IntroductionTuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. The advent of immunobiologic therapy with TNF inhibitors agents, has been associated with a significant increase in incident cases of tuberculosis in this population.ObjectiveTo estimate the incidence of tuberculosis in patients receiving TNF inhibitors therapy for rheumatic diseases. As secondary objectives, we sought to evaluate mortality and the clinical impact of screening for latent tuberculosis infection.MethodsThis retrospective study included patients with rheumatic diseases of Public Health System from the Brazilian state, a high TB incidence area, who received prescriptions of TNF inhibitors agents between 2006 and 2016.ResultsA total of 5853 rheumatic disease patients were included. Patients were predominantly women (68.7%) aged 49.5 (± 14.7) years old. Forty-three cases of TB were found (2.86 cases per 1000 person-years; 18 times higher than in the general population). Adalimumab and certolizumab users presented a higher risk for TB development compared to etanercept users (RR: 3.11, 95%CI 1.16–8.35; 7.47, 95%CI 1.39–40.0, respectively). In a subgroup of patients, screening for latent tuberculosis infection was performed in 86% of patients, and 30.2% had a positive tuberculin skin test. Despite latent TB treatment, TB was diagnosed in 2 out of 74 (2.7%) patients. Overall, TB diagnosis did not increase mortality.ConclusionIn this population-based study of rheumatic disease patients from a high incident area, TNF inhibitor exposure was associated with an 18-time increased TB incidence. Adalimumab and certolizumab were associated with greater and earlier TB diagnosis compared to etanercept.

Central venous catheters (CVCs) are frequently used, but the rate of complications is high. This study evaluates the effects of a short training program for CVC insertion in a university-based teaching hospital. A sample of adults with CVCs inserted outside the intensive care unit was selected from two academic years: 2015, year without structured training, and 2016, year with structured training. Clinical and laboratory information, as well as the procedure’s characteristics and complications (mechanical and infectious) were collected. The incidence of complications before and after the training was compared. A total of 1502 punctures were evaluated. Comparing the pre- and post-training period, there was an increase in the choice for jugular veins and the use of ultrasound. A numerical reduction in the rate of complications was identified (RR 0.732; 95% CI 0.48–1.12; P = 0.166). This difference was driven by a statistically significant lower rate of catheter-related infections (RR 0.78; 95% CI 0.64–0.95; P = 0.047). In the multivariate analysis, aspects regarding technique (ultrasound use, multiple punctures) and year of training were associated with outcomes. Structured training reduces the rate of complications related to CVC insertion, especially regarding infections.

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BackgroundTuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, with a high incidence in the general population of Brazil. The advent of immunobiologic therapy with anti-TNF agents for rheumatic diseases, despite achieving substantial efficacy in controlling disease activity, has been associated with a significant increase in incident cases of tuberculosis in this population due to blockade of TNF, which is responsible for maintenance of granuloma structure.ObjectivesEstimate the incidence of tuberculosis in Public Health System patients receiving anti-TNF therapy for rheumatic diseases. As secondary objectives, we sought to evaluate mortality and the influence of screening for latent tuberculosis infection on clinical outcomes in this population.MethodsThis retrospective cohort study included all Public Health System patients from the Brazilian state of Rio Grande do Sul (RS) who received prescriptions of anti-TNF agents for treatment of rheumatic diseases between 2006 and 2016. All data were obtained from official government records (drug dispensing, tuberculosis reporting, and mortality) where notification was mandatory. For a subset of patients, latent tuberculosis screening data were obtained through a review of medical records.ResultsA total of 5853 patients were included from 2006 to 2016, out of which 3653 (62.4%) had rheumatoid arthritis, 1150 (19.7%) had ankylosing spondylitis, 872 (14.9%) had psoriatic arthritis, and 123 (2.1%) had juvenile idiopathic arthritis. Overall, 43 cases of TB were found, with an incidence of 734.7 cases per 100,000 exposed, which corresponds to 2.86 per 1000 person-years exposed. Two hundred and fifty deaths occurred in this cohort. In a subgroup of patients recruited from the outpatient rheumatology clinic of Hospital de Clínicas de Porto Alegre (n = 268), screening for latent tuberculosis infection (LTBI) was performed in 86% of patients before initiation of anti-TNF therapy; 30.1% had a positive tuberculin skin test. LTBI treatment was administered to 74 patients. In this subgroup of patients, 5 cases of TB were diagnosed, 2 in patients who had previously completed LTBI treatment.ConclusionIn this population-based study, a high incidence of tuberculosis among patients with rheumatic diseases exposed to anti-TNF agents was found, reinforcing the need for screening and treatment of LTBI to reduce the risk of reactivation of granulomatous disease. No significant impact on mortality was demonstrated.References[1] Gómez-Reino JJ, Carmona L, Rodríguez Valverde V, Mola EM, Montero MD. Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: A multicenter active-surveillance report. Arthritis Rheum. 2003;[2] Arkema E V, Jonsson J, Baecklund E, Bruchfeld J, Feltelius N, Askling J. Are patients with rheumatoid arthritis still at an increased risk of tuberculosis and what is the role of biological treatments?Ann Rheum Dis. 2014;[3] Gomez-Reino JJ, Carmona L, Angel Descalzo M. Risk of...