RESUMO O papel dos elementos-traço na virulência da dengue não é ainda conhecido. O presente estudo avaliou os níveis séricos de dois micronutrientes, cobre e ferro, em casos de dengue. O estudo envolveu 96 pacientes dos quais 48 apresentavam dengue grave ou não grave (com ou sem sinais de alerta), e outros 48 pacientes com outras doenças febris (OFI) representaram os controles. Níveis séricos de cobre e ferro foram avaliados na admissão e no momento da defervescência usando kits comerciais disponíveis. À admissão, nenhuma diferença nos níveis séricos de cobre foi observada entre casos e controles. No grupo com dengue, os níveis de cobre se encontravam significativamente reduzidos nos casos graves e não graves com sinais de alerta, em comparação aos casos não graves sem sinais de alerta. Contrariamente, no momento da defervescência os níveis de cobre se encontravam aumentados em todos os casos de dengue em relação aos controles com outras doenças febris (OFI), no entanto, nenhuma diferença foi observada entre os casos de dengue. Diferentemente dos pacientes com outras doenças febris, os casos de dengue mostraram um padrão de elevação dos níveis de cobre do dia da admissão até a defervescência. Por outro lado, estas diferenças não foram observadas em relação aos níveis de ferro entre os dois grupos, com exceção de níveis de ferro reduzidos encontrados nos casos graves, em comparação aos não graves com sinais de alerta. Os resultados mostram que o cobre está associado à gravidade da dengue e esta observação enfatiza a necessidade de investigação do envolvimento de elementostraço na gravidade da doença para melhorar o prognóstico da dengue.

SUMMARY The role of trace elements in dengue virulence is not yet known. The present study assessed the serum levels of two micronutrients, copper and iron, in cases of dengue fever. The study involved 96 patients of whom 48 had either severe or non-severe forms of dengue (with and without warning signs), and the remaining 48 were patients with other febrile illnesses (OFI), used as controls. Serum levels of copper and iron were evaluated at admission and by the time of defervescence using commercially available kits. At admission, no difference in the level of serum copper was observed between cases and controls. In the group of dengue cases, the copper level was found to be significantly decreased in severe and non-severe cases with warning signs, compared to non-severe cases without warning signs. In contrast, by the time of defervescence the copper level was found to be increased in all dengue cases compared to OFI controls, but no difference was observed among dengue cases. Unlike OFI controls, dengue cases showed an increasing pattern of copper levels from admission until defervescence. On the other hand, no such significant differences were observed in the serum level of iron in the clinical groups, except for a decreased iron level found in severe cases, compared to non-severe dengue without warning signs. The results show that copper is associated with dengue severity and this finding emphasizes the need to investigate the involvement of trace elements in disease severity so as to improve the prognosis of dengue.

PROBLEM: Antiretroviral therapy (ART) programmes have been successful in several countries. However, whether they would succeed as part of a national programme in a resource-constrained setting such as India is not clear. The outcomes and specific problems encountered in such a setting have not been adequately studied. APPROACH: We assessed the efficacy and functioning of India's national ART programme in a tertiary care centre in northern India. All ART-naive patients started on ART between May 2005 and October 2006 were included in the study and were followed until 31 April 2008. Periodic clinical and laboratory evaluations were carried out in accordance with national guidelines. Changes in CD4+ lymphocyte count, body weight and body mass index were assessed at follow-up, and the operational problems analysed. LOCAL SETTING: The setting was a tertiary care centre in northern India with a mixed population of patients, mostly of low socioeconomic status. The centre is reasonably well resourced but faces constraints in health-care delivery, such as lack of adequate human resources and a high patient load. RELEVANT CHANGES: The response to ART in the cohort studied was comparable to that reported from other countries. However, the programme had a high attrition rate, possibly due to patient-related factors and operational constraints. LESSONS LEARNT: A high rate of attrition can affect the overall efficacy and functioning of an ART programme. Addressing the issues causing attrition might improve patient outcomes in India and in other resource-constrained countries.

PROBLEMA: Los programas de tratamiento antirretroviral (TAR) han cosechado buenos resultados en varios países. Sin embargo, no está claro si se desarrollarían también de forma satisfactoria como componente de un programa nacional en un entorno con recursos limitados como la India. Los resultados y los problemas específicos observados en esas circunstancias no han sido estudiados adecuadamente. ENFOQUE: Se evaluó la eficacia y el funcionamiento del programa nacional de TAR de la India en un centro de atención terciaria del norte del país. Se incluyó en el estudio a todos los pacientes sin tratamiento antirretrovírico previo que empezaron a tomar antirretrovirales entre mayo de 2005 y octubre de 2006, los cuales fueron sometidos a seguimiento hasta el 31 de abril de 2008. De forma periódica se llevaron a cabo evaluaciones clínicas y de laboratorio de conformidad con las directrices nacionales. En cada sesión de seguimiento se analizaron la variación del recuento de linfocitos CD4+, el peso corporal y el índice de masa corporal, así como los problemas operacionales surgidos. CONTEXTO LOCAL: Se trabajó en un centro de atención terciaria del norte de la India con una población diversa de pacientes, la mayoría de nivel socioeconómico bajo. El centro cuenta con unos recursos razonables, pero ve tensionada su capacidad asistencial debido a la falta de recursos humanos apropiados y al alto volumen de pacientes. CAMBIOS DESTACABLES: La respuesta a la TAR en la cohorte estudiada fue comparable a la descrita en otros países. Sin embargo, el programa presentó una tasa de deserción elevada, posiblemente debido a factores relacionados con el paciente y a limitaciones operacionales. ENSEÑANZAS EXTRAÍDAS: Una alta tasa de deserción puede menoscabar la eficacia y el funcionamiento globales de los programas de ART. Encarando los problemas causantes de esas deserciones se podría conseguir que los pacientes evolucionaran mejor en la India y en otros países con recursos limitados.

PROBLÉMATIQUE: Les programmes de traitement antirétroviral (TARV) ont donné des résultats satisfaisants dans plusieurs pays. Néanmoins, il n'est pas certain qu'un tel programme réussisse dans le cadre du programme national d'un pays aux ressources limitées comme l'Inde. Les résultats et les problèmes spécifiques rencontrés dans ce type de contexte n'ont pas encore été suffisamment étudiés. DÉMARCHE: Nous avons évalué l'efficacité et le fonctionnement du Programme TARV national indien dans le cadre d'un centre de soins tertiaires du Nord de l'Inde. Tous les patients auparavant naïfs de traitement ARV et ayant débuté ce traitement entre mai 2005 et octobre 2006 ont été inclus dans l'étude et ont été suivis jusqu'au 31 avril 2008. Des évaluations cliniques et analytiques périodiques ont été effectuées conformément aux directives nationales. Les évolutions de la numération des lymphocytes CD4+, du poids corporel et de l'indice de masse corporelle ont été évaluées dans le cadre du suivi et les difficultés opérationnelles ont été analysées. CONTEXTE LOCAL: L'étude s'est déroulée dans un centre de soins tertiaires du Nord de l'Inde, sur une population mixte de patients, dont la plupart présentaient un faible statut socioéconomique. Ce centre était raisonnablement bien doté en ressources, mais devait faire face à des contraintes dans la délivrance des soins, telles que le manque de personnel approprié et la forte affluence des patients. MODIFICATIONS PERTINENTES: La réponse au TARV dans la cohorte étudiée était comparable à celles rapportés dans d'autres pays. Néanmoins, le programme présentait un taux d'attrition élevé, pouvant être dû à des facteurs liés aux patients et aux contraintes de fonctionnement du centre. ENSEIGNEMENTS TIRÉS: Un taux élevé d'attrition peut nuire à l'efficacité globale et au fonctionnement du programme TARV. Remédier aux problèmes à l'origine de cette attrition pourrait améliorer les résultats thérapeutiques pour les patients en Inde et dans d'autres pays à ressources limitées.