Abstract From the arrival of Chikungunya virus in the Americas in 2013 until March 2016, approximately two million cases of the disease have been reported. In Brazil, the virus was identified in 2014 and thousands of people have been affected. The disease has high attack rates, infecting 50% of a population within a few months. Approximately 50% of infected people develop chronic symptoms lasting for months or years. Joint involvement is the main clinical manifestation of Chikungunya. It is characterized by swelling and intense pain that is poorly responsive to analgesics, both in the acute and chronic phase of the disease. This significantly compromises quality of life and may have immeasurable psychosocial and economic repercussions, constituting therefore, a serious public health problem requiring a targeted approach. Physicians are often not familiar with how to approach the management of pain, frequently prescribing limited analgesics, such as dipyrone, in sub-therapeutic doses. In addition, there are few published studies or guidelines on the approach to the treatment of pain in patients with Chikungunya. Some groups of specialists from different fields have thus developed a protocol for the pharmacologic treatment of Chikungunya-associated acute and chronic joint pain; this will be presented in this review.
Objective. The objective of this case-control study was to identify prognostic factors for the outcome of pulmonary tuberculosis among 297 patients who were treated between 1994 and 1999 at the Federal University of Pernambuco Clinics Hospital, in Recife, Pernambuco, Brazil. Methods. The cases were defined as individuals whose treatment ended in death, dropout, or failure. The controls were persons whose treatment ended in cure. The following independent variables were submitted to uni- and multivariate analyses: sex, age, schooling, being a smoker, consuming alcohol, previous treatment for tuberculosis, response to the tuberculin test, HIV serology, resistance to antimicrobial agents, results of direct investigation of alcohol- and acid-resistant bacilli, and treatment approach used. After that, the uni- and multivariate analyses were repeated, including as cases only deaths and individuals with treatment failure. Results. Four risk factors for tuberculosis treatment failure were found: excessive alcohol intake (odds ratio (OR) = 2.58; P = 0.014), co-infection with HIV (OR = 3.40; P = 0.028), previous tuberculosis treatment (OR = 4.89; P < 0.001), and resistance to two or more antituberculosis drugs (OR = 3.49; P = 0.017). In the second multivariate analysis, which excluded dropout cases, no association was found between treatment outcome and excessive alcohol consumption, but the other associations remained. This result suggests a close relationship between alcoholism and treatment dropout. Conclusions. In the group that was studied the prognostic factors for failure of pulmonary tuberculosis treatment were interrelated and were of a biological, clinical, and social character. These factors should be identified at the beginning of treatment in order to allow implementation of specific follow-up procedures such as the strategy of directly observed treatment. This would strengthen tuberculosis control at the local level.
Objetivos. O objetivo deste estudo caso-controle foi identificar fatores prognósticos para desfecho do tratamento da tuberculose pulmonar em 297 pacientes (Hospital das Clínicas, Universidade Federal de Pernambuco, Brasil) entre 1994 e 1999. Materiais e métodos. Foram considerados casos indivíduos com alta por óbito, abandono ou falência do tratamento. Os controles foram indivíduos com alta por cura. Foram realizadas análises uni e multivariada com as variáveis independentes sexo; idade; escolaridade; hábito de fumar; hábito de ingerir álcool; tratamento anterior para tuberculose; resposta ao teste tuberculínico; sorologia para HIV; grau de resistência aos antimicrobianos; resultado da pesquisa direta de bacilos álcool-ácido-resistentes; esquema terapêutico utilizado. Além disso, repetiram-se as análises uni e multivariada considerando como casos apenas os óbitos e os indivíduos com falência do tratamento. Resultados. A ingestão excessiva de álcool (OR = 2,58; P = 0,014), a co-infecção pelo HIV (OR = 3,40; P = 0,028), o a tratamento anterior para tuberculose (OR = 4,89; P < 0,001) e resistência a duas ou mais drogas antituberculose (OR = 3,49; P = 0,017) foram fatores de risco para o insucesso do tratamento. Na segunda análise multivariada, excluindo os casos de abandono, não houve associação entre a o ingestão excessiva de álcool e desfecho do tratamento, mantendo-se as demais associações, o que sugere uma estreita relação entre o abandono do tratamento e o etilismo. Conclusões. Os fatores prognósticos para insucesso do tratamento da tuberculose pulmonar entre os indivíduos estudados estão interrelacionados, sendo de natureza biológica, clínica e social. Devem ser identificados no início do tratamento para que sejam implementados procedimentos diferenciados de acompanhamento, tais como tratamento diretamente supervisionado, de forma a fortalecer o controle da tuberculose em nível local.