Resumo em Espanhol:

Este artículo describe un amplio estudio longitudinal, iniciado en 1993, acerca de la historia natural de la infección por papilomavirus humanos (PVH) y las neoplasias cervicales en una población de bajos recursos económicos de São Paulo, Brasil, una de las ciudades con mayor riesgo de cáncer cervical en todo el mundo. Esta investigación epidemiológica, conocida como el estudio de cohorte Ludwig-McGill, se centra en la infección persistente por tipos oncogénicos de PVH como el acontecimiento precursor que conduce a la neoplasia cervical. Sus objetivos consistieron en: 1) estudiar la epidemiología de la infección cervical persistente por PVH en mujeres asintomáticas; 2) investigar si la infección persistente por PVH incrementa el riesgo de lesiones intraepiteliales escamosas cervicales de bajo y alto grado; 3) identificar los determinantes de la infección persistente por PVH; 4) buscar variantes moleculares de los PVH que puedan estar asociadas a un aumento del riesgo de lesiones; 5) determinar si la carga vírica está correlacionada con la infección persistente y el riesgo de lesiones; 6) averiguar si la respuesta de anticuerpos frente a los PVH permite predecir la persistencia de la infección y la progresión de las lesiones, y 7) investigar el papel de los tipos HLA y del polimorfismo del codón 72 del gen p53 como mediadores de la persistencia de los PVH y de la gravedad de las lesiones. Hasta marzo de 1997 se reclutaron 2 528 mujeres que fueron examinadas cada cuatro meses en el primer año y cada seis meses en los años subsecuentes. Las participantes se someten a una entrevista basada en un cuestionario; a la obtención de una muestra cervical para citología de Papanicolaou y detección de PVH, y a la extracción de una muestra de sangre para identificar anticuerpos anti-PVH. Además, en el primer año se les realiza una cervicografía, que después se repite cada dos años. En este artículo se describen el diseño y los métodos del estudio, se presentan las características basales de la cohorte y se realiza una evaluación preliminar del valor pronóstico del estado basal de los PVH.

Resumo em Inglês:

This article reports on a large longitudinal study, begun in 1993, of the natural history of human papillomavirus (HPV) infection and cervical neoplasia in a population of low-income women in São Paulo, Brazil, a city with one of the highest risks worldwide for cervical cancer. Known as the Ludwig-McGill cohort study, the epidemiological investigation focuses on persistent infection with oncogenic HPV types as the precursor event leading to cervical neoplasia. The objectives of this study are to: 1) study the epidemiology of persistent cervical HPV infection in asymptomatic women, 2) investigate whether persistent HPV infection increases risk of low-grade and high-grade cervical lesions, 3) search for determinants of persistent HPV infection, 4) search for molecular variants of HPV that may be associated with an increased risk of lesions, 5) investigate whether viral burden is correlated with persistent infections and with lesion risk, 6) study the antibody response to HPV as a predictor of persistence and lesion progression, and 7) examine the role of HLA typing and codon 72 p53 gene polymorphism in mediating HPV persistence and lesion severity. The study accrued 2 528 female subjects through March 1997. Subjects were followed up every 4 months in the first year, with twice-yearly return visits to take place in subsequent years. Participants undergo a questionnaire-based interview, have a cervical specimen taken for Pap cytology and HPV testing, and have a blood sample drawn for HPV antibody testing. A cervicography is performed once in the first year and every two years thereafter. In this article we describe the design and methods of the study, provide baseline cohort characteristics, and present a preliminary assessment of the prognostic value of baseline HPV status.

Resumo em Espanhol:

La Organización Mundial de la Salud ha puesto en marcha un programa para la vigilancia de la resistencia a los antibacterianos, denominado WHONET, que se desarrolló en Argentina mediante una red de 23 laboratorios de instituciones hospitalarias públicas y privadas sometidos a programas nacionales e internacionales de control de calidad. Entre enero de 1995 y diciembre de 1996 se determinó por el método de difusión en agar la sensibilidad a los antibacterianos de 16 073 aislados clínicos consecutivos, siguiendo las recomendaciones del Comité Nacional de Estándares para Laboratorios Clínicos (National Committee for Clinical Laboratory Standards: NCCLS) de los Estados Unidos de América. Más de la mitad de los aislados urinarios de Escherichia coli fueron resistentes a la ampicilina, y más de 30% a la trimetoprima-sulfametoxazol. Cuando se comparó la sensibilidad de los aislados urinarios de pacientes ambulatorios y hospitalizados, se observó una marcada diferencia en los perfiles de actividad (porcentaje de microorganismos resistentes aislados en pacientes hospitalizados frente a pacientes ambulatorios) de la gentamicina (8% frente a 2%), la norfloxacina (6% frente a 2%) y las cefalosporinas de tercera generación (18% frente a 10%). Los aislados de Klebsiella pneumoniae recuperados de hemocultivos presentaron resistencia a las cefalosporinas de tercera generación y a la gentamicina en 71 y 60% de los casos, respectivamente. La proporción de Staphylococcus aureus resistentes a la oxacilina fue de 39%. Cerca de la mitad de los aislados de Enterococcus spp. presentaron resistencia de alto nivel a los aminoglucósidos, pero no se detectó resistencia a los glicopéptidos. En nuestro medio, la ampicilina y la trimetoprima-sulfametoxazol no fueron apropiadas para el tratamiento de las diarreas; Shigella flexneri presentó mayor porcentaje de aislados resistentes a ambos fármacos (87 y 74%, respectivamente) que Shigella sonnei (47 y 71%, respectivamente). Se detectó resistencia a las cefalosporinas de tercera generación en 40% de los aislados de Salmonella spp. recuperados en hospitales pediátricos. En casos de meningitis bacteriana, las tasas de resistencia de Streptococcus pneumoniae a la penicilina (18%) y de Haemophilus influenzae a la ampicilina (19%) se situaron en el rango intermedio de las descritas en países americanos y europeos.

Resumo em Inglês:

The World Health Organization has implemented a surveillance program for antimicrobial resistance that is known as WHONET. In Argentina the program was developed through a network of 23 public and private hospitals that participate in national and international quality-control programs. Between January 1995 and December 1996, the antimicrobial susceptibility of 16 073 consecutive clinical isolates was determined, using the recommended standards of the National Committee for Clinical Laboratory Standards of the United States of America. More than half of the Escherichia coli urinary isolates were resistant to ampicillin and more than 30% to trimethoprim/sulfamethoxazole (SXT). When the percentage of resistant isolates from outpatients (OPs) was compared to that observed in hospitalized patients (HPs), a marked difference in antimicrobial activity was noted in the case of gentamicin (2% from OPs resistant vs. 8% from HPs resistant), norfloxacin (2% vs. 6%), and third-generation cephalosporins (7% vs. 15%). Of the Klebsiella pneumoniae isolates recovered from blood cultures, 71% and 60% showed resistance to third-generation cephalosporins and to gentamicin, respectively. The overall rate of oxacillin resistance in Staphylococcus aureus was 39%. Around half of the Enterococcus spp. isolates showed high resistance to aminoglycosides, but resistance to glycopeptides was not found. In Argentina, ampicillin and SXT were not suitable for treating diarrhea. Shigella flexneri had a higher number of isolates resistant to both of those drugs (87% and 74%, respectively) than Sh. sonnei did (47% and 71%, respectively). About 40% of the Salmonella spp. isolated in pediatric hospitals were resistant to third-generation cephalosporins. When microorganisms causing bacterial meningitis were examined, Streptococcus pneumoniae showed a resistance rate of 18% to penicillin and Haemophilus influenzae a resistance rate of 19% to ampicillin. These rates are within the intermediate range reported for other countries of the Americas and for Europe.

Resumo em Português:

A catarata é a principal causa de cegueira no mundo, embora seja passível de recuperação por intervenção cirúrgica relativamente simples e de baixo custo. O presente estudo, realizado em 1997 e 1998 em cinco municípios do Estado de São Paulo, Brasil, teve o propósito de identificar as razões para a falta de acesso ao tratamento cirúrgico por parte dos deficientes visuais por catarata senil. Foram entrevistados pacientes atendidos em um projeto comunitário de reabilitação da cegueira por catarata, o Projeto Zona Livre de Catarata. Obteve-se uma amostra prontamente acessível, composta por 776 sujeitos que procuraram a assistência do projeto e que apresentavam acuidade visual menor do que 0,2 no olho melhor (média de idade = 70 anos). Foi aplicado um questionário por entrevista. Dentre os pacientes, 683 haviam procurado atendimento oftalmológico antes do Projeto Catarata; o tipo mais comum de atendimento procurado foi o serviço público de saúde (27%). Dificuldades financeiras (69%) e ainda enxergar bem (69%) foram as razões predominantes alegadas pelos pacientes para não terem se submetido à cirurgia de catarata. Dentre os que manifestaram receio da cirurgia, a principal alegação foi medo de ficar cego. Todos os pacientes que receberam indicação cirúrgica no período do estudo concordaram em se submeter à cirurgia. Aparentemente, existe uma lacuna entre a busca de serviços oftalmológicos e a resolução cirúrgica da catarata. Os fatores predominantes para a não realização da cirurgia foram econômicos e logísticos. É necessário facilitar o acesso da população à cirurgia de catarata por meio de modelos assistenciais descentralizados e de projetos e campanhas comunitárias de prevenção da cegueira por catarata.

Resumo em Inglês:

Cataracts are the main cause of blindness in the world, although they can be treated with relatively simple and inexpensive surgery. This study was carried out in 1997 and 1998 in five cities in the state of São Paulo, Brazil, to identify the reasons for persons not having cataract surgery. The population studied were patients seen at a community project for the rehabilitation of cataract-caused blindness, Projeto Zona Livre de Catarata (the Cataract-free-Zone Project). A questionnaire was used to interview 776 individuals with cataracts who sought assistance at the project and who had a visual acuity of 20/100 or less in the better eye. Six hundred and eighty-three patients had previously sought ophthalmic care, most frequently (27%) at public health services. The main reasons for subjects not having had cataract surgery were financial (69% of respondents) and the feeling of "still having good eyesight" (69% of respondents). Among patients who said they were afraid of surgery, the main reason was concern about being left blind. All the subjects whom the project deemed suitable for surgery agreed to undergo the procedure. Apparently, there is a gap between searching for ophthalmic services and the surgical resolution of cataracts. The predominant reasons for not having surgery were financial and logistical. There is a need to facilitate access to cataract surgery by decentralizing social services and by developing community projects to prevent cataract-caused blindness.

Resumo em Espanhol:

Se determinó la prevalencia de las infecciones por micobacterias en una muestra de 155 individuos infectados por el virus de la inmunodeficiencia humana (VIH) tratados en el Instituto de los Seguros Sociales (ISS) de Cali, Colombia. Se les realizó la prueba de la tuberculina (PPD 2UT RT23) y se investigó activamente la presencia de micobacterias mediante microscopia directa y cultivo de sangre, orina, heces y aspirado gástrico; cuando así lo indicó el cuadro clínico, también se examinaron y cultivaron muestras de líquido cefalorraquídeo, médula ósea y esputo. La ausencia de reactividad a la tuberculina fue significativamente más frecuente en los pacientes que en los controles (91,3%, frente a 57,4%. ji² = 33; P = 0). La prevalencia de la tuberculosis fue de 6,5%, en comparación con 0,04% en los afiliados al ISS VIH-negativos (intervalo de confianza binomial exacto de 95%: 0,0313 a 0,1154%). Las micobacterias no tuberculosas (MNT), presentes en 43 pacientes, fueron significativamente más frecuentes que Mycobacterium tuberculosis (27,7% frente a 6,5%. ji² = 24,78; P = 0,000 001), pero solo fueron causa de enfermedad en algunos casos. Las especies más frecuentes fueron las del complejo M. avium-intracellulare. M. avium-intracellulare y M. fortuitum tuvieron una prevalencia total de 7,1% y fueron las MNT de mayor prevalencia como causantes de enfermedad en estos pacientes (4,5%); además fueron responsables de tres casos de infección diseminada. La enfermedad clínica por M. tuberculosis o MNT y la anergia completa a la tuberculina se asociaron al estadio IV de la infección por VIH y a los recuentos de linfocitos CD4 <= 400/µL. No obstante, la falta de respuesta inmunocelular, manifestada por una escasa reactividad a la tuberculina, se detectó desde el estadio de portador asintomático del VIH. El progresivo deterioro del sistema inmunitario de los pacientes VIH-positivos es el factor determinante de la alta morbilidad y mortalidad de las infecciones por micobacterias, que requieren la pronta instauración de quimioprofilaxis o tratamiento.

Resumo em Inglês:

The prevalence of mycobacterial infections was determined in a sample of 155 individuals infected with human immunodeficiency virus (HIV) who were treated in the Social Security Institute (SSI) of Cali, Colombia. A tuberculin test (2 TU PPD RT23) was used, and the presence of mycobacteria was checked through direct microscopy and culturing blood, urine, feces, and gastric aspirate. When clinically indicated, samples of cerebrospinal fluid, bone marrow, and sputum were also examined and cultivated. The absence of reactivity to tuberculin was significantly more frequent in the patients than in the controls (91.3%, compared to 57.4%; chi² = 33, P = 0). The prevalence of tuberculosis was 6.5%, in comparison with 0.04% among a group of HIV-negative ISS members (exact binomial 95% confidence interval: 0.0313% to 0.1154%). Non- tuberculous mycobacteria (NTM), present in 43 patients, were significantly more frequent than Mycobacterium tuberculosis (27.7%, versus 6.5%; chi² = 24.78, P = 0.000 001), but they caused illness only in some cases. The most common species were those of the M. avium-intracellulare complex. M. avium-intracellulare and M. fortuitum had a total prevalence of 7.1% and were the most-prevalent NTM that caused disease in these patients (4.5%); they were also responsible for three cases of disseminated infection. Clinical disease caused by M. tuberculosis or NTM and complete tuberculin anergy were associated with stage-IV HIV infection and with CD4 lymphocyte counts <= 400/µL. However, the lack of immunocellular response, shown by limited tuberculin reactivity, was found beginning with the asymptomatic HIV carrier stage. The progressive deterioration of the immune system of HIV-positive patients is the determining factor in the high morbidity and mortality with mycobacteria infections and requires prompt chemoprophylaxis or treatment.

Resumo em Espanhol:

Para determinar el estado nutricional de los niños de 12 a 71 meses de edad, el Ministerio de Salud de Honduras realizó en 1996 una encuesta nacional sobre micronutrientes en la que se incluyeron mediciones antropométricas. De los 1 744 niños que participaron, 38% presentaban retraso del crecimiento, grave en 14%; 24% bajo peso, grave en 4%, y 1% emaciación, grave en 0,1%. El país se puede dividir en tres zonas en función del nivel de retraso del crecimiento y bajo peso: 1) la de baja prevalencia, formada por Tegucigalpa, San Pedro Sula y ciudades medianas; 2) la de prevalencia intermedia, formada por otras zonas urbanas y las zonas rurales del norte y del sur, y 3) la de alta prevalencia, integrada por las zonas rurales del oeste. Mediante un análisis de regresión logística se identificaron los siguientes factores como determinantes importantes del retraso del crecimiento: el nivel de escolaridad de las madres/cuidadoras y de los padres, las fuentes de agua, la localización geográfica de la residencia del niño y la "puntuación de posesiones", referida a la posesión de aparatos como radios, televisores, refrigeradores, equipos de música o planchas eléctricas. A su vez, los factores que predijeron el bajo peso fueron el estado de los micronutrientes, la diarrea, el nivel de escolaridad de las madres/cuidadoras, el tipo de instalación sanitaria y la "puntuación de posesiones". Los datos históricos indican que la prevalencia nacional de desnutrición crónica ha cambiado poco en los últimos 10 años, pese a la importante mejoría de los servicios de salud y a la puesta en marcha de varios planes nacionales de alimentación y nutrición. Es posible que estas intervenciones positivas hayan sido contrarrestadas por los lentos progresos del desarrollo económico. Las futuras intervenciones nutricionales deberían tomar en consideración las necesidades y prioridades percibidas a nivel doméstico, con el fin de fijar objetivos nutricionales realistas.

Resumo em Inglês:

In 1996, the Ministry of Health of Honduras conducted a national micronutrient survey that included anthropometric measurements to determine the nutrition status of children 12-71 months old. Among the 1 744 children who participated, 38% of them were stunted, including 14% who were severely stunted; 24% were underweight, of which 4% were severely underweight; and 1% were wasted, of which 0.1% were severely wasted. The country can be divided into three groupings based on the level of stunting and underweight: 1) lowest prevalence: Tegucigalpa, San Pedro Sula, and medium cities; 2) medium prevalence: other urban areas, the rural north, and the rural south; and 3) highest prevalence: the rural west. Using logistic regression analysis, the important determinants of stunting were found to be: mother/caretaker's and father's schooling, source of water, the dominion (geographic location and strata) in which the child lived, and the "possession score" for ownership of such items as a radio, television, refrigerator, stereo system, and electric iron. The predictors for underweight were micronutrient status, diarrhea, maternal/caretaker's schooling, type of toilet, and possession score. Historical data indicate that the national prevalence of chronic undernutrition has changed little over the last 10 years despite the number of national food and nutrition plans implemented and the significant improvements in health services. It is possible that these positive interventions have been offset by the slow progress in economic development. Future nutrition interventions should take into account household-level perceived needs and priorities in order to set realistic nutrition targets.

Resumo em Português:

A assistência de puericultura é fundamental para a prevenção de diversas doenças durante os primeiros anos de vida da criança. O início precoce e a realização de pelo menos nove consultas no primeiro ano são metas desejáveis na assistência à criança. Inquéritos periódicos são fundamentais para que se possa acompanhar a obtenção destas metas. Em 1994, um estudo transversal utilizou amostragem por conglomerados em três estágios para avaliar cobertura de puericultura e fatores associados entre crianças em São Luís, Estado do Maranhão, Brasil. Para a coleta de dados, um questionário padronizado foi respondido pela mãe ou responsável pela criança. O percentual de recusas e ausências foi de 7%. O presente trabalho analisa os dados relativos a 290 crianças entre 1 e 23 meses. As estimativas pontuais e por intervalo de confiança de 95% das proporções levaram em conta o efeito de desenho. Na estimativa da razão ajustada de prevalências empregou-se a regressão de Cox modificada para estudos transversais. A cobertura de puericultura para a população estudada foi de 80%; 44% das crianças realizaram até seis consultas no primeiro ano de vida -- o que está bem abaixo do recomendável -- com média de 7,8 consultas no primeiro ano. Oitenta e um por cento das crianças utilizaram o Sistema Único de Saúde para o atendimento, sendo de apenas 15% a utilização do seguro-saúde. Após ajuste para fatores de confusão, os fatores "maior número de irmãos no domicílio" e "pai com 4 ou menos anos de estudo" estiveram associados à não realização de consultas de puericultura. O fator "renda familiar" não permaneceu associado após o ajuste. O reforço às atividades educativas e, talvez, aos programas de planejamento familiar, é uma estratégia importante no sentido de aumentar a cobertura de puericultura no município.

Resumo em Inglês:

Pediatric care is fundamental to preventing several diseases during the early years of childhood. Early medical care and having at least nine checkups in the first year of life are the ideal in pediatric care. It is essential to periodically assess whether or not these goals are being met. In 1994, a cross-sectional study was carried out using three-stage cluster sampling to measure coverage of pediatric care and factors associated with that care among children in the city of São Luís, in the state of Maranhão, Brazil. For data collection, a standardized questionnaire was used with the mother of the child or another person responsible for the child. The percentage of those refusing to participate or who were absent was 7%. This work analyzes data concerning 290 children between 1 and 23 months of age. The coverage estimates and 95% confidence intervals took into consideration possible effects of the study design. Cox's regression, modified for cross-sectional studies, was used to estimate adjusted relative risks. Pediatric care coverage for the population studied was 80%. The children had an average of 7.8 checkups in the first year; 44% of the children had six or fewer checkups during the first year of life, well below the recommended number. Eighty-one percent of the children were seen in the Brazilian public health care system (Sistema Único de Saúde, SUS), and only 15% used health insurance. After adjusting for confounding factors, the factors "greater number of siblings at home" and "father with four or fewer years of schooling" were associated with not having checkups. After adjustment, family income was not associated with the number of checkups. Encouraging educational activities and perhaps also family planning programs are important strategies for increasing the coverage of pediatric care in the city of São Luís.

Resumo em Inglês:

This document, which was prepared with the assistance of the American Blood Bank Association and validated by PAHO/WHO's ad hoc Advisory Group for Blood Banks, is intended to provide blood bank managers with quality assurance standards for their units and blood products. The document, which begins by defining the responsibilities of blood bank managers, establishes norms for maintaining a quality assurance system and for the control of (a) documents, information, and registries; (b) the acquisition of goods and services; (c) procedures, including the processing of autologous blood products; (d) product storage, distribution, transportation, labeling, measurement, and follow-up; (e) the inspection and testing of products and of equipment used to inspect, measure, and test; (f) product inspection status; (g) unsatisfactory products and services, and (h) design of new blood products. In the chapter on process control, which is the longest and most technical, the following are discussed: (a) use of informatics programs; (b) qualifications for donors of allogeneic products; (c) blood collection and storage (d) preparation of blood products; (e) compatibility tests and tests to be performed on donors' blood; (f) labeling, emission, and reemission of products; (g) selection of products for transfusion; (h) general conditions for transfusion; (i) irradiation of blood and blood components; (j) procedures for apheresis (plasmapheresis, cytapheresis, and therapeutic apheresis), and (k) special considerations regarding transfusions in children under 4 months of age. Also discussed in the document are the following: (a) the review of agreements with users and with other institutions and centers; (b) corrective action plans or plans to prevent real or potential deficiencies; (c) quality assessments; (d) personnel training; (e) use of statistical methods, and (f) safety of donors, recipients, and personnel.