Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT).

BACKGROUND: Several therapies have been used or proposed for the treatment of COVID-19, although their effectiveness and safety have not been properly evaluated. The purpose of this document is to provide recommendations to support decisions about the drug treatment of outpatients with COVID-19 in Brazil. METHODS: A panel consisting of experts from different clinical fields, representatives of the Brazilian Ministry of Health, and methodologists (37 members in total) was responsible for preparing these guidelines. A rapid guideline development method was used, based on the adoption and/or adaptation of recommendations from existing international guidelines combined with additional structured searches for primary studies and new recommendations whenever necessary (GRADE-ADOLOPMENT). The rating of quality of evidence and the drafting of recommendations followed the GRADE method. RESULTS: Ten technologies were evaluated, and 10 recommendations were prepared. Recommendations were made against the use of anticoagulants, azithromycin, budesonide, colchicine, corticosteroids, hydroxychloroquine/chloroquine alone or combined with azithromycin, ivermectin, nitazoxanide, and convalescent plasma. It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients, as their benefit is uncertain and their cost is high, with limitations of availability and implementation. CONCLUSION: To date, few therapies have demonstrated effectiveness in the treatment of outpatients with COVID-19. Recommendations are restricted to what should not be used, in order to provide the best treatment according to the principles of evidence-based medicine and to promote resource savings by aboiding ineffective treatments.

Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT)

ABSTRACT Background Several therapies have been used or proposed for the treatment of COVID-19, although their effectiveness and safety have not been properly evaluated. The purpose of this document is to provide recommendations to support decisions about the drug treatment of outpatients with COVID-19 in Brazil. Methods A panel consisting of experts from different clinical fields, representatives of the Brazilian Ministry of Health, and methodologists (37 members in total) was responsible for preparing these guidelines. A rapid guideline development method was used, based on the adoption and/or adaptation of recommendations from existing international guidelines combined with additional structured searches for primary studies and new recommendations whenever necessary (GRADE-ADOLOPMENT). The rating of quality of evidence and the drafting of recommendations followed the GRADE method. Results Ten technologies were evaluated, and 10 recommendations were prepared. Recommendations were made against the use of anticoagulants, azithromycin, budesonide, colchicine, corticosteroids, hydroxychloroquine/chloroquine alone or combined with azithromycin, ivermectin, nitazoxanide, and convalescent plasma. It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients, as their benefit is uncertain and their cost is high, with limitations of availability and implementation. Conclusion To date, few therapies have demonstrated effectiveness in the treatment of outpatients with COVID-19. Recommendations are restricted to what should not be used, in order to provide the best treatment according to the principles of evidence-based medicine and to promote resource savings by aboiding ineffective treatments.

Diagnostic yield of real-time polymerase chain reaction in the diagnosis of intrapartum maternal rectovaginal colonization by group B Streptococcus: a systematic review with meta-analysis.

Group B Streptococcus is the leading etiologic factor of neonatal sepsis. Intrapartum real-time polymerase chain reaction (RT-PCR) may allow faster and more accurate detection of maternal colonization. The aim of this study was to determine the sensitivity and specificity of RT-PCR when compared to the reference standard culture in selective broth media collected from rectovaginal tract from laboring women. We selected 15 studies that included 6368 women. Papers selection, data extraction, and quality assessment were carried out by two independent researchers. The prevalence of maternal colonization was 23.8% by RT-PCR and 22.1% by culture. The meta-analysis demonstrated an RT-PCR sensitivity of 93.7% (CI 92.1-95.3), and specificity of 97.6% (CI 97.0-98.1). This result is above the cutoff point defined by the Centers for Disease Control and Prevention for clinical usefulness. In conclusion, RT-PCR for GBS screening in labor ward is a promising tool; however, further well-designed studies to justify its use are needed.

Determination of lymphocyte subset reference ranges in peripheral blood of healthy adults by a dual-platform flow cytometry method.

Flow cytometry has emerged as a useful screening approach to evaluate whether specific cell populations are present or absent. Previous studies have shown different reference ranges in several countries. The aim of this study was to determine reference ranges of lymphocyte subsets in peripheral blood by flow cytometric method in Brazilian adults. In this study, relative and absolute reference ranges of lymphocyte subsets were: CD3+: 51.3-83.5%, 718-2494cells/µl; CD4+: 24.4-54.2%, 456-1492cells/µl; CD8+: 12.8-40.2%, 272-1144cells/µl; CD4+CD8+: double-positive 0.01-3.6%, 2-88cells/µl; TCR γδ: 1.0-15.9%, 19-345cells/µl; CD3+CD4-CD8-: 1.2-13.3%, 28-292cells/µl; TCR αß+: 44.3-77.0%, 855-2384cells/µl; CD4/CD8 ratio: 0.68-3.61; CD19+: 6.3-20.8%, 112-622cells/µl; mature NK cells: 3.1-27.4%, 70-745cells/µl; immature NK cells: 0.08-1.1%, 1-23cells/µl; total NK cells: 3.7-28.5%, 82-760cells/µl; and NKT cells: 0.9-21.4%, 18-488cells/µl. Comparison with other studies showed differences among some of them. This suggests that there are differences among lymphocyte subsets in the worldwide population and also it is important to determine reference ranges in different populations in order to better assess and monitor patients.

The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil.

OBJECTIVE: To estimate the burden of disease due to tuberculosis in the state of Santa Catarina, Brazil, in 2009. METHODS: This was an epidemiological study with an ecological design. Data on tuberculosis incidence and mortality were collected from specific Brazilian National Ministry of Health databases. The burden of disease due to tuberculosis was based on the calculation of disability-adjusted life years (DALYs). The DALYs were estimated by adding the years of life lost (YLLs) and years lived with disability (YLDs). Absolute values were transformed into rates per 100,000 population. The rates were calculated by gender, age group, and health care macroregion. RESULTS: The burden of disease due to tuberculosis was 5,644.27 DALYs (92.25 DALYs/100,000 population), YLLs and YLDs respectively accounting for 78.77% and 21.23% of that total. The highest rates were found in males in the 30-44 and 45-59 year age brackets, although that was not true in every health care macroregion. Overall, the highest estimated burden was in the Planalto Norte macroregion (179.56 DALYs/100,000 population), followed by the Nordeste macroregion (167.07 DALYs/100,000 population). CONCLUSIONS: In the majority of the health care macroregions of Santa Catarina, the burden of disease due to tuberculosis was concentrated in adult males, the level of that concentration varying among the various macroregions.

The anabolic steroid nandrolone enhances motor and sensory functional recovery in rat median nerve repair with long interpositional nerve grafts.

BACKGROUND: Recovery from peripheral nerve repair is frequently incomplete. Hence drugs that enhance nerve regeneration are needed clinically. OBJECTIVES: To study the effects of nandrolone decanoate in a model of deficient reinnervation in the rat. METHODS: In 40 rats, a 40-mm segment of the left median nerve was removed and interposed between the stumps of a sectioned right median nerve. Starting 7 days after nerve grafting and continuing over a 6-month period, we administered nandrolone at a dose of 5 mg/kg/wk to half the rats (n = 20). All rats were assessed behaviorally for grasp function and nociceptive recovery for up to 6 months. At final assessment, reinnervated muscles were tested electrophysiologically and weighed. Results were compared between rats that had received versus not received nandrolone and versus 20 nongrafted controls. RESULTS: Rats in the nandrolone group recovered finger flexion faster. At 90 days postsurgery, they had recovered 42% of normal grasp strength versus just 11% in rats grafted but not treated with nandrolone. At 180 days, the average values for grasp strength recovery in the nandrolone and no-nandrolone groups were 40% and 33% of normal values for controls, respectively. At 180 days, finger flexor muscle twitch strength was 16% higher in treated versus nontreated rats. Thresholds for nociception were not detected in either group 90 days after nerve grafting. At 180 days, nociceptive thresholds were significantly lower in the nandrolone group. CONCLUSIONS: Nandrolone decanoate improved functional recovery in a model of deficient reinnervation.

Cartilaginous choristoma of the tongue with an immunohistochemical study.

By definition, choristomas are normal tissues found in anomalous topography. The cartilaginous features of these lesions are rare in the soft tissues of the oral cavity. The majority of cartilaginous choristomas of the tongue--the primary site of emergence of the oropharynx--are associated with adipose, fibrous or bone tissues--apart from that, only a few of these were confirmed by an immunohistochemical study. The neoplasm exclusively composed of chondromatous tissue is extremely rare in the tongue. This paper reports the clinical, surgical and pathological characteristics of a cartilaginous choristoma of the tongue diagnosed in a 64-year-old woman.

Performance of RT-PCR in the detection of Streptococcus agalactiae in the anogenital tract of pregnant women.

INTRODUCTION: Infection with Group B Streptococcus (GBS) is the most frequent in the first weeks of life of a newborn. The identification of pregnant women with GBS colonization may reduce neonatal infection. METHODS: This cross-sectional study evaluated the performance of real-time polymerase chain reaction (RT-PCR) to detect GBS colonization in the anogenital tract of pregnant women. Anogenital swabs were collected from 266 pregnant women from December 2010 to August 2011. GBS was detected using culture (gold standard) and RT-PCR to determine sip gene expression. The presence of DNA was confirmed using betaglobin amplification, and the guanidine technique was used for DNA extraction. When results were discordant, the test was repeated using conventional PCR. The results were evaluated to determine sensitivity, specificity, positive and negative predictive values and accuracy. RESULTS: Of the 266 samples collected, 254 were adequate for analysis. Prevalence was 28.7% using the gold standard criterion and 38.2% using RT-PCR. The comparison of RT-PCR with culture revealed a sensitivity of 89% (95% CI 0.81-0.96), specificity of 82% (95% CI 0.76-0.87), positive predictive value of 67% (95% CI 0.57-0.76) and negative predictive value of 94% (95% CI 0.91-0.99). CONCLUSION: Further studies using other DNA extraction techniques, targeting other GBS genes and using sample enhancement before RT-PCR should be conducted to determine whether the sensitivity and specificity recommended by the CDC may be reached using the same thermal cycler.

Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae: a review of epidemiological and clinical aspects.

INTRODUCTION: The indiscriminate use of antibiotics associated with other situations has revealed a considerable increase in outbreaks caused by microorganisms resistant to antimicrobial drugs. Among these is the Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae. AREAS COVERED: This review provides an overview of the KPC-producing K. pneumoniae with emphasis on the epidemiological and clinical aspects. EXPERT OPINION: The KPC-producing K. pneumoniae was first described in the US. Most cases were reported between 2007 and 2009. It is widespread in almost all continents. The presence of severe comorbidities, previous use of fluoroquinolones and broad-spectrum cephalosporin are independent factors for this type of infection. Besides the increasing number of resistant strains that greatly complicates the therapeutic management of patients, the clinical characteristics of infection make the diagnosis difficult, resulting in high morbidity and mortality rates. The spread of KPC-producing K. pneumoniae shows how we are prone to pandemics. Transport systems, the exchange of healthcare professionals, the transfer of patients between hospitals and, mainly, the lack of preventive measures such as hand washing are related to the spread of KPC-producing Klebsiella pneumoniae in virtually all continents.

Diagnosis of the pulmonary tuberculosis by polymerase chain reaction: a comparative study between HIV-positive and -negative individuals.

This study was performed to assess the efficiency of polymerase chain reaction (PCR) directly from sputum for the diagnosis of pulmonary tuberculosis by comparison between HIV-positive and HIV-negative individuals. Sputum samples were collected from hospitalized patients admitted with a clinical diagnosis of pulmonary tuberculosis, and subjected to smear microscopy, culture on LJ medium and detection of M. tuberculosis by PCR. Sensitivity, specificity, and predictive values (positive and negative) were calculated using smear and/or culture at day 42 as the gold standard, by comparing the yield in HIV-positive and HIV-negative individuals. Regardless of serostatus, the technique's yield had 62% sensitivity, 70% specificity, 79% positive predictive value, 50% negative predictive value, and 65% accuracy. HIV-negative had 64% sensitivity, 74% specificity, 75% positive predictive value, 63% negative predictive value, and 68% accuracy. HIV-positive had 59% sensitivity, 33% specificity, 87% positive predictive value, 10% negative predictive value, and 56% accuracy. The PCR showed a higher yield in HIV-negative individuals compared to HIV-positive individuals.

The clinical utility of induced sputum for the diagnosis of bacterial community-acquired pneumonia in HIV-infected patients: a prospective cross-sectional study.

BACKGROUND: Bacterial pneumonias have been overcoming pneumocytosis in frequency. Controversy still remains about how to manage immunocompromised patients and those with lung diseases. Sputum analysis is a noninvasive and simple method, and when interpreted according to specific criteria it may help with diagnosis. We conducted a study to evaluate sensitivity, specificity, positive and negative predicted values, and the accuracy of induced sputum (IS) for bacterial community-acquired pneumonia diagnosis in HIV-positive patients. MATERIAL AND METHODS: This cross sectional study evaluated a diagnostic procedure in a reference hospital for HIV patients in Florianópolis, SC, Brazil. From January 1, 2001 to September 30, 2002, 547 HIV-positive patients were analyzed and 54 inpatients with pulmonary infection were selected. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were considered the gold standards. Gram stains and quantitative cultures of IS and BAL were obtained. The cut-offs for quantitative cultures were 10(6) CFU/mL for IS and 10(4) CFU/mL for BAL. RESULTS: The mean age was 35.7 years, 79.6% were males and 85.2% were caucasians. The mean lymphocyte count was 124.8/mm(3). Bacterial pneumonia was diagnosed in 20 patients. The most prevalent bacteria was Streptococcus pneumoniae. Considering IS for the diagnosis of bacterial pneumonia, sensitivity was 60%, specificity 40%, the positive predictive value was 80%, negative predictive value 20% and accuracy 56%. CONCLUSION: IS with quantitative culture can be helpful for the diagnosis of bacterial pneumonia in HIV-positive patients.

Radiographic alterations in patients presenting human immunodeficiency virus/tuberculosis coinfection: correlation with CD4+ T cell counts.

OBJECTIVE: To look for correlations between radiological patterns and CD4+ T cell counts in patients coinfected with tuberculosis and human immunodeficiency virus. METHODS: Patients included were selected from among those presenting human immunodeficiency virus/tuberculosis coinfection and admitted to the Nereu Ramos Hospital, located in Florianópolis, Brazil, between January of 2000 and December of 2003. RESULTS: A total of 87 patients were included. The mean age was 34 +/- 8 years, and 6.8% were non-Caucasian. The mean CD4+ T cell count was 220.2 cells/mm(3) (median, 144 cells/mm(3)), and 56.4% of the patients presented less than 200 cells/mm(3). We identified the following radiographic patterns and related them to the CD4+ T cell counts: the alveolar pattern in 50.6% of the cases (56.8% CD4+ T cells < 200); the interstitial pattern in 32.2% (53.6% CD4+ T cells < 200); pleural effusion in 24.1% (47.6% CD4+ T cells < 200); cavitation in 24.1% (57.1% CD4+ T cells < 200); enlarged mediastinal or hilar lymph nodes in 11.5% (90% CD4+ T cells < 200); and a normal pattern in 11.5% (60% CD4+ T cells < 200). The mean CD4+ T cell counts for the radiologic patterns isolated were as follows: 235.2/mm(3) (alveolar consolidation); 208.8/mm(3) (interstitial); 243.3/mm(3) (pleural effusion); 265/mm(3) (cavitation); 115.1/mm(3) (enlarged mediastinal or hilar lymph nodes) (p < 0.05); and 205.5/mm(3) (presenting no radiological alterations). As noted, mediastinal/hilar lymph node enlargement was the only pattern that correlated with the degree of cell-mediated immunity in a statistically significant way. CONCLUSION: With the exception of mediastinal/hilar lymph node enlargement, the radiographic patterns were randomly distributed in relation to the CD4+ T cell counts.