RESUMO
Secondary prophylaxis of rheumatic heart diseases is efficient in reducing disease recurrence, heart damage, and cardiac impairment. We aimed to monitor the clinical evolution of a large Brazilian cohort of rheumatic patients under prolonged secondary prophylaxis. From 1986 to 2018, a cohort of 593 patients with rheumatic fever was followed every 6 months by the Reference Center for the Control and Prevention of Rheumatic Fever and Rheumatic Cardiopathy (CPCFR), Paraná, Brazil. In this cohort, 243 (41%) patients did not present cardiac damage (group I), while 350 (59%) were diagnosed with rheumatic heart disease (RHD) (group II) using the latest case definition. Among group II, 233 and 15 patients had impairment of the mitral and aortic valves, respectively, while 102 patients had impairment of both valves. Lesions on the mitral and aortic valves presented a regression in 69.9 and 48.7% of the patients, respectively. Active patient recruitment in the reference center and early detection of oropharyngeal GAS were important factors for optimal adherence to the prophylactic treatment. Patients with disease progression were associated with noncompliance to secondary prophylaxis. No patients undergoing regular prophylaxis presented progression of the rheumatic cardiac disease. Eighteen valvular surgeries were performed, and four (0.7%) patients died. This study confirmed that tailored and active efforts invested in rheumatic heart disease secondary prevention allowed for significant clinical improvement.
RESUMO
BACKGROUND: Patients treated for invasive aspergillosis may relapse during subsequent periods of immunosuppression and should receive secondary prophylaxis. Little is known about the frequency of relapse and practices of secondary prophylaxis for invasive fusariosis (IF). OBJECTIVES: Evaluate practices of secondary prophylaxis and the frequency of relapse in patients who survived IF and were exposed to subsequent periods of immunosuppression. METHODS: Multicentre retrospective study of patients with haematological malignancies who developed IF, survived the initial fungal disease period, and were exposed to subsequent periods of immunosuppression. RESULTS: Among 40 patients, 35 received additional chemotherapy and developed neutropenia (median, 24 days; range, 4-104), and five received glucocorticoids for the treatment of graft-vs-host disease. Overall, 32 patients received secondary prophylaxis (voriconazole in 24) for a median of 112 days (range, 12-468). IF relapsed in five patients (12.5%): 2/8 (25%) not on prophylaxis and 3/32 (9.4%) receiving prophylaxis. Among 28 patients with disseminated IF, relapse occurred in 2/2 (100%) not on prophylaxis and in 3/26 (11.5%) on prophylaxis (P = 0.03). All patients who relapsed IF died. CONCLUSIONS: Patients with IF who survive the initial disease may relapse if exposed to subsequent episodes of immunosuppressive therapies. Secondary prophylaxis should be considered, especially if IF was disseminated.
Assuntos
Quimioprevenção/métodos , Fusariose/tratamento farmacológico , Fusariose/prevenção & controle , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Prevenção Secundária/métodos , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Fusariose/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Classic histoplasmosis is a systemic endemic mycosis due to Histoplasma capsulatum var. capsulatum. A significant reduction in the morbidity and mortality of AIDS-related histoplasmosis has been observed since the introduction of highly active antiretroviral therapy (HAART) and secondary antifungal prophylaxis. AIMS: The aim of this study was to determine the current state of prognosis and treatment response of HIV-positive patients with histoplasmosis in the Francisco J. Muñiz Infectious Diseases Hospital in Buenos Aires City. METHODS: A retrospective study was conducted using the demographic, clinical, immunological and treatment data of 80 patients suffering from AIDS-related histoplasmosis. RESULTS: Of the 80 cases studied 65 were male, the median age was 36 years, with 73.7% of the patients being drug addicts, 82.5% of the patients was not receiving HAART at diagnosis, and 58.7% of the cases had less than 50 CD4+ cells/µl at the beginning of the treatment. The initial phase of treatment consisted of intravenous amphotericin B and/or oral itraconazole for 3 months, with 78.7% of the cases showing a good clinical response. Only 26/63 patients who were discharged from hospital continued with the follow-up of the HAART, secondary prophylaxis with itraconazole or amphotericin B. Secondary prophylaxis was stopped after more than one year of HAART if the patients were asymptomatic, had two CD4+ cell counts greater than 150cells/µl, and undetectable viral loads. No relapses were observed during a two-year follow up after prophylaxis was stopped. CONCLUSIONS: The treatment of histoplasmosis in HIV-positive patients was effective in 78.8% of the cases. The combination of HAART and secondary antifungal prophylaxis is safe, well tolerated, and effective. The low adherence of patients to HAART and the lack of laboratory kits for rapid histoplasmosis diagnosis should be addressed in the future. The usefulness of primary antifungal prophylaxis for cryptococcosis and histoplasmosis HIV-positive patients should be studied.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antifúngicos/uso terapêutico , Histoplasmose/tratamento farmacológico , Itraconazol/uso terapêutico , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Adulto , Fármacos Anti-HIV/farmacocinética , Fármacos Anti-HIV/uso terapêutico , Antifúngicos/efeitos adversos , Antifúngicos/farmacocinética , Terapia Antirretroviral de Alta Atividade , Argentina/epidemiologia , Contagem de Linfócito CD4 , Interações Medicamentosas , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Histoplasma/efeitos dos fármacos , Histoplasmose/epidemiologia , Histoplasmose/imunologia , Histoplasmose/prevenção & controle , Hospitais Especializados , Humanos , Infectologia , Itraconazol/efeitos adversos , Itraconazol/farmacocinética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/complicações , Carga Viral , Adulto JovemRESUMO
La profilaxis en el tratamiento de la hemofilia ha sido crucial en la mejoría del pronóstico y calidad de vida en las personas con hemofilia (PCH). A pesar de ello, no está globalmente implementado y no ha sido ejecutado satisfactoriamente en Latinoamérica, donde es difícil evaluar la situación, y el manejo de las PCH no se ajusta a los estándares ideales. El grupo GLAITH (Grupo Latino Americano para el Impulso del Tratamiento de la Hemofilia) discutió el problema a través de una encuesta entre sus integrantes. Los hallazgos fueron discutidos en Bogotá en mayo del 2013 en donde los participantes definieron los puntos esenciales a comunicar en un llamado a la acción. Las proporciones de casos de hemofilia A reportados fueron entre 75 y 90% y entre 10 y 25%, los de hemofilia B. La hemofilia grave representó entre el 26 y el 55% de los casos. Un alto porcentaje de PCH tiene artropatía hemofílica. La atención de PCH varía en cada país, sólo se cubre entre el 50 y 60% del tratamiento, que es a demanda en el 85 a 95% de los casos. Sólo 5 a 15% reciben profilaxis, la mayoría secundaria. Pocos países tienen programa nacional o registros homogéneos. En llamado a la acción y conclusión para la región se recomienda: establecimiento de un registro latinoamericano unificado; estudios prospectivos de costo efectividad y evaluación de criterios en profilaxis secundaria; estudios comparativos de calidad de vida, individualización del tratamiento e implementación de la profilaxis en forma global en Latinoamérica.
Prophylactic treatment in the management of hemophilia has been a crucial factor in improving the prognosis and quality of life for people with hemophilia (PCH). However, it is not globally implemented. In Latin America it is difficult to assess the status of PCH and the its management does not conform to ideal standards. The GLAITH group discussed the problem in Latin America. A survey of its members and its findings were discussed at a meeting in Bogota in May 2013. Proportions of hemophilia A and B were 75-90% and 10-25% respectively. Severe hemophilia represents 26-55% of cases. A high percentage of PCH have hemophilic arthropathy. The general care and specific treatments of PCH vary by country, only 50-60% of the treatment is covered and in 85-95% of the cases are performed on an ondemand basis. Just 5-15% receives prophylaxis, most of them secondary. Few countries have a national program or homogeneous records. Finally the GLAITH group proceeded to develop a conclusion and call to action for the region where the following points are recommended: the establishment of a unified Latin American registry; prospective cost-effectiveness studies and evaluation criteria related to secondary prophylaxis; comparative studies of quality of life with and without prophylaxis in the region; promotion of individualization of treatment and, the increase of primary and secondary prophylaxis globally in Latin America.
Assuntos
Humanos , Qualidade de Vida , Hemofilia B/terapia , Hemofilia A/terapia , Prevenção Primária/métodos , Prognóstico , Índice de Gravidade de Doença , Prevenção Secundária/métodos , América LatinaRESUMO
OBJECTIVES: To determine the level of adherence and possible barriers to secondary prophylaxis among clients with rheumatic fever in Kingston, Jamaica. METHODS: Cross-sectional survey of 39 clients diagnosed with rheumatic fever, receiving penicillin prophylaxis for more than a year using a 22-item self-administered questionnaire on adherence to secondary prophylaxis and knowledge of rheumatic fever. The patients' records were reviewed to determine the number of prophylaxis injections the patients received for the year 2010. RESULTS: The majority of participants (74%) were females and 51% were adults. Only 48·7% had a high level of adherence. The majority (72%) had low knowledge levels regarding their illness, while only 5% had a high knowledge level score. Most clients (70%) strongly agreed that nurses and doctors encouraged them to take their prophylaxis. However, over 60% reported that they travelled long distances and or waited long periods to get their injections. One-third reported that they missed appointments because of fear of injections and having to take time off from work or school. DISCUSSION: Clients attending the health centers studied had limited knowledge about rheumatic fever. Barriers to adherence included fear of the injections, long commutes, and long waiting periods at the facilities studied.
Assuntos
Antibacterianos/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Penicilinas/uso terapêutico , Febre Reumática/prevenção & controle , Prevenção Secundária/estatística & dados numéricos , Adolescente , Adulto , Antibioticoprofilaxia/psicologia , Antibioticoprofilaxia/estatística & dados numéricos , Criança , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Jamaica , Masculino , Adesão à Medicação/psicologia , Febre Reumática/psicologia , Adulto JovemRESUMO
This investigation aims to analyze the profile of long-term evolution of rheumatic fever in children and adolescents and outcomes after the control of recurrences. The cohort involved 702 patients followed from 1.3 to 16.9 years covering the two periods, before and after the implementation of a prevention program. Besides the establishment of the Reference Center in the State of Minas Gerais and the implementation of strategies to promote the compliance to prophylaxis, a project for education of health professionals was carried out in 23 cities. In addition to the clinical and epidemiological profile, the severity of the disease was analyzed. Mixed lesions were found in 27.1%, valvar regurgitation in 72.9%, and complete regression of the valvar lesions was seen in 34.4% of the patients, mostly presenting mild dysfunctions. The recurrence rate per patient-year was 0.058 and out of a total of 85 recurrences, 21.4% occurred in the first and 7.5% in the second period. More severe degrees of carditis and significant valvar sequels presented a higher prevalence in patients with recurrences. The comparative analysis between the two periods showed no changes regarding the age at the primary attack, gender, type, and site of valvar lesions and affected joints; however, important modifications in the indices of severity were observed after the control of recurrences. A significant decrease in the prevalence of severe carditis, obstructive valvar sequels, hospital admissions, surgical approach, and deaths was seen. This investigation showed that although the clinical profile of presentation remains unchanged, the control of repeated attacks can improve the morbimortality rates. In this context, the secondary prophylaxis should be the first priority in the control of the disease in developing countries, taking into account the difficulties found for effective primordial and primary prevention.
RESUMO
Se presentan los datos clínicos de 22 pacientes con criptococosis asociada al VIH que interrumpieron la profilaxis antifúngica secundaria, después de haber recibido la terapéutica antirretroviral de gran actividad (TARGA). Fueron 14 varones y 8 mujeres con edades comprendidas entre los 15 y los 50 años (X: 34 años). Todos presentaron un síndrome infeccioso general grave y 19 tuvieron meningoencefalitis. En el momento del diagnóstico 59% de los enfermos tenía recuentos de células CD4+ < 50/µL,la mediana de lascargas viralesfue de 134. 804 copias ARN/ml yla mediana de los títulosde antigenemiafue de 1/3.000. El tratamiento del episodio agudo se realizó con anfotericina B por vía venosa (0,7 mg/kg/día) o fluconazol(600 a 800 mg/día), hasta la negativización de los cultivos de LCR. La profilaxis secundaria consistió en la administración oral de 200 mg diarios de fluconazoló 2 dosis semanalesde 50 mg de anfotericina B. La profilaxis secundaria antifúngica fue interrumpida cuando los enfermos habían recibido la TARGA por un lapso medio 19 meses, la mediana de los recuentos de células CD4+ fue de 249/µl. Todos estaban asintomáticos y en buen esta-do general. El lapso medio de seguimiento posterior fue de 22 meses y ningún enfermo experimentó recidivas desu micosis.
The clinical and laboratory data of 22 patients with AIDS related cryptococcosis who were able to interrupt antifungal secondary prophylaxis afterHAART administration, are presented. They were 14 males and 8 females, between 15 and 50years old (X: 34 years old). All patients presented fever andsevere deterioration of their general health status, and 19 exhibited a meningeal syndrome. At the start of antifungal treatment, 59% of the cases presented < 50 CD4+ cells/µl, the median viral burden was 134,804 RNA copies/ml and the median titer ofserum cryptococcal antigen was 1/3,000. Amphotericin B by intravenous route, (0.7 mg/kg/day) or fluconazole (600 to 800 mg/day) were given as a treatment of the initial episode, up to CSF cultures negativization. Oral fluconazole (200 mg/day) or intravenous amphotericin B, 50 mg twice a week, were given as a secondary prophylaxis. The secondary prophylaxis was interrupted when the patients had received HAART for an average lapse of 19 months (6 to 36 months) and the medianCD4+ cells counts was 249/µl. The follow up after secondary prophylaxis discontinuation lasted for a median lapse of 22 months. These data seem to show that secondary prophylaxisis not necessary when the patient are clinically asymptomatic and the CD4+ cells counts are above 150/µl.