RESUMO
OBJECTIVE: To assess the proportion of patients meeting the 2010 SPILF-AFSSAPS guiding criteria for Streptococcuspneumoniae in patients consulting at the emergency departments of four French university hospitals for acute community-acquired pneumonia (CAP) suspicion. PATIENTS AND METHODS: The PACSCAN study prospectively included 319 patients. Medical history, clinical, biological, and radiological presentations were collected. An adjudication committee retrospectively classified the diagnostic certainty based on the initial chest CT scan data and the follow-up data up to Day 28. S. pneumoniae was looked for according to the clinician's choice of blood culture, pneumococcal urinary antigen test, nasopharyngeal PCR, and/or sputum microbiological examination. RESULTS: All patients (100%) met at least one criterion for S. pneumoniae CAP and six (2%) met all criteria. The distribution of criteria ranged from 32% (chest pain criterion) to 86% (age≥40years criterion). These figures were respectively 100%, 3%, 38%, and 82% when the study population was restricted to the 139 patients with definite or probable CAP, according to the adjudication committee. Taking into account the microbiological results, the criteria taken one by one or combined did not make it possible to differentiate the 19 S. pneumoniae CAP from the other CAPs. CONCLUSION: The 2010 SPILF-AFSSAPS guiding criteria for S. pneumoniae CAP are found in very variable proportions and do not, in their current form, make it possible to accurately guide towards a pneumococcal etiology in patients included in the PACSCAN study.
Assuntos
Pneumonia Pneumocócica/diagnóstico , Streptococcus pneumoniae/isolamento & purificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Infecções Comunitárias Adquiridas/diagnóstico , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nasofaringe/microbiologia , Pneumonia Pneumocócica/sangue , Pneumonia Pneumocócica/urina , Reação em Cadeia da Polimerase/métodos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Radiografia/métodos , Escarro/microbiologia , Tomografia Computadorizada por Raios X/métodosRESUMO
OBJECTIVE: The aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED). METHODS: We performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion. RESULTS: Among the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66-80), specificity 89% (95% CI 83-94), positive predictive value (PPV) 88% (95% CI 81-93), negative predictive value (NPV) 76% (95% CI 69-82) and area under the curve (AUC) 0.81 (95% CI 0.77-0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81-92), specificity 72% (95% CI 60-81), PPV 86% (95% CI 79-91), NPV 75% (95% CI 63-84) and AUC 0.80 (95% CI 0.73-0.87). CONCLUSION: Our CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.
Assuntos
Infecções Comunitárias Adquiridas/epidemiologia , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência , Pneumonia/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Biomarcadores , Tomada de Decisão Clínica , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/microbiologia , Gerenciamento Clínico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia/diagnóstico , Pneumonia/microbiologia , Vigilância em Saúde Pública , Radiografia Torácica , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodosRESUMO
The social, economic and political consequences of emerging infectious disease (EID) may escape the sphere in which they first arise. In recent years, many EIDs have revealed the close links between human, animal and plant health, highlighting the need for multi-scale, multisectorial EID management. Human beings play a dual role in EID because they can promote their development through numerous human-environment interfaces and expanding international trade. On the other hand, their ability to analyze, interpret and act on the determinants of EID allows them to access the expertise necessary to control these EIDs. This expertise must be constantly adapted to remain relevant as the EID evolves, particularly in its virulence or transmission channels. Flexibility should become an inherent part of the expertise-based decision-making process even if it means going backwards. A certain degree of transparency and feedback to citizens is necessary for the acceptability of political decisions basing on expertise. A key step in the management of EID is the appropriate management of the early signal of infectious emergence. This step combines multidisciplinary skills allowing access to the best pathway for containing EID by implementing early countermeasures adapted to the situation. New digital technologies could significantly improve this early detection phase. Finally, experts have a fundamental role to play because they are located at the interface between operational actors and decision-makers, which allows multidirectional feedback, ideally in real time, between professional actors and decision makers. To combat current and future EIDs, expertise should be based on a multi-sectorial approach, promotion of collegiality and continuously adaptation to the evolving nature of EIDs.
Assuntos
Doenças Transmissíveis Emergentes/prevenção & controle , Doenças Transmissíveis Emergentes/terapia , Controle de Infecções , Pesquisa Interdisciplinar , Medicina Preventiva , Animais , Doenças Transmissíveis Emergentes/epidemiologia , Prova Pericial , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Controle de Infecções/tendências , Comunicação Interdisciplinar , Pesquisa Interdisciplinar/métodos , Pesquisa Interdisciplinar/organização & administração , Pesquisa Interdisciplinar/tendências , Medicina Preventiva/métodos , Medicina Preventiva/organização & administração , Medicina Preventiva/tendências , Pesquisa/organização & administração , Pesquisa/normas , Pesquisa/tendênciasRESUMO
AIM: Ageing HIV-infected patients controlled by antiretroviral therapy (ART) frequently present age-related comorbidities, such as cardiovascular (CV) events, diabetes, dyslipidaemia, hypertension and chronic kidney disease (CKD). The prevalence of these comorbidities was evaluated in a cohort of long-term-monitored ART-controlled HIV-infected patients, then followed by a search into whether oxidative stress, like inflammation, might be associated with metabolic parameters and/or comorbidities. METHODS: Included were 352 long-term ART patients who started with protease inhibitors (PIs) in 1997-1999. They were evaluated at their final visit, 11 years later, for previous CV events, prevalence of diabetes, LDL-related and atherogenic (high TG/HDL) dyslipidaemias, hypertension and CKD. Also measured were circulating biomarkers to explore oxidative stress (Lp-PLA2, oxLDL, oxLDL/LDL ratio, paraoxonase and arylesterase activities), inflammation/immune activation (hsCRP, hsIL-6, D dimer, soluble CD14, ß2 microglobulin, cystatin C), adipokines and insulin resistance. Levels were compared in patients with and without each comorbidity or condition using non-parametric correlation tests and multivariate adjusted analyses. RESULTS: At the final visit, 81.5% of patients were male and were aged (median, IQR) 49 years (45-56); BMI was 23.0 kg/m2 (21.1-25.4), CD4+ lymphocytes were 620 cells/mm3 (453-790) and 91.5% had undetectable HIV-1 viral loads. The prevalence of diabetes was 11%, and LDL-related dyslipidaemia 28%, atherogenic dyslipidaemia 9%, hypertension 28%, CKD 9% and previous CV events 9%. Diabetes and atherogenic dyslipidaemia were associated with increased oxidative stress and independently with inflammation. LDL-related dyslipidaemia and impaired fasting glucose were associated with increased oxidative stress. No association of these biomarkers was detected with hypertension, CKD and previous CV events. CONCLUSION: In long-term-treated HIV-infected patients with frequent comorbid conditions, oxidative stress could be contributing to diabetes and LDL-related and atherogenic dyslipidaemias independently of inflammation.
Assuntos
Antirretrovirais/uso terapêutico , Diabetes Mellitus/epidemiologia , Dislipidemias/epidemiologia , Infecções por HIV , Inflamação/epidemiologia , Estresse Oxidativo/fisiologia , Aterosclerose/sangue , Aterosclerose/epidemiologia , Biomarcadores/sangue , LDL-Colesterol/sangue , Estudos de Coortes , Comorbidade , Complicações do Diabetes/sangue , Complicações do Diabetes/epidemiologia , Diabetes Mellitus/sangue , Dislipidemias/sangue , Dislipidemias/complicações , Feminino , HIV , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Sobreviventes de Longo Prazo ao HIV/estatística & dados numéricos , Humanos , Hipertensão/sangue , Hipertensão/epidemiologia , Inflamação/sangue , Inflamação/complicações , Lipoproteínas LDL/sangue , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de TempoRESUMO
CONTEXT: In 2012, the French Infectious Diseases Society (French acronym SPILF) initiated the "Coordination of epidemic and biological risk" (SPILF-COREB - Emergences [SCE]) group to support the readiness and response of healthcare workers (HCWs) to new alerts. OBJECTIVE: To present the SCE group, its functioning, and the main support it provided for frontline HCWs. METHODS: A multidisciplinary group of heads of infectious disease departments from reference hospitals was created to build a network of clinical expertise for care, training, and research in the field of epidemic and biological risk (EBR). The network developed a set of standardized operational procedures (SOPs) to guide interventions to manage EBR-suspect patients. RESULTS: A working group created the SOP aimed at frontline HCWs taking care of patients. Priority was given to the development of a generic procedure, which was then adapted according to the current alert. Five key steps were identified and hierarchized: detecting, protecting, caring for, alerting, and referring the EBR patient. The interaction between clinicians and those responsible for the protection of the community was crucial. The SOPs validated by the SPILF and its affiliates were disseminated to a wide range of key stakeholders through various media including workshops and the SPILF's website. CONCLUSION: SPILF can easily adapt and timely mobilize the EBR expertise in case of an alert. The present work suggests that sharing and discussing this experience, initiated at the European level, can generate a new collective expertise and needs to be further developed and strengthened.
Assuntos
Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Epidemias/prevenção & controle , Doença pelo Vírus Ebola/epidemiologia , Doença pelo Vírus Ebola/prevenção & controle , Coronavírus da Síndrome Respiratória do Oriente Médio , França/epidemiologia , Humanos , Risco , Fatores de Risco , Sociedades MédicasRESUMO
We present here the proceedings of the 5th seminar on emerging infectious diseases, held in Paris on March 22nd, 2016, with seven priority proposals that can be outlined as follows: encourage research on the prediction, screening and early detection of new risks of infection; develop research and surveillance concerning transmission of pathogens between animals and humans, with their reinforcement in particular in intertropical areas ("hot-spots") via public support; pursue aid development and support in these areas of prevention and training for local health personnel, and foster risk awareness in the population; ensure adapted patient care in order to promote adherence to treatment and to epidemic propagation reduction measures; develop greater awareness and better education among politicians and healthcare providers, in order to ensure more adapted response to new types of crises; modify the logic of governance, drawing from all available modes of communication and incorporating new information-sharing tools; develop economic research on the fight against emerging infectious diseases, taking into account specific driving factors in order to create a balance between preventive and curative approaches.
Assuntos
Doenças Transmissíveis Emergentes , Congressos como Assunto , Controle de Infecções , Disseminação de Informação/métodos , Mudança Climática , Doenças Transmissíveis Emergentes/epidemiologia , Doenças Transmissíveis Emergentes/terapia , Ecologia , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Controle de Infecções/tendências , Paris , Saúde Pública/métodos , Saúde Pública/tendências , Integração de SistemasAssuntos
Doenças Transmissíveis Emergentes/epidemiologia , Infectologia/tendências , Criação de Animais Domésticos/normas , Animais , Gestão de Antimicrobianos , Clima , Doenças Transmissíveis Emergentes/prevenção & controle , Doenças Transmissíveis Emergentes/transmissão , Planejamento em Desastres , Surtos de Doenças/prevenção & controle , Resistência Microbiana a Medicamentos , Contaminação de Alimentos , Política de Saúde , Humanos , Controle de Infecções , Cooperação Internacional , Saúde Pública/legislação & jurisprudência , Condições Sociais , Doença Relacionada a Viagens , Medicina Veterinária/tendências , Poluição da Água , Abastecimento de ÁguaAssuntos
Cuidadores/psicologia , Revelação/ética , Surtos de Doenças , Pessoal de Saúde/psicologia , Doença pelo Vírus Ebola/epidemiologia , Controle de Infecções/organização & administração , Infectologia/ética , Educação de Pacientes como Assunto/ética , Pacientes/psicologia , Confidencialidade , Prova Pericial , França , Doença pelo Vírus Ebola/prevenção & controle , Doença pelo Vírus Ebola/psicologia , Humanos , Infectologia/organização & administração , Disseminação de Informação , Cooperação Internacional , Notificação de Abuso , Meios de Comunicação de Massa , Aceitação pelo Paciente de Cuidados de Saúde , Relações Profissional-Família , Relações Profissional-Paciente , ConfiançaRESUMO
UNLABELLED: Infectious agents associated with community-acquired pneumonia (CAP) are under-studied. This study attempted to identify viruses from the upper respiratory tract in adults visiting emergency departments for clinically suspected CAP. Adults with suspected CAP enrolled in the ESCAPED study (impact of computed tomography on CAP diagnosis) had prospective nasopharyngeal (NP) samples studied by multiplex PCR (targeting 15 viruses and four intracellular bacteria). An adjudication committee composed of infectious disease specialists, pneumologists and radiologists blinded to PCR results reviewed patient records, including computed tomography and day 28 follow up, to categorize final diagnostic probability of CAP as definite, probable, possible, or excluded. Among the 254 patients enrolled, 78 (31%) had positive PCR, which detected viruses in 72/254 (28%) and intracellular bacteria in 8 (3%) patients. PCR was positive in 44/125 (35%) patients with definite CAP and 21/83 (25%) patients with excluded CAP. The most frequent organisms were influenza A/B virus in 27 (11%), rhinovirus in 20 (8%), coronavirus in seven (3%), respiratory syncytial virus in seven (3%) and Mycoplasma pneumoniae in eight (3%) of 254 patients. Proportion of rhinovirus was higher in patients with excluded CAP compared with other diagnostic categories (p = 0.01). No such difference was observed for influenza virus. Viruses seem common in adults attending emergency departments with suspected CAP. A concomitant clinical, radiological and biological analysis of the patient's chart can contribute to either confirm their role, or suggest upper respiratory tract infection or shedding. Their imputability and impact in early management of CAP deserve further studies. CLINICAL TRIALS REGISTRATION: NCT01574066.
Assuntos
Infecções Comunitárias Adquiridas/virologia , Reação em Cadeia da Polimerase Multiplex , Pneumonia Viral/virologia , Vírus/classificação , Vírus/isolamento & purificação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/patologia , Serviço Hospitalar de Emergência , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Nasofaringe/virologia , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/patologia , Estudos Prospectivos , Vírus/genética , Adulto JovemRESUMO
BACKGROUND: The emergence of novel A(H1N1)pdm2009 virus threatened to lead to frequent severe manifestations. OBJECTIVES: To describe the clinical, virological, and biological characteristics of the disease and identify the factors associated with severe presentations. STUDY DESIGN: This prospective multicenter study recruited consecutive hospitalized patients with confirmed A(H1N1)pdm2009 disease. Clinical, virological and biological assessments were carried out at inclusion and 30 days post-inclusion. Disease manifestations were assessed by an adjudication committee using pre-identified definitions of complications and severity scores. RESULTS: The study analyzed from November 30th, 2009 to February 8th, 2010, 40 hospitalized patients, 21 children and 19 adults. Eighteen (45%) were considered to have severe presentations. Except age, main characteristics in children and adults did not differ. The majority (18/21) of children and all adults had a respiratory presentation; extra-respiratory manifestations tended to be more frequent in children (12 vs. 6, P=0.10). Two children against 5 adults presented acute respiratory distress syndrome (ARDS, P=0.23), but more children suffered respiratory failure (7 vs. 1, P=0.046) without ARDS. At day 30, one death had occurred in each group. The main factor associated with non-severe presentation was an early (<48 h) implementation of oseltamivir treatment (P=0.038). CONCLUSIONS: Although the study failed to achieve its main objective, due mainly to the difficulty of carrying a study of this nature in the midst of a pandemic, it allowed the description of a panel of unusual and complicated forms and confirmed the added value of early oseltamivir treatment in limiting severity in hospitalized children and adults.
Assuntos
Vírus da Influenza A Subtipo H1N1/isolamento & purificação , Influenza Humana/epidemiologia , Influenza Humana/patologia , Índice de Gravidade de Doença , Adolescente , Adulto , Idoso , Antivirais/uso terapêutico , Criança , Pré-Escolar , Feminino , França , Hospitalização , Humanos , Lactente , Recém-Nascido , Influenza Humana/complicações , Influenza Humana/virologia , Masculino , Pessoa de Meia-Idade , Oseltamivir/uso terapêutico , Estudos Prospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: Cerebral complications are well-identified causes of morbidity and mortality in patients with infective endocarditis (IE). Few studies have analysed the impact of brain magnetic resonance imaging (MRI) in IE patients with neurological manifestations. OBJECTIVES: The aims of this study were to assess the MRI contribution to the management of patients with IE neurological manifestations and to compare cerebral CT and MRI findings. MATERIAL AND METHODS: Patients with definite or probable IE and neurological manifestations were prospectively enrolled from 2005 to 2008, in a university hospital (Bichat Claude Bernard Hospital, Paris). Clinical and radiological characteristics and echocardiographic findings were systematically recorded. Brain MRI with angiography was performed and compared to available CT scans. The contribution of MRI results to cerebral involvement staging and to therapeutic plans was evaluated. RESULTS: Thirty patients, 37-89 years old, were included. Nineteen suffered from pre-existing heart disease. Blood cultures were positive in 29 cases and the main micro-organisms were streptococci (n = 14) and staphylococci (n = 13). The IE was mainly located on mitral (n = 15) and aortic valves (n = 13). Neurological events were strokes (n = 12), meningitis (n = 5), seizures (n = 1), impaired consciousness (n = 11) and severe headache (n = 1). MRI findings included ischaemic lesions (n = 25), haemorrhagic lesions (n = 2), subarachnoid haemorrhage (n = 5), brain abscess (n = 6), mycotic aneurysm (n = 7), vascular occlusion (n = 3) and cerebral microbleeds (n = 17). In 19/30 cases, neurological manifestations were observed before the diagnosis of IE. MRI was more sensitive than CT scan in detecting both clinically symptomatic cerebral lesions (100 and 81%, respectively) and additional asymptomatic lesions (50 and 23%, respectively). Therapeutic plans were modified according to MRI results in 27% of patients: antibiotherapy regimen modifications in 7% (switch for molecules with high cerebral diffusion) and surgical plan modifications in 20% (indication of valvular replacement due to the embolic nature of the vegetations revealed by MRI or postponement of surgery due to haemorrhagic lesions). None of the 16/30 (51%) operated-on patients experienced postoperative neurological worsening. In-hospital death occurred in 4 patients. CONCLUSION: In patients with IE neurological manifestations, MRI revealed a broader involvement of the brain (type and number of lesions) than indicated by clinical signs and/or CT scan. With a better disease staging of neurological manifestations, MRI brain imaging may help in patient management and the decision-making process especially for cardiac surgery indication and timing of valve replacement.
Assuntos
Encefalopatias/diagnóstico , Encéfalo/irrigação sanguínea , Encéfalo/patologia , Angiografia Cerebral/métodos , Artérias Cerebrais/patologia , Imagem de Difusão por Ressonância Magnética , Endocardite Bacteriana/complicações , Angiografia por Ressonância Magnética , Adulto , Idoso , Idoso de 80 Anos ou mais , Encéfalo/diagnóstico por imagem , Encefalopatias/etiologia , Encefalopatias/mortalidade , Encefalopatias/patologia , Encefalopatias/terapia , Artérias Cerebrais/diagnóstico por imagem , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/etiologia , Ecocardiografia , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/mortalidade , Endocardite Bacteriana/terapia , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Paris , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Tomografia Computadorizada por Raios XRESUMO
Oseltamivir or zanamivir are effective in outpatients with seasonal influenza; however, factors associated with response have been incompletely described. During the 2008/2009 epidemic, in a randomized trial for influenza A-infected outpatients, clinical (time to alleviation of flu-related symptoms) and virological (rate of patients with day 2 nasal viral load <200 cgeq/µL) responses to oseltamivir or zanamivir were assessed and associated factors were determined using multivariate analysis. For oseltamivir (141 patients) and zanamivir (149 patients) median times to alleviation of symptoms were 3 and 4 days, respectively; 59% and 34% had virological response. For oseltamivir, a lower clinical response was associated with female gender (HR, 0.53; 95% CI, 0.36-0.79), baseline symptoms score >14 (HR, 0.47; 0.32-0.70), viral load ≥5 log cgeq/µL (HR, 0.63; 0.43-0.93), and initiation of antibiotics (HR, 0.30; 0.12-0.76); a lower virological response was associated with female gender (OR, 0.45; 0.21-0.96), baseline viral load ≥5 log cgeq/µL (OR, 0.40; 0.20-0.84) and days 0-2 incomplete compliance (OR, 0.31; 0.10-0.98). For zanamivir, virological response was associated with age ≥50 years (OR, 0.29; 0.10-0.85) and initiation of antibiotics at baseline (OR, 4.24; 1.07-17.50). Factors associated with lower response to neuraminidase inhibitors in outpatients appeared to be easily identifiable during routine clinical examination and, when appropriate, by nasal sampling at baseline. The unknown association between gender and response to oseltamivir was not explained by compliance.
Assuntos
Antivirais/uso terapêutico , Influenza Humana/tratamento farmacológico , Oseltamivir/uso terapêutico , Zanamivir/uso terapêutico , Adolescente , Adulto , Fatores Etários , Idoso , Antibacterianos/uso terapêutico , Feminino , Humanos , Influenza Humana/patologia , Influenza Humana/virologia , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Resultado do Tratamento , Carga Viral , Adulto JovemAssuntos
Infectologia/tendências , Animais , Doenças Transmissíveis Emergentes/tratamento farmacológico , Doenças Transmissíveis Emergentes/epidemiologia , Doenças Transmissíveis Emergentes/prevenção & controle , Doenças Transmissíveis Emergentes/veterinária , França , Educação em Saúde , Planejamento em Saúde , Humanos , Disseminação de Informação , Comunicação Interdisciplinar , Medicina Militar/tendências , Pandemias , Vigilância da População , Saúde Pública , Pesquisa , RiscoRESUMO
BACKGROUND: Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) frequently follows the initiation of antiretroviral therapy (ART) in patients with tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection. Treatment recommendations are nearly exclusively based on expert opinion. OBJECTIVE: To assess the clinical outcomes of patients treated using various strategies for TB-IRIS. METHODS: In a retrospective analysis of patients treated in Paris hospitals from 1996 to 2008, we describe TB-IRIS outcome, frequency of relapses and CD4 cell count changes after 12 months of ART for the following strategies: no treatment, interrupted ART and use of steroids. RESULT: Among 34 patients, TB-IRIS outcome was favourable in 10/10 with no treatment, 11/13 with ART interruption, 3/3 with ART interruption and simultaneous use of steroids and 8/8 with steroids alone. Relapses were observed in both the ART interruption (6/13, 46%) and steroids (4/8, 50%) groups, but were less frequent in the no-treatment group (1/10, 10%). Steroids were prescribed in 61% of the patients and had no significant side effects; steroid use was associated with a trend towards a lower median CD4 cell count at 12 months of ART compared to the others (230 vs. 322 cells/mm(3)), despite no baseline differences. CONCLUSION: TB-IRIS outcome was favourable regardless of the therapeutic strategies employed. Although steroids were widely used and well-tolerated, an initial wait-and-see attitude in the case of non-severe IRIS remains an interesting strategy to be evaluated.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Antituberculosos/uso terapêutico , HIV , Síndrome Inflamatória da Reconstituição Imune/tratamento farmacológico , Tuberculose/complicações , Adulto , Contagem de Linfócito CD4 , Coinfecção , Feminino , Seguimentos , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Síndrome Inflamatória da Reconstituição Imune/etiologia , Síndrome Inflamatória da Reconstituição Imune/imunologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Tuberculose/tratamento farmacológico , Tuberculose/imunologiaRESUMO
The aim of this study was to determine factors associated with complete satisfaction with the care provided (satisfaction with physicians and satisfaction with services and organization) among HIV-infected patients followed up in the French ANRS CO8 APROCO-COPILOTE cohort. Analyses focused on cross-sectional data collected during the ninth year of cohort follow-up. Satisfaction with care, sociodemographic characteristics, and behavioral data were collected using self-administered questionnaires, while clinical data were derived from medical records. Complete satisfaction with care was defined as being 100% satisfied. Two logistic regression models were used to identify predictors of (1) complete satisfaction with physicians (n=404) and (2) complete satisfaction with services and organization (n=396). Sixteen percent of patients were completely satisfied with physicians, while 15.9% were completely satisfied with services and organization. Being older and reporting fewer discomforting antiretroviral therapy (ART) side effects were factors independently associated with complete satisfaction with both physicians and services and organization. Strong support from friends and absence of hepatitis C (HCV) co-infection were independently associated with complete satisfaction with physicians, while strong support from one's family and comfortable housing conditions were independently associated with complete satisfaction with services and organization. Even after nine years of follow-up, social vulnerabilities still strongly influence HIV-infected patients' interactions with the health care system. Day-to-day experience with the disease, including perceived treatment side effects, appears to play a key role in the quality of these interactions. More attention should be given to patient satisfaction, especially for socially vulnerable patients, in order to avoid potentially detrimental consequences such as poor adherence to ART.
Assuntos
Terapia Antirretroviral de Alta Atividade , Atenção à Saúde/normas , Infecções por HIV , Preferência do Paciente , Satisfação do Paciente/estatística & dados numéricos , Adulto , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Terapia Antirretroviral de Alta Atividade/métodos , Terapia Antirretroviral de Alta Atividade/psicologia , Estudos de Coortes , Coinfecção , Gerenciamento Clínico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/psicologia , Feminino , Infecções por HIV/complicações , Infecções por HIV/psicologia , Infecções por HIV/terapia , Hepatite C/complicações , Humanos , Masculino , Registros Médicos Orientados a Problemas/estatística & dados numéricos , Adesão à Medicação/psicologia , Pessoa de Meia-Idade , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Relações Profissional-Paciente , Melhoria de Qualidade , Qualidade de Vida , Autorrelato , Apoio SocialRESUMO
Systemic lupus erythematosus (SLE) remains of unknown origin. Herpes viridae infections seem to play a role in the pathogenesis of this disease. We report a 31-year-old man who presented an acute cytomegalovirus (CMV) infection with persistent fever and myopericarditis as the presenting manifestation of SLE. This case report emphasizes a difficult differential diagnosis between SLE and an acute CMV infection and suggests a possible role of this virus in the pathogenesis of SLE.
Assuntos
Infecções por Citomegalovirus/complicações , Citomegalovirus , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/virologia , Doença Aguda , Adulto , Antimaláricos/uso terapêutico , Antirreumáticos/uso terapêutico , Citomegalovirus/isolamento & purificação , Citomegalovirus/patogenicidade , Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/tratamento farmacológico , Diagnóstico Diferencial , Quimioterapia Combinada , Febre/virologia , Glucocorticoides/uso terapêutico , Humanos , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Masculino , Miocardite/virologia , Pericardite/virologia , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of the study was to determine whether the chemokine (C-C motif) receptor 5 (CCR5) Delta32 deletion is associated with long-term response to combination antiretroviral treatment (cART) in HIV-1-infected patients. METHODS: The genetic substudy of the Agence Nationale de Recherche sur le SIDA (ANRS) CO8 APROCO-COPILOTE cohort included 609 patients who started protease inhibitor-containing cART in 1997-1999. Patients were considered to have a sustained virological response if all plasma HIV RNA measurements in the period considered were <500 HIV-1 RNA copies/ml, allowing for a single blip. Virological response was compared between patients heterozygous for CCR5 Delta32 (Delta32/wt) and wild-type patients (wt/wt) from month 4 to year 3 and from month 4 to year 5. Logistic regression analysis was used to adjust for baseline demographical data, HIV RNA, CD4 cell count, antiretroviral exposure status, time spent on antiretroviral therapy at years 3 and 5 and adherence to treatment (month 4 to year 3 or 5). RESULTS: A sustained virological response was more frequent in Delta32/wt than in wt/wt patients from month 4 to year 3, with 66%vs. 52% of patients, respectively, showing a sustained response (P=0.02); after adjustment for potential confounders, the association of Delta32 with a sustained response was nearly significant (P=0.07). A sustained virological response was also more frequent in Delta32/wt patients up to year 5, with 48% showing a sustained response vs. 35% of wt/wt patients (P=0.01); after adjustment, Delta32 remained significantly associated with a sustained virological response up to year 5 (P=0.04). There was no association with CD4 response. CONCLUSION: The Delta32 deletion in Delta32/wt patients is associated with a beneficial virological response to cART in the long term. Whether this association is a direct effect of the Delta32 deletion remains unclear and requires confirmation in further observational studies.
Assuntos
Infecções por HIV/genética , Inibidores da Protease de HIV/uso terapêutico , HIV-1 , Receptores CCR5/genética , Adulto , Fatores Etários , Alelos , Terapia Antirretroviral de Alta Atividade/métodos , Contagem de Linfócito CD4 , Feminino , Deleção de Genes , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , HIV-1/efeitos dos fármacos , HIV-1/genética , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Reação em Cadeia da Polimerase , Estudos Prospectivos , RNA Viral/sangue , Receptores CCR5/imunologia , Resultado do TratamentoRESUMO
The case of a woman with native mitral valve endocarditis due to Haemophilus parainfluenzae (HPI) associated with a pelvic abscess and endometriosis is reported. Although HPI is an infrequent pathogen involved in endocarditis, association to a gynaecological infection has never been reported. Endometriosis could increase this risk.