A prevalência das deficiências físicas da hanseníase após alta medicamentosa em municípios que alcançaram a meta de eliminação / The prevalence of physical disabilities of leprosy after discharge in municipalities that have reached the elimination goal

INTRODUÇÃO: A Organização Mundial da Saúde preconiza o grau de incapacidade como instrumento de avaliação, para propor ações de prevenção, monitoramento e tratamento do dano físico causado pela Hanseníase. OBJETIVO: comparar o grau de deficiência física no diagnóstico, alta e pós-alta de indivíduos que tiveram hanseníase. MÉTODOS: Estudo ecológico, analítico com 126 indivíduos, diagnosticados no período 2004-2013, utilizando: formulário de avaliação neurológica simplificada, classificação do grau de incapacidades físicas e formulário elaborado pela pesquisadora. RESULTADOS: Média de idade 56,02 anos, sendo 73,01% multibacilares, com predomínio da forma dimorfa (36,80%). Verificou-se, no diagnóstico, percentual elevado (63,49%) de indivíduos que já apresentavam deficiência física (grau 1 e 2). A comparação entre diagnóstico e pós-alta demonstrou piora das deficiências físicas, principalmente nos multibacilares, com percentual (51,59%) de reação hansênica durante o tratamento. Do total da amostra, 61 (48,41%) mantiveram o mesmo grau de incapacidade, 44 (34,92%) pioraram e 21 (16,67%) melhoraram. Membros inferiores foram os mais acometidos (58%). CONCLUSÃO: O estudo permite concluir que, ao realizar a comparação nos momentos do diagnóstico e pós-alta, houve piora das deficiências físicas, principalmente na forma multibacilar, sendo os membros inferiores os segmentos que mais apresentam evolução expressiva do grau de deficiência.

INTRODUCTION: The World Health Organization recommends the degree of disability as an evaluation tool, to propose actions for prevention, monitoring and treatment of physical harm caused by leprosy. OBJECTIVE: This study aimed to compare the degree of disability at diagnosis, discharge and post-discharge of individuals who have had leprosy. METHODS: ecological, analytical study of 126 individuals diagnosed in the period 2004-2013 using: simplified neurological assessment form and classification of the degree of physical disability and form prepared by researcher. In the data analysis. RESULTS: Mean age 56.02 years, and 73.01% multibacillary, with a predominance of form dimorphic (36.80%). It was, in the diagnosis, high percentage (63.49%) of individuals who have had disability (grade 1 and 2).The comparison between diagnosis and post-discharge showed worsening physical, especially in multibacillary, with percentage (51.59%) of leprosy reactions during treatment. Of the total sample, 61 (48.41%) maintained the same level of disability, 44 (34.92%) got worse and 21 (16.67%) improved. Lower limbs were the most affected (58%). CONCLUSION: The study shows that, when making the comparison in the diagnosis and post-discharge, worsening of disabilities, especially in multibacillary, and the lower limbs segments that have most significant evolution of the degree of disability.

Meaning of leprosy for people who have experienced treatment during the sulfonic and multidrug therapy periods / Significado da hanseníase para pessoas que viveram o tratamento no período sulfônico e da poliquimioterapia / Significado de la lepra para personas que experimentaron el tratamiento en el período sulfónico y de poliquimioterapia

AbstractObjective: to analyze the meanings of leprosy for people treated during the sulfonic and multidrug therapy periods.Method: qualitative nature study based on the Vigotski's historical-cultural approach, which guided the production and analysis of data. It included eight respondents who have had leprosy and were submitted to sulfonic and multidrug therapy treatments. The participants are also members of the Movement for Reintegration of People Affected by Leprosy.Results: the meanings were organized into three meaning cores: spots on the body: something is out of order; leprosy or hanseniasis? and leprosy from the inclusion in the Movement for Reintegration of People Affected by Leprosy.Conclusion: the meanings of leprosy for people submitted to both regimens point to a complex construction thereof, indicating differences and similarities in both treatments. Health professionals may contribute to the change of the meanings, since these are socially constructed and the changes are continuous.

ResumoObjetivo:analisar significados da hanseníase para as pessoas que foram tratadas no período sulfônico e no período da poliquimioterapia.Método:estudo de natureza qualitativa fundamentado na abordagem histórico-cultural de Vigotski, a qual orientou a construção e análise dos dados. Foram incluídos oito entrevistados que já tiveram hanseníase e que realizaram tratamento no período sulfônico e da poliquimioterapia, sendo participantes do Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Resultados:os significados foram organizados em três núcleos de significação: manchas no corpo: alguma coisa está fora de ordem; lepra ou hanseníase? e hanseníase a partir da inserção no Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Conclusão:os significados de hanseníase para pessoas tratadas nos dois períodos apontam para a construção complexa dos mesmos, indicando diferenças e semelhanças nos dois períodos. Os profissionais de saúde podem contribuir para a mudança de significados, pois esses são socialmente construídos e as transformações são contínuas.

ResumenObjetivo:analizar los significados de la lepra para las personas que fueron tratadas en el período sulfónico y en el período de poliquimioterapia.Método:estudio de naturaleza cualitativa fundamentado en el abordaje histórico cultural de Vygotsky, el cual orientó la construcción y análisis de los datos. Fueron incluidos ocho entrevistados que ya tuvieron lepra y que realizaron tratamiento en el período sulfónico y de poliquimioterapia, siendo participantes del Movimiento de Reintegración de Personas Afectadas por la Lepra.Resultados:los significados fueron organizados en tres núcleos de significación: manchas en el cuerpo: alguna cosa está fuera de orden; ¿Lepra o enfermedad de Hansen?; y lepra a partir de la inserción en el Movimiento de Reintegración de Personas Afectadas por la Lepra. Conclusión: los significados de la lepra para las personas tratadas en los dos períodos apuntan para la construcción compleja de los mismos, indicando diferencias y semejanzas en los dos períodos. Los profesionales de la salud pueden contribuir para el cambio de significados, ya que estos son socialmente construidos y las transformaciones son continuas.

Efeitos adversos da poliquimioterapia para hanseníase: utilização de doses alternativas e avaliação pós alta / Adverse effects of multidrug therapy for leprosy: use of alternative doses and post discharge evaluation

O tratamento da hanseníase pode causar efeitos adversos relacionados à Rifampicina (RMP) ou Dapsona (DDS) levando à mudança no esquema terapêutico. Objetivou-se determinar as causas da mudança do tratamento e avaliar as condições clínicas dermatológicas dos pacientes que fizeram uso da terapêutica alternativa. De 182 pacientes tratados entre 1997-2008, 34 (18,7%) fizeram doses alternativas e 21 foram entrevistados. O perfil foi constituído por casados, de 40 à 59 anos, baixa condição socioeconômica e escolaridade. Os pacientes paucibacilares (PB) e multibacilares (MB) sem o uso de DDS e de RMP tiveram as últimas baciloscopias (BAAR) negativas (>50%), e os resultados positivos dos outros mostrou involução lenta. A forma clínica mais incidente foi a virchowiana nos intolerantes à DDS, e a dimorfa nos sem a RMP. Os efeitos adversos acometeram mais os MB. Nos intolerantes à DDS, a mudança do esquema terapêutico foi relacionada às causas hematológicas (48,5%) e os à RMP, as hepáticas (50%). Na avaliação as placas e nódulos desapareceram. As manchas, dor geral ou localizada em membros, diminuição da sensibilidade e da força muscular com aparecimento de garra móvel foram significativas. A evolução das incapacidades revelou a necessidade de monitorar atentamente a função neural nos casos de alta.

Leprosy treatment can cause adverse effects related to rifampin (RMP) or dapsone (DDS) leading to changes of the therapeutic regimen. The objective was to determine the causes of changes in the treatment and to evaluate the clinical dermatological conditions of patients who underwent alternative therapy. Out of 182 patients treated between 1997- 2008, 34 (18.7%) underwent alternative doses, and 21 were interviewed. The profile of the patients was: married, 40 to 59 years, low socioeconomic and educational status. The latest bacilloscopic index (BI) of paucibacillary (PB) and multibacillary (MB) patients that did not use DDS and RMP was negative (> 50%), and the positive results observed in the other patients evidenced slow recovery. The most frequent clinical form was lepromatous in patients intolerant to DDS and borderline leprosy in those without RMP. Adverse effects were most commonin MB patients. Intolerance to DDS was related to hematological causes (48.5%), and intolerance to RMP was due to hepatic conditions (50%). Upon evaluation nodules and plaques disappeared. Plaques, generalor localized pain in limbs, reduced sensitivity and muscular strength with the appearance of claw were significant findings. The development of disabilities revealed the need of careful monitoring of the neural function in cases discharged from treatment.

Hanseníase no município de Buriticupu, estado do Maranhão, Brasil: estudo de incapacidades em indivíduos no pós-alta / Leprosy in municipality of Buriticupu, State of Maranhão, Brazil: study of disabilities in individuals in post-discharge

O município de Buriticupu apresenta indicadores epidemiológicos que o classificam como hiperendêmico para hanseníase. Levando em conta o potencial da doença em causar incapacidades físicas e limitações de natureza psicossocial foi desenvolvido um estudo como objetivo de caracterizar o grau de limitação funcional,de atividade física e da participação social de indivíduos após alta por cura. O estudo, transversal e descritivo, foi desenvolvido no período de junho a dezembro de 2010 em uma amostra de 69 indivíduos que tinham recebido alta do tratamento entre 2007 e 2009. Foi feita avaliação simplificada da função neural, aplicação da escala SALSA(para caracterizar a limitação de atividade e consciência de risco) e da escala de participação (para caracterizara restrição à participação social do indivíduo), além do cálculo do escore OMP. Foi identificada uma população predominante do sexo masculino, na faixa etária economicamente ativa e com ocupação relacionada a demandas por esforço físico, com destaque para lavrador.O percentual de 76,8% dos pacientes não apresentava incapacidades físicas e 59,4% não apresentava limitação de atividades. Não foi constatada percepção de risco de sofrer lesões traumáticas por 69,6% dos indivíduos, enquanto 72,5% dos indivíduos não apresentaram restrição significativa à participação social. Apesar dos dados favoráveis, o percentual que apresentou alterações reflete a necessidade de melhoria na atenção pós-alta ao indivíduo no município.

The municipality of Buriticupu presents the epidemiologicalindicators are classified as hiperendêmico for leprosy. Taking into account the potential of disease incausing physical disability and limitations of psychosocial nature was developed a study to characterize thedegree of functional impairment, physical activity andsocial participation of individuals after high for cure. The study, transversal and descriptive, was developed during the period from June to December 2010 in a sampleof 69 individuals who had received the treatment between 2007 and 2009. Simplified evaluation was made of neural function, applying the scale SALSA to characterize the limitation of activity and awareness of risk and of the scale of participation to characterize the restriction on the individual’s social participation, in addition to the calculation of the OMP score. It was identified a predominantly male population, economically active age group and occupation related to demands for physical effort,high lighted by a farmer. The percentage of 76.8% of patientshad no physical disabilities, while 59.4% had nolimitation of activity. There was no perception of risk ofsuffering traumatic injuries by 69.6% of individuals, while72.5% of individuals showed no significant constraintto social participation. However, the percentage whichshowed changing reflects the necessity of improving ondischarging attention at the municipality.

Does circumcision influence recurrences in herpes genitalis?

BACKGROUND AND AIMS: The effect of therapeutic circumcision in men for preventing recurrences of herpes genitalis remains largely unelucidated despite its well documented albeit conflicting role in reducing the risk of acquiring sexually transmitted infections, including genital herpes. METHODS: Twenty volunteer adult males with a history of recurrent herpes genitalis were included in the study after informed consent and circumcision was carried out. Twenty more adult males having recurrent herpes genitalis and registered in the clinic during the same period were selected as controls. All patients and controls were followed-up for recurrences of herpes genitalis. RESULTS AND CONCLUSIONS: Six patients and six controls did not follow-up. Seven patients reported no recurrences during 3-18 years, seven patients had two to six recurrences during 11-27 years of postcircumcision follow-up, 0.0080 (average) recurrences per person per year as compared with 0.20 (average) recurrences per person per year recorded before the circumcision. Two patients had first recurrence 11 years after the circumcision. In comparison, 14 controls had 0.17 (average) recurrences per person per year, comparable with the number of recurrences in uncircumcised patients, and frequently at shorter intervals. Despite being a small study, the circumcision appears to reduce the number of recurrences on an average and evidently prolongs the disease-free period in between two recurrences.

Efectividad del tratamiento farmacológico en la lepra multibacilar: un seguimiento de 34 pacientes multibacilares tratados con multiterapia hasta la negativización de los frotis cutaneos

Los ensayos sobre el terreno de la Organización Mundial de la Salud (OMS) con tratamientos farmacológicos combinados (MDT), se iniciaron en el Centro Schieffelin para Investigación y Formación en Lepra (SL R & IC), Karigiri, India en Diciembre de 1981. Se administraron a los pacientes 2 tratamientos farmacológicos distintos. El primero (régimen A) consistía en 600 mgr. de rifampicina y 300 mgr de clofazimina, administrada bajo supervisión mensualmente durante 2 días consecutivos, una inyección bimensual de 225 mgr de acedapsona y 100 mgr de dapsona diarios. El segundo (régimen: B) era el MDT convencional (OMS/MDT), rifampicina 600 mgr y clofazimin a 300 mgr, supervisada una vez al mes y 100 mgr dapsona y 50 mgr. clofazi- mina diarios no supervisados. Se administraron ambos tratamientos durante un período mínimo de 2 años o hasta la negatividad bacteriológica. Se reevaluaron 34 nuevos pacientes de lepra (MB) no tratados previamente , 16 de los cuales se les había administrado el régimen A y 18 el régimen B. Ambos regímenes resultaron bien tolerados y aceptados por los pacientes. La pigmentación por clofazimina fue el único efecto colateral adverso de la MDT. Después de completar la MDT, los pacientes se controlaron con un seguimiento durante un total de 466 personas/ año, con un promedio de 13.7ñ 1.4 paciente. No se detectaron recidivas (AU)

Relapses in multibacillary leprosy patients: effect of length of therapy.

Two groups of MB leprosy patients, one treated to the point of smear negativity (TSN) and the other given therapy for fixed duration (24 doses of WHO MB regimen) (FDT), were compared for relapse rates during treatment and in the post-treatment period. During the follow-up of 980.2 person years in 260 patients treated with FDT, 20 relapses (2.04/100 patient years) were observed. In the other group of 301 patients, who received therapy till smear negativity, 12 relapses in 1085.46 person years (1.10/100 patient years) occurred. Comparison of survival rates (without relapse) has shown that although there is no difference up to 4 years, the risk of relapse was significantly higher on longer follow-up in the FDT group. In addition, when patients were compared on the basis of initial bacterial load, it was found that the relapse rates in patients with BI > or = 4 was significantly higher (P < 0.01) in the FDT group as compared to those receiving treatment till the point of smear negativity (4.29 versus 1.27/100 patient years). All the relapsed patients responded to retreatment with the same drug combination, indicating that the exacerbation in their condition was because of insufficient treatment. It is suggested that to prevent or reduce relapses, treatment where feasible would be continued till smear negativity, at least in patients with high BI.

Recidivas en pacientes de lepra multibailares: resultado de la duración del tratamiento

Se comparan dos grupos de pacientes MB: uno tratado hasta negatividad en frotis (TSN) y el otro con terapia de duración fija (24 dosis MB OMS) (FDT), para determinar los índices de recidivas durante el tratamiento y el período post tratamiento, encontrando 20 recidivas (2.04/100 pacientes/año) durante el seguimiento de 980.2 personas/año en 260 pacientes tratados en FDT. En el otro grupo, 301 pacientes recibieron tratamiento hasta negativización. detectándose 12 recidivas en 1085.46 personas/año (l.10/100 pacientes año). La comparación de los índices de supervivencia (sin recidivas) revela que aunque no hay diferencia significativa hasta los 4 años, el riesgo de recidiva es significativamente mayor en el grupo FDT durante un período mayor de seguimiento. Además, cuando se compara en los pacientes la carga bacilar inicial, se observa un índice de recidivas mayor en el grupo con IB_4, significativamente mayor (p<0.01) que en el grupo FDT comparado con el grupo que recibe tratamiento hasta la completa negativización del frotis (4.29 años 1.27/100 pacientes/años).Todos los pacientes con recidivas respondieron al tratamiento con la misma combinación de medicamentos, indicando que la exacerbación de su condición es por insuficiente tratamiento. Se sugiere para prevenir o reducir recidivas, el continuar cuando sea posible el tratamiento hasta negativización del frotis, al menos en pacientes con IB elevado (AU)

Leprosy and renal transplantation.

Nine cases of leprosy in patients treated at a large renal transplant centre in South Asia are described. Three had leprosy diagnosed before transplantation and had either completed or were continuing chemotherapy at the time of transplantation. One showed exacerbation of undisclosed leprosy after transplantation. Five patients developed the disease for the first time 22 months to 12 years after transplantation. Immunosuppression did not adversely affect the treatment of leprosy in any of the patients though concurrent liver disease required cessation of rifampicin in one patient.

A phase II study of oral clofazimine in unresectable and metastatic hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is highly refractory to most chemotherapeutic agents. Clofazimine, a riminophenazine compound used to treat leprosy since 1962, inhibits various cancer cell lines, including hepatocellular carcinoma cell lines, via phospholipase A2 dependant processes. Clofazimine also inhibits p170-glycoprotein, the mdr1 gene product. PATIENTS AND METHODS: Thirty patients (26 males and four females) with unresectable (25) or metastatic (5) hepatocellular carcinoma received oral clofazimine 600 mg daily for two weeks, followed by 400 mg daily until progression or death. RESULTS: There were three responses (10%)--one of a soft tissue metastasis, and two of local disease, with 13 patients disease stabilizing for up to 20 months. The overall median survival was 13 weeks. Adverse events included hyperpigmentation, eczematous skin rashes and palpitations. CONCLUSIONS: Although only three patients had an objective response (10%), the 13 patients with stable disease for up to 20 months, and an overall median survival of 13 weeks, suggest that clofazimine, or other riminophenazine compounds may prove to be of value in hepatocellular carcinoma.

Prognostic significance of the receptor for urokinase plasminogen activator in breast cancer.

We have recently described the urokinase-type plasminogen activator (uPA) and its type 1 inhibitor (PAI-1) as strong prognostic variables in breast cancer (J. A. Foekens et al., Cancer Res., 52: 6101-6105, 1992; J. Grondahl-Hansen et al., Cancer Res., 53: 2513-2521, 1993; J. A. Foekens et al., J. Clin. Oncol., 11: 899-908, 1994). A specific cell surface receptor (uPAR) binds uPA and strongly enhances plasmin generation, and the amount of uPAR in the tumor tissue might therefore be a rate-limiting factor in the extracellular proteolysis involved in tumor invasion. Here, we report on the prognostic value of uPAR in cytosolic (uPARc) and Triton (uPARt) extracts prepared from 505 primary breast tumors. The median observation time was 54 (range: 12-125) months. uPAR levels were determined by a sandwich ELISA. Univariate analysis showed that high uPAR levels (above the median value) were significantly associated with a shorter overall survival, showing a stronger discriminatory effect for uPARc [relative hazard rate (RHR): 1.47; P = 0.012)] as compared with uPARt (RHR, 1.33; P = 0.059), while no statistically significant differences were found for relapse-free survival. Multivariate analysis including all patients showed that when including other biochemical variables (estrogen receptor, progesterone receptor, PS2, cathepsin D, uPA, and PAI-1), the only retained independent variable via backward elimination was PAI-1 for both relapse-free survival and overall survival. When analyzed separately in clinically relevant subgroups, the prognostic value of uPAR was particularly strong in a subgroup of 201 node-positive postmenopausal women, showing considerably shorter overall (RHR: 2.39; P < 0.0001) and relapse free (RHR: 1.91; P = 0.0006) survival for patients with high uPARc content. High uPARt levels were also significantly associated with shorter overall survival in this subgroup of patients (RHR: 1.5; P = 0.047), but not with relapse-free survival (P = 0.64). Multivariate analysis, including the basic model, estrogen and progesterone receptors, PS2, cathepsin D, uPA, PAI-1, uPARc, and uPARt in the subgroup of postmenopausal node-positive patients, showed that only uPARc and PAI-1 were significant independent prognostic parameters, with respect to overall survival, RHRs being 2.72 (P < 0.0001) and 1.81 (P = 0.005), respectively. In multivariate analysis of relapse-free survival, uPARc, PAI-1, and uPA were independent parameters with respective relative relapse rates of 1.91 (P = 0.002) for uPARc, 1.68 (P = 0.02) for PAI-1, and 1.6 (P = 0.03) for uPA. These data lend support to the hypothesis that uPAR is an important molecule in plasmin-mediated extracellular matrix degradation leading to cancer cell dissemination and death of the patient.