimentador de cigarros para fumante atual foram consumo de álcool (baixo/ocasional, OR = 3,28; regular/elevado, OR = 2,16), uso de drogas ilícitas (OR = 3,61) e amigos fumantes (OR = 7,20). CONCLUSÕES: O tabagismo atual associou-se com um perfil de correlatos socioeconômicos diferentes daqueles associados apenas à experimentação. Nossos achados (tabagismo atual associou-se a amigos fumantes, consumo de álcool e de drogas ilícitas) sugerem a necessidade de abordagens abrangentes para o desencorajamento do uso dessas substâncias na adolescência.

OBJECTIVE The objective of this study is to evaluate the performance of the Tuberculosis Control Program in municipalities of the State of São Paulo. METHODS This is a program evaluation research, with ecological design, which uses three non-hierarchical groups of the municipalities of the State of São Paulo according to their performance in relation to operational indicators. We have selected 195 municipalities with at least five new cases of tuberculosis notified in the Notification System of the State of São Paulo and with 20,000 inhabitants or more in 2010. The multiple correspondence analysis was used to identify the association between the groups of different performances, the epidemiological and demographic characteristics, and the characteristics of the health systems of the municipalities. RESULTS The group with the worst performance showed the highest rates of abandonment (average [avg] = 10.4, standard deviation [sd] = 9.4) and the lowest rates of supervision of Directly Observed Treatment (avg = 6.1, sd = 12.9), and it was associated with low incidence of tuberculosis, high tuberculosis and HIV, small population, high coverage of the Family Health Strategy/Program of Community Health Agents, and being located on the countryside. The group with the best performance presented the highest cure rate (avg = 83.7, sd = 10.5) and the highest rate of cases in Directly Observed Treatment (avg = 83.0, sd = 12.7); the group of regular performance showed regular results for outcome (avg cure = 79.8, sd = 13.2; abandonment avg = 9.5, sd = 8.3) and supervision of the Directly Observed Treatment (avg = 42.8, sd = 18.8). Large population, low coverage of the Family Health Strategy/Program of Community Health Agents, high incidence of tuberculosis and AIDS, and being located on the coast and in metropolitan areas were associated with these groups. CONCLUSIONS The findings highlight the importance of the Directly Observed Treatment in relation to the outcome for treatment and raise reflections on the structural and managerial capacity of municipalities in the implementation of the Tuberculosis Control Program. RESUMO OBJETIVO Avaliar o desempenho do Programa de Controle da Tuberculose em municípios paulistas. MÉTODOS Pesquisa de avaliação de serviços, com delineamento ecológico, utilizando três agrupamentos não hierárquicos de municípios paulistas de acordo com seu desempenho em relação a indicadores operacionais. Foram selecionadas 195 cidades com no mínimo cinco casos novos de tuberculose notificados no Sistema de Notificação do Estado de São Paulo e 20.000 habitantes ou mais em 2010. A análise de correspondência múltipla foi utilizada para a identificação da associação entre os grupos de distintos desempenhos e as características epidemiológicas, demográficas e de sistemas de saúde dos municípios. RESULTADOS O grupo de pior desempenho apresentou as taxas mais elevadas de abandono (média [md] = 10,4; desvio padrão [dp] = 9,4) e as menores proporções de efetivação de Tratamento Diretamente Observado (md = 6,1; dp = 12,9) e esteve associado à baixa incidência de tuberculose, alta confecção tuberculose e HIV, pequeno porte populacional, alta cobertura de Estratégia Saúde da Família/Programa de Agentes Comunitários em Saúde e localização no interior. O grupo de melhor desempenho apresentou a maior taxa de cura (md = 83,7; dp = 10,5) e a maior proporção de casos em Tratamento Diretamente Observado (md = 83,0; dp = 12,7); enquanto o grupo de desempenho regular mostrou resultados regulares de desfecho (cura: md = 79,8; dp = 13,2; abandono: md = 9,5; dp = 8,3) e de efetivação do Tratamento Diretamente Observado (md = 42,8; dp = 18,8). Grande porte populacional, baixa cobertura de Estratégia Saúde da Família/Programa de Agentes Comunitários em Saúde, alta incidência de tuberculose e aids, e localização no litoral e em áreas metropolitanas estiveram associados com esses grupos. CONCLUSÕES Os achados destacam a importância do Tratamento Diretamente Observado em relação ao desfecho do tratamento e levantam reflexões sobre a capacidade estrutural e gerencial dos municípios na operacionalização do Programa de Controle da Tuberculose.

Objectives To assess the incidence of tuberculosis and to screen for latent tuberculosis infection among Brazilians with rheumatoid arthritis using biologics in clinical practice. Patients and methods This cohort study used data from the Brazilian Registry of Biological Therapies in Rheumatic Diseases (Registro Brasileiro de Monitoração de Terapias Biológicas - BiobadaBrasil), from 01/2009 to 05/2013, encompassing 1552 treatments, including 415 with only synthetic disease-modifying anti-rheumatic drugs, 942 synthetic DMARDs combined with anti-tumor necrosis factor (etanercept, infliximab, adalimumab) and 195 synthetic DMARDs combined with other biologics (abatacept, rituximab and tocilizumab). The occurrence of tuberculosis and the drug exposure time were assessed, and screening for tuberculosis was performed. Statistical analysis: Unpaired t-test and Fisher's two-tailed test; p < 0.05. Results The exposure times were 981 patient-years in the controls, 1744 patient-years in the anti-TNF group (adalimumab = 676, infliximab = 547 and etanercept = 521 patient-years) and 336 patient-years in the other biologics group. The incidence rates of tuberculosis were 1.01/1000 patient-years in the controls and 2.87 patient-years among anti-TNF users (adalimumab = 4.43/1000 patient-years; etanercept = 1.92/1000 patient-years and infliximab = 1.82/1000 patient-years). No cases of tuberculosis occurred in the other biologics group. The mean drug exposure time until the occurrence of tuberculosis was 27(11) months for the anti-TNF group. Conclusions The incidence of tuberculosis was higher among users of synthetic DMARDs and anti-TNF than among users of synthetic DMARDs and synthetic DMARDs and non-anti-TNF biologics and also occurred later, suggesting infection during treatment and no screening failure. Resumo Objetivos Avaliar incidência de tuberculose e triagem para tuberculose latente em brasileiros com artrite reumatoide em uso de agentes biológicos na prática clinica. Pacientes e métodos Estudo de coorte com dados do Registro Brasileiro de Monitoração de Terapias Biológicas (BiobadaBrasil), de 01/2009 a 05/2013, abrangeu 1.552 tratamentos, 415 somente com drogas modificadoras do curso da doença (MMCDs) sintéticas, 942 MMCDs sintéticas em associação com anti-TNF (etanercepte, infliximabe, adalimumabe) e 195 MMCDs sintéticas em associação com outros biológicos (abatacepte, rituximabe e tocilizumabe). Avaliaram-se ocorrência de tuberculose, tempo de exposição às drogas e triagem para TB. Análise estatística: teste t não pareado e teste de Fisher bicaudal; p < 0,05. Resultados O tempo de exposição dos controles foi de 981 pacientes-ano, do grupo de anti-TNF foi de 1.744 pacientes-ano (adalimumabe = 676, infliximabe = 547 e etanercepte = 521 pacientes-ano) e o de outros biológicos de 336 pacientes-ano. A incidência de TB foi de 1,01/1.000 pacientes-ano nos controles e de 2,87 pacientes-ano nos usuários de anti-TNF (adalimumabe = 4,43/1.000 pacientes-ano; etanercepte = 1,92/1.000 pacientes-ano e infliximabe = 1,82/1.000 pacientes-ano). Não houve casos de tuberculose no grupo de outros biológicos. O tempo médio de exposição até a ocorrência de tuberculose foi de 27(11) meses para o grupo anti-TNF. Conclusões A incidência de tuberculose foi maior nos usuários de MMCDs sintéticas e anti-TNF do que nos usuários de MMCDs sintéticas e de MMCDs sintéticas e biológicos não anti-TNF, e também mais tardia, sugerindo infecção durante o tratamento, e não falha na triagem.

Objetivou-se analisar o percurso do doente de tuberculose (TB) durante o tratamento no sistema de serviços de saúde. Estudo epidemiológico, descritivo, realizado em Ribeirão Preto, São Paulo. Como fontes de dados utilizaram-se os registros relacionados ao tratamento da TB do Sistema de prontuários eletrônicos municipal e o sistema de notificação estadual. As variáveis selecionadas para o estudo foram categorizadas nas dimensões de análise: demanda, recursos, processos/produtos e resultados. Foram selecionados 109 registros de doentes de TB acompanhados em ambulatórios de referência para o tratamento da doença. Frente a alguma intercorrência notou-se a preferência por procurar o Pronto-atendimento 67(61,5%). O atendimento era centrado em médicos e auxiliares/técnicos de enfermagem 108(99,1%), sendo estes os principais responsáveis pelas visitas domiciliares e pela supervisão medicamentosa (71,6%). Os resultados permitiram observar a centralização do atendimento no nível secundário da atenção, privilegiando equipes especializadas e mantendo este ponto como o principal ordenador do cuidado.

Objective: To evaluate the frequency of and factors associated with indeterminate interferon-gamma release assay (IGRA) results in people living with HIV/AIDS (PLWHA). Methods: We tested 81 PLWHA in the central-west region of Brazil, using the tuberculin skin test and an IGRA. Information on sociodemographic and clinical variables was gathered through the use of questionnaires and from medical records. The association of those variables with indeterminate results was analyzed by calculating the adjusted ORs in a multivariate logistic regression model. Concordance was evaluated by determining the kappa statistic. Results: Among the 81 patients evaluated, the tuberculin skin test results were positive in 18 (22.2%) of the patients, and the IGRA results were positive in 10 (12.3%), with a kappa of 0.62. The IGRA results were indeterminate in 22 (27.1%) of the patients (95% CI: 17.8-38.1%). The odds of obtaining indeterminate results were significantly higher in smokers (adjusted OR = 6.0; 95% CI: 1.4-26.7) and in samples stored for less than 35 days (adjusted OR = 14.0; 95% CI: 3.1-64.2). Patients with advanced immunosuppression (CD4+ T-cell count < 200 cells/mm3) were at a higher risk for indeterminate results (OR adjusted for smoking and inadequate duration of sample storage = 4.7; 95% CI: 0.91-24.0), although the difference was not significant. Conclusions: The high prevalence of indeterminate results can be a major limitation for the routine use of IGRAs in PLWHA. The need to repeat the test increases its costs and should be taken into account in cost-effectiveness studies. The processing of samples can significantly alter the results. RESUMO Objetivo: Avaliar a frequência de resultados indeterminados de um interferon-gamma release assay (IGRA, ensaio de liberação de interferon-gama) e os fatores relacionados com esses resultados em pessoas vivendo com HIV/AIDS (PVHA). Métodos: Foram avaliadas 81 PVHA na região Centro-Oeste do Brasil, por meio do teste tuberculínico e de um IGRA. Informações a respeito de variáveis sociodemográficas e clínicas foram obtidas por meio de questionários e prontuários médicos. A relação entre essas variáveis e os resultados indeterminados foi avaliada por meio do cálculo da OR ajustada em um modelo de regressão logística multivariada. A concordância foi avaliada por meio do coeficiente kappa. Resultados: Os resultados do teste tuberculínico e do IGRA foram positivos em 18 (22,2%) e 10 (12,3%), respectivamente, dos 81 pacientes avaliados (κ = 0,62). O resultado do IGRA foi indeterminado em 22 (27,1%) dos pacientes (IC95%: 17,8-38,1%). A chance de resultados indeterminados foi significativamente maior em fumantes (OR ajustada = 6,0; IC95%: 1,4-26,7) e em amostras armazenadas durante menos de 35 dias (OR ajustada = 14,0; IC95%: 3,1-64,2). Pacientes com imunossupressão avançada (contagem de células T CD4+ < 200 células/mm3) apresentaram maior risco de resultados indeterminados (OR ajustada para tabagismo e tempo inadequado de armazenamento das amostras = 4,7; IC95%: 0,91-24,0), embora a diferença não tenha sido significativa. Conclusões: A alta prevalência de resultados indeterminados pode ser um grande obstáculo ao uso rotineiro de IGRAs em PVHA. A necessidade de repetir o teste aumenta seu custo e deve ser levada em conta em estudos da relação entre custo e eficácia. O processamento das amostras pode alterar significativamente os resultados.

OBJETIVO: Descrever os aspectos epidemiologicos da tuberculose infantil (TB) em hospital de referencia. METODOS: Estudo retrospectivo (1999-2008) de 473 individuos (0-14 anos) com TB confirmada, ou com melhora clinica ate o quarto mes de tratamento sob os cuidados da unidade, incluindo a revisao dos prontuarios medicos, fichas de acompanhamento clinico de TB e fichas de notificacao da unidade de TB do hospital. RESULTADOS: Dentre os 473 casos de TB incluidos no estudo, 52% apresentou reatividade a prova tuberculinica, 66% historia de contato com paciente com tuberculose pulmonar, principalmente intradomiciliar, sendo o pai/padrasto o familiar mais envolvido; TB disseminada em 22%. O resultado do teste de HIV foi obtido em 265 casos (56%), sendo positivo em 45 (17%). O diagnostico de TB foi confirmado em 31% dos casos, mais frequentemente em criancas com idade acima de 5 anos, com prova tuberculinica negativa, e nas formas disseminadas. Das 65 culturas positivas para a TB realizadas no estudo, o teste da sensibilidade as drogas anti-TB foi obtido em 30 casos (46%), entre os quais 10 (33%) eram resistentes a um ou mais farmacos anti-TB, e 2 (0,8%) eram multirresistentes. Entre os pacientes com tuberculose pulmonar confirmada, 31% nao preencheram os criterios para iniciar o tratamento com anti-TB de acordo com pontuacao do Ministerio da Saude (< 25 pontos). CONCLUSAO: A elevada percentagem de TB resistente a farmacos e a co-infeccao com HIV identificados neste estudo enfatiza a necessidade de realizar estudos adicionais para avaliar tal impacto nas atividades de controle da TB infantil.

O primeiro contato do doente de tuberculose (TB) com o sistema de saúde se dá na porta de entrada, e é fundamental para o acesso ao diagnóstico. Objetivou-se identificar e analisar a porta de entrada no sistema de saúde de Ribeirão Preto para o diagnóstico da TB. Baseou-se em um instrumento do Primary Care Assessment Tool, adaptado para a TB no Brasil. Realizou-se entrevista estruturada com 100 doentes de TB diagnosticados entre Junho de 2006 e Julho de 2007. Destes, 61% chegaram ao local de diagnóstico por encaminhamento e apenas 29% se apresentaram espontaneamente; 66% procuraram por serviços de atenção primária, 34% por serviços de nível secundário e terciário. Ademais, 89% foram diagnosticados em serviços públicos e destes, 44% foram diagnosticados nos pronto-atendimentos. Além disso, 88% foram diagnosticados fora de sua área de abrangência. Apesar dos doentes terem procurado atendimento na atenção primária e mais próximo de suas residências, o diagnóstico se deu na atenção secundária e terciária. The first contact of TB (tuberculosis) patients with the health system occurs at the front door and is essential to access to diagnosis. The objective of this study was to identify and analyze patients' first contact with the health system for TB diagnosis in Ribeirão Preto. The study was based on an instrument of the Primary Care Assessment Tool, adapted for TB care in Brazil. Structure interviews were conducted with 100 TB patients diagnosed between June 2006 and July 2007. Of all patients, 61% were referred to the diagnosis place and only 29% sought the service spontaneously; 66% sought for primary care services, and 34% for secondary and tertiary services. Public services diagnosed 89% of all cases, 44% of which were diagnosed in emergency services. A total 88% of patients were not from the area covered by the service. Although patients have sought for primary care services, close to their houses, the diagnosis occurred in secondary and tertiary health care. El primer contacto del enfermo de tuberculosis (TB) con el sistema de salud acontece en la puerta de entrada y es fundamental para acceder al diagnóstico. Se objetivó identificar y analizar la entrada al sistema de salud de Ribeirão Preto para diagnóstico de TB. Se usó un instrumento del Primary Care Assessment Tool, adaptado para TB en Brasil. Se realizó entrevista estructurada con 100 pacientes de TB diagnosticados entre junio/2006 y julio/2007. 61% de los enfermos llegó al lugar de diagnóstico por derivación, apenas 29% se presentó espontáneamente. 66% solicitó servicios primarios, 34% procuraron servicios secundarios y terciarios. 89% fue diagnosticado en servicios públicos, de ellos, 44% fue diagnosticado en los servicios de urgencia. 88% fue diagnosticado fuera del área urbana correspondiente. A pesar de que los enfermos buscaron atención en el servicio de urgencias más próximo a sus domicilios, el diagnóstico se dio en atención secundaria y terciaria.

INTRODUÇÃO: Analisar espacialmente a co-infecção tuberculose/vírus da imunodeficiência humana e associá-la com variáveis socioeconômicos, São José do Rio Preto, SP, 1998-2006. MÉTODOS: Foram geocodificados casos novos de TB/HIV e calculados coeficientes de incidência segundo unidades espaciais. Utilizou-se o índice de Moran para avaliar a dependência espacial das incidências. Regressões múltiplas foram realizadas para selecionar variáveis com maior poder de explicação da dependência espacial. O indicador local de associação espacial foi utilizado para identificação de agrupamentos espaciais significantes. RESULTADOS: O índice de Moran foi de 0,0635 (p = 0,0000), indicando ocorrência de dependência espacial. A variável que apresentou maior poder de explicação da dependência espacial da incidência foi a porcentagem de chefes de família com até três anos de instrução. O LISA cluster map para os coeficientes de incidência de co-infecção TB/HIV evidenciou aglomerados de alta incidência na região norte e baixa incidência na sul e oeste do município. CONCLUSÕES: O estudo possibilitou a compreensão da distribuição geográfica espacial da co-infecção TB/HIV no município e apontou a sua associação com variáveis socioeconômicas dando subsídios para o planejamento orientado para a priorização das regiões com maior carência social e consequentemente maiores incidências da doença.

OBJETIVO: Determinar o perfil de resistência a drogas de Mycobacterium tuberculosis no estado de Mato Grosso do Sul no período entre 2000 e 2006. MÉTODOS: Estudo descritivo de casos notificados de tuberculose no Sistema de Informação de Agravos de Notificação, com cultura positiva para M. tuberculosis e testes de sensibilidade a rifampicina, isoniazida, estreptomicina e etambutol. Para as culturas, utilizaram-se os meios sólidos Löwenstein-Jensen e Ogawa-Kudoh, assim como um sistema automatizado com meio líquido; para os testes de sensibilidade, o método das proporções. RESULTADOS: De 783 casos, 69,7% eram de pacientes masculinos, na faixa etária de 20-49 anos (70%), com forma pulmonar (94,4%) e sorologia positiva para HIV (8,6%); 645 (82,4%) eram casos novos, e 138 (17,6%) eram casos tratados. Identificou-se qualquer resistência em 143 casos (18,3%). A taxa de resistência primária (RP) foi, respectivamente, 8,1%, 1,6%, 2,8% e 12,4%, para monorresistência, multirresistência (MR), outros padrões de associação de drogas e qualquer resistência, ao passo que a taxa de resistência adquirida (RA) foi, respectivamente, 14,5%, 20,3%, 10,9% e 45,7%, e a taxa de resistência combinada (RC) foi, respectivamente, 9,2%, 4,9%, 4,2% e 18,3%. A estreptomicina foi a droga mais comum na RP (3,4%), e a isoniazida foi a mais comum na RA e RC (7,2% e 3,7%, respectivamente). CONCLUSÕES: Os níveis de resistência são elevados, prejudicando o controle da tuberculose em Mato Grosso do Sul. A MR adquirida, 12,7 vezes superior à MR primária, evidencia o uso prévio de medicamentos como indicativo de resistência. Os níveis refletem a fragilidade da atenção ao doente, mostrando a importância do tratamento diretamente observado, assim como das culturas e testes de sensibilidade para o diagnóstico precoce da resistência. OBJECTIVE: To determine the drug resistance profile of Mycobacterium tuberculosis in the state of Mato Grosso do Sul, Brazil, between 2000 and 2006. METHODS: Descriptive study of reported tuberculosis cases in the Brazilian Case Registry Database. We included only those cases in which M. tuberculosis culture was positive and sensitivity to drugs (rifampicin, isoniazid, streptomycin and ethambutol) was tested. Löwenstein-Jensen and Ogawa-Kudoh solid media were used for cultures, as was an automated liquid medium system. Sensitivity tests were based on the proportion method. RESULTS: Among the 783 cases evaluated, males predominated (69.7%), as did patients in the 20-49 year age bracket (70%), a diagnosis of pulmonary tuberculosis (94.4%) and positive HIV serology (8.6%); 645 (82.4%) were new cases, and 138 (17.6%) had previously been treated. Resistance to at least one drug was found in 143 cases (18.3%). The primary resistance (PR) rate was, respectively, 8.1%, 1.6%, 2.8% and 12.4%, for monoresistance, multidrug resistance (MDR), other patterns of resistance and resistance to at least one drug, whereas the acquired resistance (AR) rate was 14.5%, 20.3%, 10.9% and 45.7%, respectively, and the combined resistance (CR) rate was 9.2%, 4.9%, 4.2% and 18.3%, respectively. In PR, streptomycin was the most common drug, whereas isoniazid was the most common in AR and CR (7.2% and 3.7%, respectively). CONCLUSIONS: These high levels of resistance undermine the efforts for tuberculosis control in Mato Grosso do Sul. Acquired MDR was 12.7 times more common than was primary MDR, demonstrating that the previous use of drug therapy is an indicator of resistance. These levels reflect the poor quality of the health care provided to these patients, showing the importance of using the directly observed treatment, short course strategy, as well as the need to perform cultures and sensitivity tests for the early diagnosis of drug resistance.

Diariamente novos artigos científicos sobre tuberculose (TB) são publicados em todo mundo. No entanto, é difícil para o profissional sobrecarregado na rotina de trabalho acompanhar a literatura e discernir o que pode e deve ser aplicado na prática diária juntos aos pacientes com TB. A proposta das "III Diretrizes para TB da Sociedade Brasileira de Pneumologia e Tisiologia (SBPT)" é revisar de forma crítica o que existe de mais recente na literatura científica nacional e internacional sobre TB e apresentar aos profissionais da área de saúde as ferramentas mais atuais e úteis para o enfrentamento da TB no nosso país. As atuais "III Diretrizes para TB da SBPT" foram desenvolvidas pela Comissão de TB da SBPT e pelo Grupo de Trabalho para TB a partir do texto das "II Diretrizes para TB da SBPT" (2004). As bases de dados consultadas foram LILACS (SciELO) e PubMed (Medline). Os artigos citados foram avaliados para determinação do nível de evidência científica, e 24 recomendações sobre TB foram avaliadas, discutidas por todo grupo e colocadas em destaque. A primeira versão das "III Diretrizes para TB da SBPT" foi colocada no website da SBPT para consulta pública durante três semanas, e as sugestões, críticas e o nível de evidência da referência científica que as embasavam foram avaliados e discutidos antes de serem incorporadas ou não ao texto final.

Este estudo objetivou analisar o envolvimento de equipes da Atenção Básica à Saúde nas ações de controle da tuberculose, ante a percepção dos coordenadores do Programa de Controle da Tuberculose de nove municípios prioritários do Estado de São Paulo. Trata-se de uma pesquisa qualitativa, cujos dados foram coletados em junho/2005 por meio de entrevista semi-estruturada com nove coordenadores e analisados pela técnica de análise de conteúdo-modalidade temática. Os resultados apontaram dificuldades para incorporação das ações de controle da tuberculose, na atenção básica, relacionadas à debilidade quantitativa e qualitativa de recursos humanos e à visão centralizada e fragmentada da organização dessas ações no sistema de saúde. A integração das atividades de controle da tuberculose na atenção básica será possível mediante organização do sistema de saúde, seguindo os princípios da atenção primária e elaboração/implementação de uma política de recursos humanos que garanta formação e capacitação contínua das equipes de saúde. This study was aimed at analyzing the involvement of Health Primary Care teams in the tuberculosis control actions in the perception of the Tuberculosis Control Program coordinators of nine priority municipalities of the State of São Paulo. It is a qualitative research whose data were collected in June of 2005 through semi-structured interviews with nine coordinators. The content thematic modality was used for the analysis of the data. The results pointed out to difficulties in the implementation of the tuberculosis control actions in primary care related to quantitative and qualitative deficiencies of human resources and to a centralized and fragmented view regarding the organization of these actions in the health system. The integration of tuberculosis control activities in primary care is possible provided the system is organized according to primary care principles and a policy of human resources that ensures continuous education and capacity-building of health teams is elaborated/implemented. En este estudio se tuvo por objetivo analizar el involucramiento de los equipos de Atención Básica a la Salud en las acciones de control de la tuberculosis, a partir de la percepción de los coordinadores del Programa de Control de la Tuberculosis de nueve municipios prioritarios del Estado de Sao Paulo. Se trata de una investigación cualitativa, cuyos datos fueron recolectados en junio/2005 por medio de una entrevista semi-estructurada realizada a nueve coordinadores y analizados por la técnica de análisis de contenido-modalidad temática. Los resultados apuntaron dificultades para la incorporación de las acciones de control de la tuberculosis, en la atención básica, relacionadas a la debilidad cuantitativa y cualitativa de recursos humanos y a la visión centralizada y fragmentada de la organización de esas acciones en el sistema de salud. La integración de las actividades de control de la tuberculosis en la atención básica será posible mediante la organización del sistema de salud, siguiendo los principios de la atención primaria y elaboración/implementación de una política de recursos humanos que garantice la formación y capacitación continua de los equipos de salud.

Foi elaborado um método de cultivo alternativo, denominado por nós PKO (iniciais referentes à Petroff, Kudoh e Ogawa), para o isolamento do Mycobacterium tuberculosis em amostras de escarro para o diagnóstico da tuberculose pulmonar (TB). Para validação da técnica, amostras de escarro de pacientes suspeitos de TB foram submetidas aos métodos de baciloscopia (direta e pós-concentração), PKO, Swab e Petroff. A análise comparativa entre o método de Petroff e o PKO mostrou paridade de resultados em relação ao isolamento e número de colônias de M. tuberculosis. Porém, pelo método PKO, 65% das cepas isoladas foi detectada em um período £15 dias, enquanto que pelo método de Petroff a melhor detecção ocorreu em um intervalo de 16-29 dias (71%). O tempo médio de isolamento pelo PKO é somente superior ao sistema comercial Bactec 460TB em amostras positivas na baciloscopia. A exclusão da etapa de neutralização de pH no método PKO reduz a manipulação das amostras, diminui o tempo de execução do cultivo em relação ao de Petroff e facilita o treinamento de profissionais que realizam o diagnóstico laboratorial da TB. We elaborated an alternative culture method, which we denominated PKO (initials in tribute of respect to Petroff, Kudoh and Ogawa), for isolating Mycobacterium tuberculosis from sputum for diagnosis of pulmonary tuberculosis (TB), and to compare its performance with the Swab and Petroff methods. For the technique validation, sputum samples from patients suspected of pulmonary TB cases were examined by acid-fast microscopy (direct and concentrated smear), PKO, Swab and Petroff methods. We found that Petroff and PKO methods have parity in the effectiveness of M. tuberculosis isolation. However, by the PKO method, 65% of isolated strains were detected in a period of £15 days, while by the Petroff method the best detection was in an interval of 16-29 days (71%). In positive smear samples, the average time of PKO isolation is only superior to the one related for Bactec 460TB. In conclusion, the exclusion of the neutralization stage of pH in the PKO reduces the manipulation of the samples, diminishes the execution time of the culture according to the Petroff method and facilitates the qualification of professionals involved in the laboratorial diagnosis of Tuberculosis.

OBJETIVO: O estudo teve como propósito caracterizar o perfil epidemiológico dos casos de tuberculose notificados em Ribeirão Preto (SP), no período de 1998 a 2003, segundo a condição sorológica para o vírus da imunodeficiência humana, sexo, faixa etária e resultado do tratamento. MÉTODOS: Trata-se de uma investigação epidemiológica de cunho descritivo, que utilizou como instrumento de coleta de dados o banco de dados do Sistema de Informação da Tuberculose. A população do estudo constituiu-se na totalidade dos casos de co-infecção tuberculose e vírus da imunodeficiência humana, de residentes em Ribeirão Preto, notificados nos anos de 1998 a 2003. RESULTADOS: Nesse período foram notificados 1.273 casos de tuberculose, sendo que 377 apresentaram sorologia positiva para o vírus da imunodeficiência humana, o que significou taxa de co-infecção igual a 30%. Em relação ao sexo, observou-se neste grupo que 76% dos casos notificados foram de homens, havendo predominância na faixa etária de 20 a 59 anos. Quanto ao resultado terapêutico, a média de cura alcançada foi de 52%, de abandono de 11% e de óbito de 32%. A forma clínica predominante foi a pulmonar, com 58% dos casos. CONCLUSÃO: Foi observada alta prevalência da co-infecção no município estudado, sendo nítido que a conclusão terapêutica desses casos reflete a necessidade de se adotar estratégias especiais de acompanhamento dessa clientela. Quanto ao sexo e faixa etária, o acometimento foi equivalente ao de casos de tuberculose não infectados pelo vírus da imunodeficiência humana. OBJECTIVE: This study aimed to characterize the epidemiological profile of tuberculosis cases reported in the city of Ribeirão Preto between 1998 and 2003, according to patient HIV status, gender, age bracket and treatment outcome. METHODS: This was a descriptive epidemiological study that employed the Brazilian National Tuberculosis Notification Database as an instrument of data collection. The study sample consisted of all cases of human immunodeficiency virus/tuberculosis co-infection occurring in residents of Ribeirão Preto and reported between 1998 and 2003. RESULTS: During this period, 1273 new cases of tuberculosis were reported, 377 of which were in HIV-positive individuals, for a co-infection rate of 30%. Of the cases of co-infection, 76% were in men, and the majority occurred in individuals in the 20-59 age bracket. In terms of treatment outcome, cure was achieved in 52%, treatment abandonment was reported in 11%, and death occurred in 32%. The predominant clinical form of tuberculosis was the pulmonary form, which accounted for 58% of the cases. CONCLUSION: A high prevalence of co-infection was observed in the community studied. The treatment outcomes seen among the cases in our study sample underscore the need to adopt special strategies to monitor this clientele. Comparing the cases of tuberculosis in isolation with the cases of co-infection, no gender-related or age-related differences were observed.

Among all infectious diseases that afflict humans, tuberculosis (TB) remains the deadliest. At present, epidemiologists estimate that one-third of the world population is infected with tubercle bacilli, which is responsible for 8 to 10 million new cases of TB and 3 million deaths annually throughout the world. Approximately 95% of new cases and 98% of deaths occur in developing nations, generally due to the few resources available to ensure proper treatment and where human immunodeficiency virus (HIV) infections are common. In 1882, Dr Robert Koch identified an acid-fast bacterium, Mycobacterium tuberculosis, as the causative agent of TB. Thirty-nine years later, BCG vaccine was introduced for human use, and became the most widely used prophylactic strategy to fight TB in the world. The discovery of the properties of first-line antimycobacterial drugs in the past century yielded effective chemotherapies, which considerably decreased TB mortality rates worldwide. The later introduction of some additional drugs to the arsenal used to treat TB seemed to provide an adequate number of effective antimicrobial agents. The modern, standard short-course therapy for TB recommended by the World Health Organization is based on a four-drug regimen that must be strictly followed to prevent drug resistance acquisition, and relies on direct observation of patient compliance to ensure effective treatment. Mycobacteria show a high degree of intrinsic resistance to most antibiotics and chemotherapeutic agents due to the low permeability of its cell wall. Nevertheless, the cell wall barrier alone cannot produce significant levels of drug resistance. M. tuberculosis mutants resistant to any single drug are naturally present in any large bacterial population, irrespective of exposure to drugs. The frequency of mutants resistant to rifampicin and isoniazid, the two principal antimycobacterial drugs currently in use, is relatively high and, therefore, the large extra-cellular population of actively metabolizing and rapidly growing tubercle bacilli in cavitary lesions will contain organisms which are resistant to a single drug. Consequently, monotherapy or improperly administered two-drug therapies will select for drug-resistant mutants that may lead to drug resistance in the entire bacterial population. Thereby, despite the availability of effective chemotherapy and the moderately protective vaccine, new anti-TB agents are urgently needed to decrease the global incidence of TB. The resumption of TB, mainly caused by the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains and HIV epidemics, led to an increased need to understand the molecular mechanisms of drug action and drug resistance, which should provide significant insight into the development of newer compounds. The latter should be effective to combat both drug-susceptible and MDR/XDR-TB.

INTRODUÇÃO: A solução de tuberculina é armazenada em frascos de diferentes tamanhos. Sua adsorção ao frasco pode influenciar o resultado da prova tuberculínica. OBJETIVO: Avaliar o efeito do tamanho do frasco de armazenamento da tuberculina nos resultados obtidos na prova tuberculínica. MÉTODO: Sessenta e três pacientes internados com diagnóstico de tuberculose ativa foram submetidos a duas provas tuberculínicas simultâneas, em ambos os antebraços. A técnica usada foi a de Mantoux e consistiu na aplicação de 0,1 ml de tuberculina armazenada em frascos de 5 ml ou de 1,5 ml, no antebraço direito e no antebraço esquerdo, de forma aleatória. A leitura da induração foi efetuada de forma cega por um único leitor treinado previamente. As leituras com diferenças de até 2 mm foram consideradas resultados concordantes. RESULTADOS: Vinte e um pacientes não tiveram induração e foram excluídos da análise. Entre os 42 pacientes restantes, a média dos diâmetros das indurações obtidas nas provas com tuberculina armazenada nos frascos grandes foi maior do que as obtidas com a armazenada em frascos pequenos. A concordância entre as leituras foi obtida em 40,5% delas (17/42), e a diferença foi negativa (frasco grande menor que frasco pequeno) em 16,7% (7/42) e positiva em 42,9% delas (18/42). CONCLUSÃO: O tamanho do frasco de armazenamento da tuberculina pode influenciar o resultado da prova tuberculínica. A adsorção da tuberculina à parede do frasco pode explicar o fenômeno. Os autores alertam para o impacto dessas variações nos estudos epidemiológicos e operacionais. BACKGROUND: Tuberculin purified protein derivative is stored in vials of various sizes. Its adsorption to the vial can influence the results of tuberculin tests. OBJECTIVE: To evaluate the effect of vial size on the results obtained in tuberculin tests. METHODS: Sixty-four inpatients with active tuberculosis were submitted to two simultaneous tuberculin tests using the Mantoux technique. Patients were randomly allocated to receive two 0.1-ml injections, either one in the right forearm from a 1.5-ml vial and one in the left forearm from a 5-ml vial or vice versa. Induration was determined in a blinded fashion by a single, previously trained observer. Right arm-left arm differences of 2 mm or less were considered concordant results. RESULTS: Twenty-one patients presented no induration and were excluded from analysis. Among the 42 remaining patients, mean induration diameters obtained in tuberculin tests using the larger vials were greater than those obtained in tests using the smaller vials. Concordance was achieved in 40.5% (17/42). The difference was negative (large-vial indurations smaller than small-vial indurations) in 16.7% (7/42) and positive in 42.9% (18/42). CONCLUSIONS: The size of the vial may influence tuberculin test results. Adsorption to the sides of the vial may explain this phenomenon. The authors caution others to be aware of the impact of these variations in epidemiological and operational studies.

OBJECTIVE To evaluate the validity and reliability of an instrument that evaluates the structure of primary health care units for the treatment of tuberculosis.METHODS This cross-sectional study used simple random sampling and evaluated 1,037 health care professionals from five Brazilian municipalities (Natal, state of Rio Grande do Norte; Cabedelo, state of Paraíba; Foz do Iguaçu, state of Parana; Sao José do Rio Preto, state of Sao Paulo, and Uberaba, state of Minas Gerais) in 2011. Structural indicators were identified and validated, considering different methods of organization of the health care system in the municipalities of different population sizes. Each structure represented the organization of health care services and contained the resources available for the execution of health care services: physical resources (equipment, consumables, and facilities); human resources (number and qualification); and resources for maintenance of the existing infrastructure and technology (deemed as the organization of health care services). The statistical analyses used in the validation process included reliability analysis, exploratory factor analysis, and confirmatory factor analysis.RESULTS The validation process indicated the retention of five factors, with 85.9% of the total variance explained, internal consistency between 0.6460 and 0.7802, and quality of fit of the confirmatory factor analysis of 0.995 using the goodness-of-fit index. The retained factors comprised five structural indicators: professionals involved in the care of tuberculosis patients, training, access to recording instruments, availability of supplies, and coordination of health care services with other levels of care. Availability of supplies had the best performance and the lowest coefficient of variation among the services evaluated. The indicators of assessment of human resources and coordination with other levels of care had satisfactory performance, but the latter showed the highest coefficient of variation. The performance of the indicators “training” and “access to recording instruments” was inferior to that of other indicators.CONCLUSIONS The instrument showed feasibility of application and potential to assess the structure of primary health care units for the treatment of tuberculosis. OBJETIVO Analisar a validade e confiabilidade de instrumento de avaliação da estrutura dos serviços de atenção básica para o tratamento da tuberculose.MÉTODOS Estudo transversal com amostragem aleatória simples para 1.037 profissionais de saúde de cinco municípios (Natal, RN; Cabedelo, PB; Foz do Iguaçu, PR; São José do Rio Preto, SP e Uberaba, MG) em 2011. Foram identificados e validados indicadores estruturais, considerando as diferentes modalidades de organização do sistema de saúde de municípios de diferentes portes populacionais. A “estrutura” correspondeu aos recursos existentes para a execução dos serviços: físicos (equipamentos, materiais de consumo e instalações); humanos (número e qualificação); e fontes para manutenção da infraestrutura e da tecnologia existente, entendida como organização do serviço de saúde. Os procedimentos estatísticos utilizados no processo de validação foram análise de confiabilidade, análise fatorial exploratória e confirmatória.RESULTADOS O processo de validação determinou a retenção de cinco fatores com 85,9% de variância total explicada, consistência interna entre 0,6460 e 0,7802 e qualidade de ajustamento da análise confirmatória de 0,995 para ogoodness-of-fit index. Os fatores retidos compuseram os cinco indicadores estruturais: profissionais envolvidos com o atendimento de tuberculose; capacitação; acesso a instrumentos de registro; disponibilidade de insumos; e articulação do serviço de saúde com outros níveis de atenção. O indicador com melhor desempenho foi disponibilidade de insumos, com menor coeficiente de variação nos serviços avaliados. Os indicadores de avaliação dos recursos humanos e articulação com outros níveis de serviços apresentaram percentuais satisfatórios; entretanto, este último apresentou o maior coeficiente de variação. Os indicadores de capacitação e acesso a instrumentos de registro apresentaram percentuais de avaliação inferiores aos demais.CONCLUSÕES O instrumento apresentou viabilidade de aplicação e potencial de avaliação da estrutura dos serviços de saúde para o tratamento da tuberculose na atenção básica.

OBJECTIVE: To describe the prevalence of anemia and of its types in hospitalized patients with pulmonary tuberculosis. METHODS: This was a descriptive, longitudinal study involving pulmonary tuberculosis inpatients at one of two tuberculosis referral hospitals in the city of Rio de Janeiro, Brazil. We evaluated body mass index (BMI), triceps skinfold thickness (TST), arm muscle area (AMA), ESR, mean corpuscular volume, and red blood cell distribution width (RDW), as well as the levels of C-reactive protein, hemoglobin, transferrin, and ferritin. RESULTS: We included 166 patients, 126 (75.9%) of whom were male. The mean age was 39.0 ± 10.7 years. Not all data were available for all patients: 18.7% were HIV positive; 64.7% were alcoholic; the prevalences of anemia of chronic disease and iron deficiency anemia were, respectively, 75.9% and 2.4%; and 68.7% had low body weight (mean BMI = 18.21 kg/m2). On the basis of TST and AMA, 126 (78.7%) of 160 patients and 138 (87.9%) of 157 patients, respectively, were considered malnourished. Anemia was found to be associated with the following: male gender (p = 0.03); low weight (p = 0.0004); low mean corpuscular volume (p = 0.03);high RDW (p = 0; 0003); high ferritin (p = 0.0005); and high ESR (p = 0.004). We also found significant differences between anemic and non-anemic patients in terms of BMI (p = 0.04), DCT (p = 0.003), and ESR (p < 0.001). CONCLUSIONS: In this sample, high proportions of pulmonary tuberculosis patients were classified as underweight and malnourished, and there was a high prevalence of anemia of chronic disease. In addition, anemia was associated with high ESR and malnutrition.

Objective: To determine whether serum selenium levels are associated with the conversion of bacteriological tests in patients diagnosed with active pulmonary tuberculosis after eight weeks of standard treatment. Methods: We evaluated 35 healthy male controls and 35 male patients with pulmonary tuberculosis, the latter being evaluated at baseline, as well as at 30 and 60 days of antituberculosis treatment. For all participants, we measured anthropometric indices, as well as determining serum levels of albumin, C-reactive protein (CRP) and selenium. Because there are no reference values for the Brazilian population, we used the median of the serum selenium level of the controls as the cut-off point. At 30 and 60 days of antituberculosis treatment, we repeated the biochemical tests, as well as collecting sputum for smear microscopy and culture from the patients. Results: The mean age of the patients was 38.4 ± 11.4 years. Of the 35 patients, 25 (71%) described themselves as alcoholic; 20 (57.0%) were smokers; and 21 (60.0%) and 32 (91.4%) presented with muscle mass depletion as determined by measuring the triceps skinfold thickness and arm muscle area, respectively. Of 24 patients, 12 (39.2%) were classified as moderately or severely emaciated, and 15 (62.5%) had lost > 10% of their body weight by six months before diagnosis. At baseline, the tuberculosis group had lower serum selenium levels than did the control group. The conversion of bacteriological tests was associated with the CRP/albumin ratio and serum selenium levels 60 days after treatment initiation. Conclusions: Higher serum selenium levels after 60 days of treatment were associated with the conversion of bacteriological tests in pulmonary tuberculosis patients. Objetivo: Determinar se os níveis séricos de selênio estão associados à conversão dos testes bacteriológicos em pacientes diagnosticados com tuberculose pulmonar ativa após oito semanas de tratamento-padrão. Métodos: No início do estudo, avaliamos 35 controles saudáveis, do sexo masculino, e 35 pacientes do sexo masculino com tuberculose pulmonar. Estes foram também avaliados após 30 e 60 dias de tratamento antituberculose. Todos os participantes submeteram-se a medições antropométricas e quantificação dos níveis séricos de albumina, proteína C reativa (PCR) e selênio. Como não há valores de referência para a população brasileira, usamos a mediana dos resultados de selênio sérico dos controles como ponto de corte. Aos 30 e 60 dias do tratamento antituberculose, todos os testes bioquímicos foram repetidos, e foram coletadas amostras de escarro para baciloscopia e cultura. Resultados: A média de idade dos pacientes foi de 38,4 ± 11.4 anos. Dos 35 pacientes, 25 (71,0%) referiram alcoolismo, 20 (57,0%) eram fumantes, e 21 (60,0%) e 32 (91,4%) apresentavam depleção muscular pela medição da dobra cutânea tricipital e da área muscular do braço, respectivamente. De 24 pacientes, 12 (39,2%) foram classificados em moderadamente ou gravemente magros, e 15 (62,5%) apresentaram perda de peso > 10% em até seis meses antes do diagnóstico. No início do estudo, o grupo com tuberculose apresentou menores níveis de selênio sérico que os controles. A conversão dos testes bacteriológicos associou-se à relação PCR/albumina e aos níveis de selênio sérico 60 dias após o início do tratamento. Conclusões: Níveis maiores de selênio sérico após 60 dias de tratamento associaram-se à conversão bacteriológica em pacientes com tuberculose pulmonar.

Iron, copper, and zinc are key micronutrients that play an important role in the immune response to Mycobacterium tuberculosis. The present study aimed to evaluate the association between serum levels of those micronutrients, inflammatory markers, and the smear and culture conversion of M. tuberculosis during 60 days of tuberculosis treatment. Seventy-five male patients with pulmonary tuberculosis (mean age, 40.0 ± 10.7 years) were evaluated at baseline and again at 30 and 60 days of tuberculosis treatment. Serum levels of iron, copper, zinc, albumin, globulin, C-reactive protein, and hemoglobin, and smear and cultures for M. tuberculosis in sputum samples were analyzed. Compared to healthy subjects, at baseline, patients with PTB had lower serum iron levels, higher copper levels and copper/zinc ratio, and similar zinc levels. During the tuberculosis treatment, no significant changes in the serum levels of iron, zinc, and copper/zinc were observed. Lower serum copper levels were associated with bacteriological conversion in tuberculosis treatment (tuberculosis-negative) at 30 days but not at 60 days (tuberculosis-positive). C-reactive protein levels and the C-reactive protein/albumin ratio were lower in tuberculosis-negative patients than in tuberculosis-positive patients at 30 and 60 days after treatment. Albumin and hemoglobin levels and the albumin/globulin ratio in patients with pulmonary tuberculosis increased during the study period, regardless of the bacteriological results. High serum globulin levels did not change among pulmonary tuberculosis patients during the study. Serum copper levels and the C-reactive protein/albumin ratio may be important parameters to evaluate the persistence of non-conversion after 60 days of tuberculosis treatment, and they may serve as predictors for relapse after successful treatment.

This study sought to assess the accessibility to the diagnosis of tuberculosis in health services in Victoria, state of Espirito Santo. It featured a cross-sectional study conducted in 2009 of patients with tuberculosis using the Primary Care Assessment Tool and statistical analysis with the Chi-square test (p