Is severe visceral leishmaniasis a systemic inflammatory response syndrome? A case control study

INTRODUCTION: The objective of the study is to identify the main risk factors for death by New World visceral leishmaniasis and establish a coherent pathogenic substrate of severe disease based on clinical findings. METHODS: Seventy-six deceased inpatients and 320 successfully treated inpatients with VL were studied in a case control study. RESULTS: Bacterial infection and bleeding were mutually exclusive events leading to death. Five risk factors were unique for death by bacterial infection (malnutrition, pulmonary rales, severe anemia, severe absolute neutropenia and higher neutrophil count), while another six were unique for death by bleeding (jaundice, severe relative neutropenia, severe thrombocytopenia, liver injury, kidney failure, higher bone marrow parasite load). Bacterial infection, bleeding, severe anemia, diarrhea, dyspnea, edema, jaundice and bone marrow parasite load were the main syndromes of visceral leishmaniasis among successfully treated patients. CONCLUSIONS: The data support the idea that bacterial infections are due to immune paralysis. Broad organ and system involvement is plausibly due to the high production of proinflammatory cytokines, whose actions fit well with visceral leishmaniasis. The syndromes and causative mediators are typical of a slowly developing systemic inflammatory response syndrome.

Insights into the clinical and functional significance of cardiac autonomic dysfunction in Chagas disease

INTRODUCTION: Exclusive or associated lesions in various structures of the autonomic nervous system occur in the chronic forms of Chagas disease. In the indeterminate form, the lesions are absent or mild, whereas in the exclusive or combined heart and digestive disease forms, they are often more pronounced. Depending on their severity these lesions can result mainly in cardiac parasympathetic dysfunction but also in sympathetic dysfunction of variable degrees. Despite the key autonomic effect on cardiovascular functioning, the pathophysiological and clinical significance of the cardiac autonomic dysfunction in Chagas disease remains unknown. METHODS: Review of data on the cardiac autonomic dysfunction in Chagas disease and their potential consequences, and considerations supporting the possible relationship between this disturbance and general or cardiovascular clinical and functional adverse outcomes. RESULTS: We hypothesise that possible consequences that cardiac dysautonomia might variably occasion or predispose in Chagas disease include: transient or sustained arrhythmias, sudden cardiac death, adverse overall and cardiovascular prognosis with enhanced morbidity and mortality, an inability of the cardiovascular system to adjust to functional demands and/or respond to internal or external stimuli by adjusting heart rate and other hemodynamic variables, and immunomodulatory and cognitive disturbances. CONCLUSIONS: Impaired cardiac autonomic modulation in Chagas disease might not be a mere epiphenomenon without significance. Indirect evidences point for a likely important role of this alteration as a primary predisposing or triggering cause or mediator favouring the development of subtle or evident secondary cardiovascular functional disturbances and clinical consequences, and influencing adverse outcomes.

Cost of drugs manufactured by the University Hospital - role of the Central Pharmacy

The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clinicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

Conization, frozen section examination, and planned hysterectomy in the treatment of high-grade cervical intraepithelial neoplasia

PURPOSE: We tested the role of frozen section examination of the cone specimen in the evaluation of the resection margin status and to rule out invasion in patients with high-grade cervical intraepithelial neoplasia. METHODS: Twenty-five patients with cervical intraepithelial neoplasia underwent conization followed by frozen section examination and planned hysterectomy. The results of the definitive paraffin exam were compared with frozen section examination. RESULTS: In the evaluation of the margins by frozen section examination, 16 patients (64%) had positive cone margins and 9 (36%) had negative margins. The definitive paraffin examination of margin status was concordant in all the cases. Intraoperative diagnosis of invasion was made in 5 cases, and 1 of these was microinvasive. Among the remaining 20 cases, we detected 2 additional microinvasive carcinomas after paraffin study, so the diagnosis of the frozen section examination was concordant with the paraffin sections in 23/25 cases (92%). Two cases of microinvasive carcinoma were diagnosed as cervical intraepithelial neoplasia by frozen section examination and had less than 2 mm stromal invasion. CONCLUSIONS: In high-grade cervical intraepithelial neoplasia, frozen section examination can provide immediate and precise evaluation of the cone margin status in high-grade cervical intraepithelial neoplasia. It can identify frank invasion and permit adequate treatment in a one-stage procedure. In early microinvasive disease, frozen section examination fails to detect the area of invasion but reliably detects clear resection margins.

Diffuse panbronchiolitis: an underdiagnosed disease? Study of 4 cases in Brazil

BACKGROUND: Diffuse panbronchiolitis is a clinical pathologic condition characterized by chronic inflammation of respiratory bronchioles, with clinical features that position it as a differential diagnosis among the sinopulmonary syndromes. METHODS AND RESULTS: We present 4 cases (1 Black, 2 Japanese descendants, and 1 Japanese), living in Brazil, in which the diagnosis was made by the clinical and radiological features and confirmed by transbronchial biopsy. The clinical findings included chronic sinusitis, productive cough, rhonchi, and wheezes. The pulmonary function tests showed an obstructive pattern. High resolution computerized tomography showed a diffuse nodular pattern, airway ectasia, and airway wall thickening. The biopsy showed interstitial accumulation of foam cells and lymphoid cells in the walls of respiratory bronchioles: 2 of our cases had bronchus-associated lymphoid tissue hyperplasia. We searched for the HLA Bw54 in all of our patients, but only 1 was positive. A low dose macrolide treatment was introduced, resulting in with clinical and functional improvement. A score that rated the extent of nodules, airway ectasia, mucus plugging, and airway wall thickening was applied on pre- and post-treatment High resolution computerized tomography results, revealing an improvement in tomographic pattern related to that observed in the pulmonary function tests. CONCLUSION: We conclude that diffuse panbronchiolitis is a systemic disease that is not exclusive to the Asian population, whose clinical and radiological features should be better known by occidental pulmonary physicians.

Increasing the efficiency of utilization of soil and fertilizer phosphorus in the subtropical and tropical agricultural systems C

As a rule, soils of the subtropical and tropical regions, in which rainfall is not limiting, are acidic, and low in phosphorus, and, to a less extent, in other macro and micronutrients as well, such a sulfur, boron and zinc. The establishment of a permanent agricultural prac. tice therefore, demands relatively high usage of liming and phosphatic fertilization, to begin with. Several approaches, not mutually exclusive, could be used in order to increase the efficiency of utilization of soil and fertilizer phosphorus so that, goal of diminishing costs of production is reached. The use of liming materials bringing up pH to 6.0-6.5 causes the conversion of iron and aluminum phosphates to more available calcium phosphates; on the other hand, by raising calcium saturation in the exchange complex, it improves the development and operation if the root system which allows c or a higher utilization of all soil nutrients, including phosphorus, and helps of stand water deficits which may occur. The role of mycorrhizal fungi should be considered as a way of increasing soil and fertilizer P utilization, as well as the limitations thereof. Screening of and breeding for varieties with higher efficiency of uptake and utilization of soil and fertilizer phosphorus leads to a reduction in cost of inputs and to higher benefit/cost ratios. Corrective fertilization using ground rock phosphate helps to saturate the fixation power of the soil thereby reducing, as a consequence, the need for phosphorus in the maintenance fertilization. Maintenance fertilization, in which soluble phos-phatic sources are used, could be improved by several means whose performance has been proved: limimg, granula tion, placement, use of magnesium salts. Last, cost of phosphate fertilization could be further reduced, without impairing yields, through impairing yields, through changes in technology designed to obtain products better adapted to local conditions and to the availability or raw materials and energy sources.

Male-female interaction during breeding and non-breeding seasons in Akodon azarae (Rodentia, Muridae)

Dyad encounters between male and female adults of Akodon azarae (Fischer, 1829) were analyzed by means of observational techniques in a natural closure during the breeding and non-breeding seasons. The animals were held in observation during 21 days, with daily 15-minute recordings of interindividual separation distance, relative displacements, characteristics of the male-female interaction, copulation, and construction and exclusive or shared use of nests by each pair. The couples, which bred successfully, showed, on average, the longest separation distance between male and female allowed by the closure. During the first two weeks of gestation the females exhibited more displacements than their respective mates did. The male-pregnant female encounters were significantly more aggressive than those recorded between pairs which did not breed successfully. During the non-breeding season a shorter average distance between individuals and a frequent use of nests shared by the pair were recorded. The results obtained are discussed within the framework of the social system of A. azarae.

Composition and structure of a Miridae (Hemiptera, Heteroptera) assemblage from a relict of deciduous rainforest in southern Brazil

A two-year study was carried out to evaluate the composition, abundance and species richness of Miridae from Parque Estadual do Turvo, municipality of Derrubadas, state of Rio Grande do Sul, Brazil. Samplings were made in the springs of 2003 and 2004 (October), and autumns of 2004 and 2005 (May), using a beating tray method, along two trails of the park. Sampling effort (hours x collectors) in the quantitative collections totaled 153 hours. Two-hundred mirid specimens of 50 species were collected. The most abundant mirid was Prepops setosipes (Reuter, 1910), representing 23% of the collected individuals, followed by Collaria capixaba Carvalho & Fontes, 1981 (10.5%) and Tropidosteptes cribratus (Stål, 1860) (7%), the latter recorded in all sampling periods. The highest abundance was observed in the springs of 2003 and 2004, with 53 and 78 individuals, respectively. Rarefaction method showed that estimated species richness was higher in autumn/2004 than in the other sampling periods, and higher along Yucumã than in Garcia trail. Besides a higher species richeness, Yucumã had more exclusive species than Garcia trail. The percent of species represented by one or two specimens in quantitative samplings (singletons and doubletons) was 60%. Additional samplings including hand collection, random beating tray and light trap collections added 20 species not recorded in the quantitative samplings.

Taxonomic and numeric structure of Chironomidae (Diptera) in different habitats of a Neotropical floodplain

We characterized the local benthic Chironomidae by analyzing the numerical density, biomass, diversity index of Shannon-Wiener and dominance of larvae in the main channel of the Ivinhema River, in a secondary channel, in five lakes connected to the main channel and in five lakes without connection. Of the 68 taxa identified, Aedokritus sp., Tanytarsus sp., Chironomus strenzkei Fittkau, 1968 and Procladius sp.1 were found in all sampling sites and were considered morphospecies with greater of greatest ecological plasticity. Chironomus strenzkei Fittkau, 1968, contributed with the greatest biomass in the central region of lakes without connection, whereas Aedokritus sp. dominated in the littoral of lakes. The greater values of diversity indices in the littoral region of channels were due to the greater water flow and to the higher food availability in these areas. The dominance indices, by contrast, were greater on the central region of these environments. The littoral region has exclusive characteristics, representing habitats that could play important controlling in the numerical density and index diversity on the ecosystem, whereas that the biomass of benthic invertebrates in the central region in some biotopes would have different spatial probably according organisms drift.

Diversity and population characteristics of terrestrial isopods (Crustacea, Oniscidea) across three forest environments in southern Brazil

Terrestrial isopods are important and dominant component of meso and macrodecomposer soil communities. The present study investigates the diversity and species composition of terrestrial isopods on three forests on the Serra Geral of the state of Rio Grande do Sul, Brazil. The area has two natural formations (Primary Woodland and Secondary Woodland) and one plantation of introduced Pinus. The pitfall traps operated from March 2001 to May 2002, with two summer periods and one winter. There were 14 sampling dates overall. Of the five species found: Alboscia silveirensis Araujo, 1999, Atlantoscia floridana (van Name, 1940), Benthana araucariana Araujo & Lopes, 2003 (Philoscidae), Balloniscus glaber Araujo & Zardo, 1995 (Balloniscidae) and Styloniscus otakensis (Chilton, 1901) (Styloniscidae); only A. floridana is abundant on all environments and B. glaber is nearly exclusive for the native forests. The obtained data made it possible to infer about population characteristics of this species. The Similarity Analysis showed a quantitative difference among the Secondary forest and Pinus plantation, but not a qualitative one. The operational sex ratio (OSR) analysis for A. floridana does not reveal significant differences in male and female proportions among environments. The reproductive period identified in the present study for A. floridana was from spring to autumn in the primary forest and Pinus plantation and during all year for the secondary forest. The OSR analysis for B. glaber reveals no significant differences in abundance between males and females for secondary forest, but the primary forest was a significant difference. The reproductive period for B. glaber extended from summer to autumn (for primary and secondary forest). This is the first record for Brazil of an established terrestrial isopod population in a Pinus sp. plantation area, evidenced by the presence of young, adults and ovigerous females, balanced sex ratio, expected fecundity and reproduction pattern, as compared to populations from native vegetation areas.

Ensaios de Mycologia

Morphologically the fungus reminds one of the Microsporum species of man. The microscopic elements are: the shape of the mycelia within the hairs, size and disposition of spores intercalar and terminal chlamydospores, simple clusters, hyphae, pectinate and denticulate elements. Of the 17 species of Microsporum described up to now, none can be identified with Microsporum circuluscentrum. The microsporum described is of the pure-by human type. (Culture fairly vivacious, almost total absence of spindles.) Microscopically at first sight the culture might be taken for Microsporum fulvum URIBURU 1917 or for M. felineum. These are however from animals. The bean shaped culture on potatoes leaves a place apart for it among Microsporum fungi. The anomalous elements seen in the cultures are also found in other species of Microsporum. Besides the pseudo-perithecia described and interpreted I must mention that the pseudo-nodular organs are not an exception among these fungi, for Microsporum fulvum also shows what writers have described as nodular organs. The spiral elements are also not exclusive features of the trichophytes. Microsporum tardum also shows quite characteristic spiral forms.

A vegetação do município de Ilhéus, Estado da Bahia: III - caracterização da vegetação pelo valôr dos índices das espécies

The indices found are analysed as a whole and general conclusions are drawn from them which may be of use in understanding many of the problems offered by the local flora (Ilhéus). The first column of the tables presented indicates the biological form of the species, showing the nature of the flora and the constitution of the climax. A total of 200 species of phanerophyta were found; 69 macrophanerophyta (trees), 54 are mesophanerophyta (treelets) and 77 are nanophanerophyta (shrubs). The macrophanerophyta are consequently considered as dominants and the meso-and nanophanerophyta as codominants (the biological forms: chamaephyta, hemicriptophyta, criptophyta, geophyta, therophyta, epiphyta and hydrophyta are subdominants), the more so as the first cover 80% and the others more or less 50%. This points to a climax of trees and a local vegetation mainly composed of trees also. The smaller forms are left out as they are beyond the present scope of this sort of wort in Brazil. The third column of ecological formulae indicates the reaction of the constituent species to light (C = sciophilous, F = photophilous and I = indifferents), the biological types of vegetation (H = hygrophytes, X = xerophytes and M = mesophytes) and the fidelity of the species to the climax. Of the species studied: 25 are pioneers (P. Table I), 63 are accidentals (A. Table II), 35 are companion species (O. Table III), 19 show preferences (E. Table with vitality Vn), 44 are selective (S. Table V) and 13 exclusive species (L. Table VI). This leads to the conclusion that the vegetation of the region is in full reconstitution. As to the ecological characteristics of the 200 species studied, 89 are either pioneers (a class separated by the author) or accidentals; this means that the devastated zones are being reconstituted in the subsere both with members of the prisere and alien species. Of the remaining species, 54 are companion, or accompanying species, which appear in most subclimax, serclímax and quasiclimax associations, and 57 are real constituents of the local climax. As all the species except the pioneers, selectives and exclusives (xerophytes and mesophytes) may be considered as hygrophytes this type evidently predominantes in the region and may constitute a hygrophilous serclimax and quasiclímax. In regard to light 101 are sciophilous, 32 indiferents and 67 photophilous. This leads to the conclusion that the vegetation comprises mainly tolerant species, showing the hygrophilous and mesophilous character of the region with a vegetation composed mostly of trees. The presence a large number of sciophilous species is easy to understand as the hygrophilous and mesophilous habitats and the dominance of trees favour the germination and growth of tolerant species. The last two columns analyse the percentage of individuals present and the occurrent classes to which they belong: 92 species vary between 1 and 9%; 50 between to 10 and 19%; 36 between 20 and 29%; 14 between 30 and 39%; and 8 between 40 and 49%. Only 8 species belong to occurrence class V; 14 to classe IV; 36 to class III; 50 to class II; and 92 to class I. This leads to the conclusion that the local formation is very unsociable and very complex, though the median coverture is 80% and the number of species is very large. The analysis of the data also shows that the climax is being reconstituted in the subsere with elements drawn from the prisere and alien species introduced either by man (following desvastation) or by other consequent factors (such as brusque changes of microclimates due to total or partial destruction). This modifies the subclimax appreciably and apparently also the climax of the local regional subsere. As a final conclusion it is suggested that as in the subsere the pioneer formation is xerophilous, the prisere also beging as a xerosere; but as there are and probably always were hydrophilous formation evolving in the same climate, the local climax is composed of species with medium exactions, that is of relative mesophites.

Description of the Occurrence of Canine Dirofilariasis in the State of Rio de Janeiro, Brazil

In order to evaluate the prevalence of canine heartworm in the State of Rio de Janeiro, a multicenter survey was carried out in two phases. The survey involved 1376 dogs from two cities: Rio de Janeiro and Niterói, and its surroundings, including the eastern shore and mountain resorts, which were further divided into sections. In the first phase, 795 dog blood samples were examined by the modified Knott test for the detection of microfilariae. A total of 134 samples (16.85%) were microfilaremic: 8.61% from Rio de Janeiro, 21.76% from Niterói and its surroundings, 33.33% from the eastern shore and 30.43% from the mountain resorts. In the second phase, 595 dog blood samples were examined first by the modified Knott test and the amicrofilaremic samples were subsequently examined by an immunoenzymatic test (ELISA) for antigen detection. In summary, 83 samples (13.95%) were microfilaremic and 44 (7.98%) of the amicrofilaremic samples were positive for heartworm antigen (occult infections). In Rio de Janeiro, 13.68% of the dogs were infected (i.e., antigen-and/or microfilaria-positive) and 8.51% of the dogs had microfilaremic infections. In comparison, Niterói and its surroundings showed values of 24.46% and 17.30% and the eastern shore showed values of 52.46% and 31.15%. In contrast the mountain resorts showed 20% microfilaremic only

Comparative developmental and susceptibility to insecticide of Bolivian and Brazilian populations of Triatoma infestans

The triatomine bug Triatoma infestans probably originated in Bolivia and dispersed passively over wide areas of South America, where it is the principal vector of Trypanosoma cruzi. In the region of its probable origin this species shows colonization in two different ecotopes, so that it may be encountered in sylvatic as well as in artificial habitats. The sylvatic colonization pattern is not observed in the rest of its range, where T. infestans is exclusive to man-made habitats. The objective of this study was to compare several aspects of two T. infestans populations, one from Minas Gerais (Brazil) and the other from the Cochabamba Valley (Bolivia), with a view to elucidate the factors associated with the different colonization patterns observed for this species. The differences between the developmental cycle, weight, capacity to ingest blood and mortality rate of first instar nymphs should indicate more fragility of Brazilian population that may be related to its elimination possibility.

Schistosomiasis protects against multiple sclerosis

The incidences of schistosomiasis and multiple sclerosis (MS) are mutually exclusive worldwide suggesting that schistosomiasis may offer protection against the induction of the immune-mediated disease, MS. Recent studies using the mouse model of MS, experimental autoimmune encephalomyelitis, support a direct suppression of the onset of MS by chronic Schistosoma mansoni infection. Self-reactive Th1 but not Th2 responses develop in infected mice immunized with myelin oligodendrocyte glycoprotein albeit at reduced levels indicating that the induction of auto-reactive T cells is not abolished nor phenotypically altered. CNS infiltration by inflammatory cells, particularly macrophages, is significantly reduced in S. mansoni-infected, immunized mice compared to uninfected, immunized mice. Because activated macrophages are crucial to the induction of clinical disease, these findings support the hypothesis that differences in macrophage activation may contribute to the reduced incidence and delayed progression of experimental autoimmune encephalomyelitis during schistosomiasis.