Lactobacillus johnsonii supplementation attenuates respiratory viral infection via metabolic reprogramming and immune cell modulation.

Regulation of respiratory mucosal immunity by microbial-derived metabolites has been a proposed mechanism that may provide airway protection. Here we examine the effect of oral Lactobacillus johnsonii supplementation on metabolic and immune response dynamics during respiratory syncytial virus (RSV) infection. L. johnsonii supplementation reduced airway T helper type 2 cytokines and dendritic cell (DC) function, increased regulatory T cells, and was associated with a reprogrammed circulating metabolic environment, including docosahexanoic acid (DHA) enrichment. RSV-infected bone marrow-derived DCs (BMDCs) from L. johnsonii-supplemented mice had altered cytokine secretion, reduced expression of co-stimulatory molecules, and modified CD4+ T-cell cytokines. This was replicated upon co-incubation of wild-type BMDCs with either plasma from L. johnsonii-supplemented mice or DHA. Finally, airway transfer of BMDCs from L. johnsonii-supplemented mice or with wild-type derived BMDCs pretreated with plasma from L. johnsonii-supplemented mice reduced airway pathological responses to infection in recipient animals. Thus L. johnsonii supplementation mediates airway mucosal protection via immunomodulatory metabolites and altered immune function.

Risk factors for pneumonia among children in a Brazilian metropolitan area.

OBJECTIVE: To investigate risk factors for pneumonia for infants < 2 years of age. DESIGN: Hospital-based, case-control study with neighborhood control subjects. SETTING: Urban area in southern Brazil. SUBJECTS: Five hundred ten infants with radiologically confirmed pneumonia who were admitted to a pediatric hospital. One age-matched neighborhood control subject was selected for each case. RESULTS: Multiple conditional regression modeling was used to control for confounding, taking into account the hierarchical relationships between risk factors. The incidence of radiologically confirmed pneumonia was associated with low paternal education, the number of persons in the household, young maternal age, attendance at day-care centers, low birth weight and weight-for-age, lack of breast-feeding and of non-milk supplements, and a history of previous pneumonia or wheezing. Day-care center attendance showed the highest risk, with an adjusted odds ratio of 11.75. CONCLUSIONS: In addition to continued efforts toward appropriate case management, actions directed against the above risk factors may help prevent the major cause of deaths of children younger than 5 years.

Determinants of abortion among women admitted to hospitals in Fortaleza, North Eastern Brazil.

BACKGROUND: Maternal mortality from complications of unsafe abortion constitutes a serious problem in several developing countries. There is, however, a paucity of well-designed and implemented studies in this area, especially in Latin America. The aim of this paper is to present the findings on the determinants and medical characteristics of abortions among women admitted to hospitals. METHODS: A descriptive cross-sectional hospital-based study was carried out between October 1992 and September 1993 in Fortaleza, Brazil. A Cox's proportional hazard model was used to estimate prevalence rate ratios after adjustment for confounding. RESULTS: Among 2074 (48%) women who admitted to terminating the pregnancy, 66% reported using misoprostol to induce abortion. Women with an induced abortion as compared with those with an unlikely induced abortion are younger, more often not married, have fewer children alive and experienced one or more previous induced abortions. We have not found any important differences with regard to complication or duration of stay in hospital. CONCLUSIONS: This finding, at odds with most previous studies, could reflect the special situation in Brazil where misoprostol is used for illegally-induced abortion. The use of misoprostol by this population may have contributed to the reduction of severe complications related to induced abortion which were most prevalent with more invasive methods. Recommendations are made as to the need for confirmatory studies as well as on information regarding cultural perceptions and concepts of abortion, and reasons why poor women fail to adopt available family planning methods.

PIP: The characteristics of induced abortion were investigated among women admitted to two public maternity hospitals in Fortaleza, Brazil, in 1992-93. A total of 4359 women admitted to the hospitals during the 12-month study period with a diagnosis of pregnancy loss were interviewed. 48% of abortions were classified as certainly induced, 40% as possibly induced, and 12% as spontaneous. 1369 (66%) of the 2074 women with certainly induced abortion reported use of misoprostol (mean dose, 400 mcg; range, 200-2400 mcg). Although sales of this abortifacient were suspended in 1991 due to concerns about congenital malformations in unsuccessful procedures, the drug remains widely available on the black market. Compared with women with an unlikely induced abortion, women with a certainly induced abortion were significantly younger, more often unmarried, had fewer living children, and were more likely to have experienced one or more previous induced abortions. The risk of infection was increased by 40% in women with certain induced abortion above that of women with unlikely induced abortion. There were no significant differences between groups in terms of the complication rate or duration of hospital stay. The use of misoprostol in this series may have contributed to the relatively low rate of severe abortion-related complications. Wider availability of emergency contraception could reduce the need for unsafe abortion in Brazil.

Women's hidden transcripts about abortion in Brazil.

Two folk medical conditions, "delayed" (atrasada) and "suspended" (suspendida) menstruation, are described as perceived by poor Brazilian women in Northeast Brazil. Culturally prescribed methods to "regulate" these conditions and provoke menstrual bleeding are also described, including ingesting herbal remedies, patent drugs, and modern pharmaceuticals. The ingestion of such self-administered remedies is facilitated by the cognitive ambiguity, euphemisms, folklore, etc., which surround conception and gestation. The authors argue that the ethnomedical conditions of "delayed" and "suspended" menstruation and subsequent menstrual regulation are part of the "hidden reproductive transcript" of poor and powerless Brazilian women. Through popular culture, they voice their collective dissent to the official, public opinion about the illegality and immorality of induced abortion and the chronic lack of family planning services in Northeast Brazil. While many health professionals consider women's explanations of menstrual regulation as a "cover-up" for self-induced abortions, such popular justifications may represent either an unconscious or artful manipulation of hegemonic, anti-abortion ideology expressed in prudent, unobtrusive and veiled ways. The development of safer abortion alternatives should consider women's hidden reproductive transcripts.

Congenital malformation of the scalp and cranium after failed first trimester abortion attempt with misoprostol.

This study reports the occurrence of three cases of an unusual congenital malformation of the skull in neonates seen at a pediatric hospital during a five-month interval in Fortaleza, Brazil. The prenatal history focused on the mothers' exposure to drugs during pregnancy. It was found that all mothers had taken misoprostol orally and/or vaginally in the first trimester of pregnancy to induce abortion. Other drugs taken during pregnancy included iron, vitamins and tetanus toxoid. There was no evidence of a family history of malformations, consanguinity or clinical infective illnesses.

PIP: Three cases of an unusual congenital malformation of the skull occurred in newborns in Fortaleza, Brazil, over a 5-month period. In each case, the only unusual feature of the pregnancy history was the fact that the mothers had taken misoprostol orally and/or vaginally in the first trimester to induce an abortion. In the first case, the mother took 800 mcg of misoprostol orally at the time of expected menses and experienced slight vaginal bleeding and intense abdominal pain. The baby was born at 36 weeks gestation with a localized fronto-temporal defect with an asymmetric, well-circumscribe deficiency of the cranium and overlying scalp and exposure of the cerebrum and dura mater. After surgery to cover the defect, the child developed convulsions which are controlled by phenobarbital. In the second case, the mother took 600 mcg misoprostol at the time of expected menses and experienced spotting and pain. One month later, she repeated the dosage and experienced only spotting. The full-term baby had a localized frontal defect with an asymmetric, well-circumscribed absence of the cranium and overlying scalp, exposing the cerebrum and dura mater. A week after surgery to cover the defect, this child also developed convulsions. In the third case, the mother took 600 mcg misoprostol orally and 200 mcg vaginally at the time of expected menses. 4 weeks later she took 1200 mcg misoprostol orally and 400 mcg vaginally. After an otherwise normal pregnancy and delivery, the child was delivered with a complete deficit in the cranium and scalp in a localized region of the frontal-temporal area. This child died postoperatively. Controlled studies have not been performed to determine the effect of misoprostol during the first trimester of pregnancy, but no teratogenic effects were found in animals. The cases reported here suggest the need for further investigation of a possible association.

[Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil]. / Uso da aspiração manual a vácuo na redução do custo e duração de internamentos por aborto incompleto em fortaleza, CE, Brasil.

INTRODUCTION: In most developed countries vacuum aspiration has been shown to be safer and less costly than sharp curettage (SC) for uterine evacuation. In many of the developing countries, including Brazil, sharp curettage (SC) is the most commonly used technique for treating cases of incomplete abortion admitted to hospital. The procedure often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. Two hypotheses are examined: the first, that the use of manual vacuum aspiration (MVA)--a variation of the vacuum aspiration, would be less costly than SC for the treatment of cases of incomplete abortion admitted to hospital; and the second, that the treatment of incomplete abortion with MVA would substantially reduce the length of hospital stay. METHODOLOGY: Thirty women with diagnosis of first trimester incomplete abortion were randomly allocated to the SC or MVA group. Rapid-assessment data collection techniques were used to identify factors that contributed to cost reduction and hospital stay. RESULTS AND CONCLUSION: The results of the study show that, overall, patients treated for incomplete abortion with MVA spent 77% less time in the hospital and consumed 41% fewer resources than similarly diagnosed patients treated with SC. Recommendations are made as to the need of certain changes in patient management. Particularly necessary is information regarding cultural perception and concepts of abortion treatment.

[Determinants of induced abortion among poor women admitted to hospitals in a locality of northeastern Brazil]. / Determinantes do aborto provocado entre mulheres admitidas em hospitais em localidade da região Nordeste do Brasil.

In Brazil, abortion is legally allowed only when it is necessary to save a woman's life or when pregnancy has occurred following rape. Despite this law, induced abortion is widely carried out. This study presents the findings as to the determinants of 2,084 abortions admitted to two major obstetric hospitals in Fortaleza, Brazil, between October 1992 and September 1993. Most of these women (2,074) have admitted an attempt to terminate pregnancy and 10 women were classified as induced abortion cases based on the findings of signs of intervention such as cervical laceration, perforation or foreign bodies in the vagina or uterus. The study findings indicate that self-administration of medicines plays an important role in terminating pregnancy. Among the 2,074 women who admitted to terminating the pregnancy 66% reported using misoprostol to induce abortion. Misoprostol, a prostaglandin E1 analogue indicated for ulcer treatment, has been widely used as an abortifacient by women in Brazil. Misoprostol has some uterine effects but it is not effective in inducing abortion. Among women who were hospitalized for complications resulting from abortion about 59.7% were 20 to 29 years old and 22.6% were aged less than 20. The majority of the women (91.6%) were Catholic and only 4.3% were illiterate. About 62% of the abortion cases lived alone or did not have a stable partner. Most of the women (59.2%) reported less than 2 live births and 11.8% had experienced a previous abortion; 61.1% of the women were not using a contraceptive method at the time of conception. The main reasons for this were "fear of side effects", "did not expect to have sexual intercourse" and "did not expect to get pregnant". The authors suggest that the situation of a high rate of self-inflicted abortion may be changed by the application of an appropriate contraceptive and reproductive health programme.

[Risk factors of stillbirths in Fortaleza-Brazil: a case-control study]. / Fatores de risco de natimortalidade em Fortaleza: um estudo de caso-controle.

Stillbirths are a common event in areas where reproductive health care is poorly delivered, such as the Northeast region of Brazil. This case-control study aimed to identify risk factors associated to foetal deaths occurred in a major obstetric facility of Fortaleza, 1.7 million inhabitants, Northeastern Brazil. 125 stillborn foetus over 20 weeks of gestation (cases) were compared to 250 healthy newborns (controls), in relation to socioeconomic, reproductive, behavioral and morbidity characteristics of their mothers. Crude and adjusted Odds Ratios were then calculated. After adjustment for confounders, the following characteristics of the mother remained as risk factors for stillbirths, with OR statistically significant at the 95% level: attending <5 antenatal consultations during pregnancy (OR=3.30; CI=1.92 - 5.07 ), illiterate mother (OR=3.30; CI=1.84 - 5.92 ), mother's age above 19 (OR=2.73; CI=1.42 - 5.24 ), monthly family income of 1 minimum wage or less (OR=2.12; CI=1.03 - 4.35 ) and severe illnesses or complication during pregnancy (OR=1.75; CI=1.01 - 3.03 ). Inadequate attendance to antenatal care consultations was the risk factor most strongly associated to stillbirths. Similarly, it was the condition most amenable to change in a short term, among those identified as risk factors.

Striking differences in the nasopharyngeal flora of healthy Angolan, Brazilian and Dutch children less than 5 years old.

Community-acquired pneumonia from enteric gram-negative bacilli is more common in developing than in industrialized countries. We investigated the nasopharyngeal flora in healthy children from Angola, Brazil and The Netherlands to see whether enteric gram-negative bacilli are more often part of the commensal flora in developing countries. Nasopharyngeal specimens were collected from children aged between 4 months and 5 years in day-care centres and immunization clinics. Children who had received antibiotics or were malnourished were excluded. Brazilian and Angolan children had a higher number of household members than Dutch children (5.5 and 7 vs 3.9 mean number of household members, respectively) (p < 0.0001). Enteric and non-fermentative gram-negative bacilli were much more prevalent in Brazilian (50%) and Angolan (57%) children than in Dutch (4%) children (p < 0.0001). By univariate analysis, carriage of enteric gram-negative bacilli was associated with the number of household members (r = 0.26; p < 0.001). The high carriage rate of enteric gram-negative bacilli in children from Angola and Brazil may explain why enteric gram-negative bacilli are a common cause of pneumonia in developing countries.

Out-patient drug treatment of pneumonia among children under two years of age in Fortaleza, Brazil.

Results are reported from a study on drug use in treatment of children with pneumonia in a pediatric hospital in the city of Fortaleza, Northeastern Brazil. There were 171 out-patients; prescription details were obtained for 149. The most commonly prescribed antimicrobial drug was procaine penicillin, accounting for 33% of antimicrobial prescriptions, followed by benzathine penicillin (31%), ampicillin or amoxicillin (12%), and cotrimoxazole (8%). Benzathine penicillin was frequently given with other drugs, but was the sole antimicrobial agent for 31 children. Compliance with antimicrobial treatment was 52% overall and was higher for the injectables. Prescription patterns varied from child to child, and children were often prescribed more than one antimicrobial in the same or repeat prescriptions; combining this information with compliance, 81 (54%) of the children were estimated to have received 5 or more days of appropriate antimicrobial treatment for pneumonia. This percentage is not high, and five days were often reached after using more than one antimicrobial and after repeat visits. The authors concluded that the need remains for simple antimicrobial regimes, attractive to comply with, that can be expected to be consistently used. Other drugs were chiefly analgesics and bronchodilators.

Risk factors for childhood pneumonia among the urban poor in Fortaleza, Brazil: a case--control study.

Reported are the results of a case-control study carried out between July 1989 and June 1990 in Fortaleza city, Ceará State, Brazil, to determine the factors that place young children living in urban slum conditions at increased risk of contracting pneumonia. Cases were 650 under-2-year-olds with a radiological diagnosis of pneumonia who were recruited at the main paediatric hospital in the city over a full calendar year. Age-matched controls were recruited from the neighbourhood where the cases lived. Cases and controls were compared with respect to a variety of sociodemographic, environmental, reproductive, nutritional, and morbidity factors, and a risk factor questionnaire was administered to the mother of each child or to the child's normal guardian. Cases and controls were also weighed and measured. Malnutrition was the most important risk factor for childhood pneumonia in the study population, with weight-for-age, height-for-age, and weight-for-height also being important risk factors. In view of the high prevalence of stunting in the study population, there is an urgent need to reduce the level of malnutrition as a priority. Attendance at a day care centre was also associated with a high odds ratio. In view of the growing numbers of children attending day care centres in both developing and developed countries, it is essential that ways be identified to improve the design and management of such centres in order to minimize the risk of pneumonia. Increased risks of childhood pneumonia were also associated with low birth weight, non-breast-feeding, crowding, high parity, and incomplete vaccination status, but not with socioeconomic status or environmental variables. Finally, children who had suffered from previous episodes of wheezing or been hospitalized for pneumonia had a greater than threefold increased risk of contracting the disease.

Preventing acute respiratory infections and diarrhoea in child care centres.

This study was designed to explore the physical characteristics and child care practices of child care centres as potential risk factors for respiratory infections and diarrhoea in children 3-35 mo of age. A dynamic cohort averaging 667 children from 40 child care centres in Campinas (Brazil) was followed up for 8 mo. Direct structured observations were made to collect information on the centres' physical structure, child activities and child care practices. Despite their good infrastructures, hand washing in the centres was infrequent, and nearly 30% of diaper changes were unhygienic. Risk factors for diarrhoea included the presence of flies during meals, infrequent child hand washing before meals, and infrequent child hand washing after defecation, with relative risks of 1.33, 1.73 and 1.63, respectively. There was 33% less diarrhoea in classes where soap was frequently used during diapering. Contrary to our hypotheses, ventilation, group size and child density were not associated with respiratory infections, as was the case for most other factors studied. Only mixing of groups and a larger classroom area were found to be negatively associated with lower and upper respiratory infections, respectively. The results indicate that improving hygiene practices is the only intervention in child care centre characteristics with good potential to reduce diarrhoea among attendees. For respiratory infections, no modifiable characteristic with intervention potential was identified.

Attendance at day care centers increases the risk of childhood pneumonia among the urban poor in Fortaleza, Brazil.

We carried out a case-control study to investigate risk factors for childhood pneumonia in two groups of 650 children aged under two years in the city of Fortaleza, Ceará, Brazil. The cases were children recruited at the main pediatric hospital with a radiological diagnosis of pneumonia, and controls were children of the same age group recruited from the neighbourhood of the cases. In this paper we focus on variables related to childcare practices. Working mothers, proportion of time the mother had worked since the child was born, and use of day care centers emerged as important risk factors with estimated relative risks of 1.58, 1.76 and 5.22, respectively. Also important were the number of children living in the house and presence of grandparents. However, the presence of siblings under two years and the birth order were not associated with pneumonia. All analysis included adjustment for confounding by income, parents' education, and other risk factors as appropriate. This is the first study from a developing country to identify attendance at day care centers as a risk factor for increased childhood morbidity, in this case pneumonia. This finding is of significant public health importance for countries such as Brazil with growing urban populations and an increasing need by mothers to find work outside the home.