Opportunistic infections among individuals with HIV-1/AIDS in the highly active antiretroviral therapy era at a Quaternary Level Care Teaching Hospital

INTRODUCTION : In this study, clinical-laboratory and epidemiological characteristics are described for a group of 700 individuals with HIV (human immunodeficiency virus)/AIDS (acquired immunodeficiency syndrome) in the ART (antiretroviral therapy) era at a teaching hospital that provides a quaternary level of care, with an emphasis on opportunistic infections (OIs), co-infections and immune profile. METHODS : A retrospective cross-sectional study of AIDS cases was conducted from 1998 to 2008 by reviewing medical records from the Base Hospital/FUNFARME (Fundação Faculdade Regional de Medicina), São José do Rio Preto, São Paulo, Brazil. RESULTS: The individuals were 14 to 75 years of age, and 458 were males. Heterosexuals accounted for 31.1% of all patients. Eighty-three percent were on ART, and 33.8% of those presented difficulties with treatment adherence. OIs were analyzed from medical records, and Pneumocystis jiroveci pneumonia was the most prevalent, regardless of the LTCD4+ (TCD4+ Lymphocytes) levels. Individuals whose viral loads were ≥10,000 showed a 90% greater chance of neurotoxoplasmosis. For P. jiroveci pneumonia, neurotoxoplasmosis, esophageal candidiasis, pulmonary tuberculosis and neurocryptococcosis, the chances of infection were higher among patients with LTCD4+ levels below 200 cells/mm3. HIV/hepatitis C virus (HCV) and HIV/hepatitis B virus (HBV) co-infections were significantly associated with death. CONCLUSIONS : OIs remain frequent in the ART era even in populations where the access to medical care is considered satisfactory.

Pharmacokinetic/pharmacodynamic target attainment of intravenous β-lactam regimens against Gram-negative bacteria isolated in a Brazilian teaching hospital

ABSTRACTINTRODUCTION: Monte Carlo simulations have been used for selecting optimal antibiotic regimens for treatment of bacterial infections. The aim of this study was to assess the pharmacokinetic and pharmacodynamic target attainment of intravenous β-lactam regimens commonly used to treat bloodstream infections (BSIs) caused by Gram-negative rod-shaped organisms in a Brazilian teaching hospital.METHODS: In total, 5,000 patients were included in the Monte Carlo simulations of distinct antimicrobial regimens to estimate the likelihood of achieving free drug concentrations above the minimum inhibitory concentration (MIC; fT > MIC) for the requisite periods to clear distinct target organisms. Microbiological data were obtained from blood culture isolates harvested in our hospital from 2008 to 2010.RESULTS: In total, 614 bacterial isolates, including Escherichia coli, Enterobacterspp., Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa, were analyzed Piperacillin/tazobactam failed to achieve a cumulative fraction of response (CFR) > 90% for any of the isolates. While standard dosing (short infusion) of β-lactams achieved target attainment for BSIs caused by E. coliand Enterobacterspp., pharmacodynamic target attainment against K. pneumoniaeisolates was only achieved with ceftazidime and meropenem (prolonged infusion). Lastly, only prolonged infusion of high-dose meropenem approached an ideal CFR against P. aeruginosa; however, no antimicrobial regimen achieved an ideal CFR against A. baumannii.CONCLUSIONS:These data reinforce the use of prolonged infusions of high-dose β-lactam antimicrobials as a reasonable strategy for the treatment of BSIs caused by multidrug resistant Gram-negative bacteria in Brazil.

Cryptococcosis in Atlántico, Colombia: an approximation of the prevalence of this mycosis and the distribution of the etiological agent in the environment

ABSTRACTINTRODUCTION:Cryptococcosis is an invasive disease acquired by inhalation of infectious propagules from the environment. Currently, compulsory notification of the spread of this disease is not required in Colombia. However, reporting of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome cases to the National Surveillance System has suggested that there is a growing population at risk of contracting cryptococcosis. Few studies have described the occurrence of cryptococcosis in Colombia. Therefore, in this study, we examined the pathology of this disease in Atlántico, Colombia and determined the distributions of Cryptococcus neoformans and Cryptococcus gattii in the environment.METHODS:Clinical samples/isolates were gathered from cases of cryptococcosis previously diagnosed at health institutions in Atlántico, and surveys were completed by clinicians. The environmental study considered 32 sampling points and three tree species, i.e., Quickstick ( Gliricidia sepium ), Almond ( Terminalia catappa ), and Pink trumpet ( Tabebuia rosea ). Environmental and clinical samples/isolates were analyzed for phenotypic and genotypic confirmation.RESULTS:From 1997-2014, 41 cases of cryptococcosis were reported. The mean patient age was 40.5 years (range: 18-63 years); 76% were men, and 78% were HIV positive. Isolation was possible in 38 cases ( C. neoformans , molecular type VNI in 37 cases and C. gattii , molecular type VGI in one case). In 2012-2014, 2,068 environmental samples were analyzed with a positivity of 0.4% ( C. neoformans , molecular type VNI) in Almond and Pink trumpet trees.CONCLUSIONS:Cryptococcus neoformans , molecular type VNI had a higher prevalence than C. gattii and was associated with human exposure and the pathogenesis of cryptococcosis in this geographical region.

Predictive factors for Leishmania infantum infection in dogs examined at a veterinary teaching hospital in Teresina, State of Piauí, Brazil

Abstract: INTRODUCTION: In Brazil, culling of seropositive dogs is one of the recommended strategies to control visceral leishmaniasis. Since infectiousness is correlated with clinical signs, control measures targeting symptomatic dogs could be more effective. METHODS: A cross-sectional study was carried out among 1,410 dogs, predictive models were developed based on clinical signs and an indirect immunofluorescence antibody test. RESULTS: The validated predictive model showed sensitivity and specificity of 86.5% and 70.0%, respectively. CONCLUSIONS: Predictive models could be used as tools to aid control programs in focusing on a smaller fraction of dogs contributing more to infection dissemination.

Prevalence rates of infection in intensive care units of a tertiary teaching hospital

OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of São Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69%) received antimicrobials on the day of study, 72 (57%) for treatment, and 15 (12%) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8%), non- intensive care unit nosocomial infection in 24 (33.3%), and intensive care unit-acquired infection in 22 patients (30.6%). Eleven patients (15.3%) had no defined type. The most frequently reported infections were respiratory (58.5%). The most frequently isolated bacteria were Enterobacteriaceae (33.8%), Pseudomonas aeruginosa (26.4%), and Staphylococcus aureus (16.9%; [100% resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8%. Patients with infection had a mortality rate of 34.7%. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms). Factors such as nasogastric intubation, postoperative status, and age ³60 years were significantly associated with infection. This study documents the clinical impression that prevalence rates of intensive care unit-acquired infections are high and suggests that preventive measures are important for reducing the occurrence of infection in critically ill patients.

Diversity of sand flies in domiciliary environment of Santarém, state of Pará, Brazil: species composition and abundance patterns in rural and urban areas

This paper aimed to evaluate the richness, abundance and frequency of sand fly occurrence in rural and urban areas American visceral Leishmaniasis -AVL is endemic in the study area of Santarém municipality, Pará state. Sand flies were collected during 1995-2000, using CDC light traps placed in neighborhoods and rural areas of the municipality. A total of 53.454 individuals and 26 species of sand flies were collected. The most abundant species in both urban and rural environments was Lutzomyia longipalpis, vector of AVL in the area. The highest species richness by capture was in rural area. In all years sampled, the largest number of species of sand fly collected was always in rural areas. The species of sand flies in urban and rural area were similar in 11 species. In the rural area other 11 species were found, a total of 22 species. Shannon-Wiener index ranged from 0.12 to 0.84 at rural areas and 0.08 to 0.34 at urban ones. In general, rural localities showed higher diversity (H') of phlebotomines than urban ones. Individual-based rarefaction curves for each area demonstrated that urban localities had the lowest expected number of phlebotomine species and the richest rural ones reach higher expected values with lower amount of individuals than urban sites. The most frequent species were Lutzomyia longipalpis, Evandromyia carmelinoi and Bichromomyia flaviscutellata.

The Need for Pedagogical Qualifications for Teaching Cardiology to Undergraduate Students

OBJECTIVE: To report a training program in cardiology emphasizing changes in its pedagogical practice. These changes were put into practice by some teachers at the Medical School of Porto Alegre of the University of Rio Grande do Sul (FAMED/UFRGS) aiming to make faculty and student activities more dynamic and to promote more efficacious learning. The training program is directed at 5th semester medical students and aims at a behavioral change in teachers and students to promote more interaction, to favor exchanges, and to make the teaching-learning process easier, always maintaining the patient in the center of the medical activity. METHODS: The program emphasizes the definition of general and specific objectives for each activity to be developed by the students, with training in the area of admission to the cardiology service, with special emphasis on behavioral change in the cognitive, motor, affective, and attitudinal areas. Knowledge was developed by means of interactive seminars with initial and final assessment tests to identify students' and teachers' performance. The students were evaluated in an immediate, continuous, and progressive way in their daily activities and through comparison of the results of 2 tests, one applied at the beginning of the training and the other at its end. These 2 tests contained the same questions. RESULTS: We systematically assessed 560 students over 4 years. The mean grades of the tests performed prior to and after the 244 seminars were 7.38±1.66 and 9.17± 0.82, respectively (p<0.0001). For the tests applied at the beginning and at the end of the training, the mean grades were 5.61±1.61 and 9.37±0.90, respectively (p<0.0001). CONCLUSION: The program proved to be efficient both for the students' learning and for assessing their performance in a systematic and objective way.

Teaching Basic Life Support to Students of Public and Private High Schools

Background:Despite being recommended as a compulsory part of the school curriculum, the teaching of basic life support (BLS) has yet to be implemented in high schools in most countries.Objectives:To compare prior knowledge and degree of immediate and delayed learning between students of one public and one private high school after these students received BLS training.Methods:Thirty students from each school initially answered a questionnaire on cardiopulmonary resuscitation (CPR) and use of the automated external defibrillator (AED). They then received theoretical-practical BLS training, after which they were given two theory assessments: one immediately after the course and the other six months later.Results:The overall success rates in the prior, immediate, and delayed assessments were significantly different between groups, with better performance shown overall by private school students than by public school students: 42% ± 14% vs. 30.2% ± 12.2%, p = 0.001; 86% ± 7.8% vs. 62.4% ± 19.6%, p < 0.001; and 65% ± 12.4% vs. 45.6% ± 16%, p < 0.001, respectively. The total odds ratio of the questions showed that the private school students performed the best on all three assessments, respectively: 1.66 (CI95% 1.26-2.18), p < 0.001; 3.56 (CI95% 2.57-4.93), p < 0.001; and 2.21 (CI95% 1.69-2.89), p < 0.001.Conclusions:Before training, most students had insufficient knowledge about CPR and AED; after BLS training a significant immediate and delayed improvement in learning was observed in students, especially in private school students.

Effects of environment on quality of tomato transplanting plants

In order to study the effects of shading and unshading combined with N fertilizing on tomato transplanting plants, an experiment in greenhouse conditions was carried on. It was concluded that N is important to produce healthy and strong plants. Under shading plus N fertilization, plants are taller and have high nitrate contents, while under unshading plus N fertilization, plants have higher diameter and more developed root system.

Two decades of colonization of the urban environment of Porto Alegre, southern Brazil, by Drosophila paulistorum (Diptera, Drosophilidae)

Drosophila paulistorum Dobzhansky & Pavan, 1949 had initially been considered absent in anthropogenically disturbed environments, but in 1985 the detection of the species in Porto Alegre city, southern Brazil, suggested its potential to colonize new habitats and laid the foundations for ecologic studies on this species' populations. This study followed the variations in D. paulistorum populations in this town almost 20 years after its first local record. Drosophilid specimens were collected in sites with different urbanization grades and the results point to the expressive decline in D. paulistorum populations in Porto Alegre. This decline may be linked to urban growth and to naturally driven population decline, as imputed to climatic changes like variations in maximum and minimum temperatures as a consequence of a global climate warming. Also, the recent introduction of exotic species Zaprionus indianus Gupta, 1970 seems to play a role in this scenario, changing the interactions between native species.

Seasonal variations in the intermediate metabolism of the crayfish Parastacus brasiliensis (Crustacea, Decapoda, Parastacidae) in the natural environment and experimental culture

The goal of this study was to evaluate the effects of seasonal variations on energy metabolism in different tissues of the freshwater crayfish Parastacus brasiliensis (von Martens, 1869). Crayfish were collected monthly from January 2001 to January 2003 in São Francisco de Paula, Rio Grande do Sul, Brazil, in a stream and in a culture tank. Haemolymph samples were collected from each crayfish in the field with a syringe, by puncturing the membrane at the base of the chelipeds. Hepatopancreas, gills, and abdominal muscle were removed for determination of free glucose, glycogen, total lipids, and triglycerides. The haemolymph samples were used for determination of glucose, total proteins, total lipids, and triglycerides. Statistical analysis revealed significant differences in biochemical composition in crayfish collected in the stream compared to the experimental tank during the year, principally in glucose and triglycerides in haemolymph, glycogen and total lipids in all tissues study, and triglycerides only in abdominal muscle. The regular food intake partially modified these seasonal variations of the metabolic pattern. Environmental conditions (e.g., food availability and water temperature) and reproductive period appeared to be the main factors influencing the seasonal patterns of variation in energy metabolism.

Prey consumed by Guiana dolphin Sotalia guianensis (Cetacea, Delphinidae) and franciscana dolphin Pontoporia blainvillei (Cetacea, Pontoporiidae) in an estuarine environment in southern Brazil

The present study provides information about the diet of sympatric populations of small cetaceans in the Babitonga Bay estuary. This is the first study on the diet of these species in direct sympatry. The stomach contents of seven Guiana dolphins Sotalia guianensis and eight franciscanas Pontoporia blainvillei were analyzed. The prey of both cetaceans was mostly teleost fishes, followed by cephalopods. We identified 13 teleost fishes as part of the diet of the franciscanas, and 20 as part of the diet of Guiana dolphins. Lolliguncula brevis was the only cephalopod recorded, and was the most important prey for both cetaceans. Stellifer rastrifer and Gobionellus oceanicus were also important for franciscana, so as Mugil curema and Micropogonias furnieri were important for Guiana dolphins. Stellifer rastrifer and Cetengraulis edentulus were the fishes with the highest frequency of occurrence for franciscana (50%), while Achirus lineatus, C. edentulus, S. brasiliensis, Cynoscion leiarchus, M. furnieri, M. curema, Diapterus rhombeus, Eugerres brasilianus and G. oceanicus showed 28.6% of frequency of occurrence for Guiana dolphins. Franciscanas captured greater cephalopods than the Guiana dolphins in both total length (z= -3.38; n= 40; p< 0.05) and biomass (z = -2.46; n = 40; p<0.05). All of the prey species identified occur inside the estuary, which represents a safe habitat against predators and food availability, reinforcing the importance of the Babitonga Bay for these cetacean populations.

Biological control of Biomphalaria tenagophila (Mollusca, Planorbidae), a schistosomiasis vector, using the fish Geophagus brasiliensis (Pisces, Cichlidae) in the laboratory or in a seminatural environment

In order to investigate a possible method of biological control of schistosomiasis, we used the fish Geophagus brasiliensis (Quoy & Gaimard, 1824) which is widely distributed throughout Brazil, to interrupt the life cycle of the snail Biomphalaria tenagophila (Orbigny, 1835), an intermediate host of Schistosoma mansoni. In the laboratory, predation eliminated 97.6% of the smaller snails (3-8 mm shell diameter) and 9.2% of the larger ones (12-14 mm shell diameter). Very promising results were also obtained in a seminatural environment. Studies of this fish in natural snail habitats should be further encouraged.

Bacillus sphaericus mosquito pathogens in the aquatic environment

The fate of Bacillus sphaericus spores in the aquatic environment was investigated by suspending spores in dialysis bags in fresh and seawater. Spore viability was lost more rapidly in seawater. Neither B. sphaericus nor B. thuringiensis israelensis (B.t.i.) spores mixed with pond sediment appeared to attach to the sediment. However, rapid decrease in B.t.i. toxicity suggested attachment of parasporal bodies to sediment. B. sphaericus toxin settled more slowly and less completely. B. sphaericus spores fed to larvae of four aquatic invertebrates were mostly eliminated from the animal gut in less than one week. An exception was the cranefly (Tipula abdominalis) where spores persisted in the posterior gut for up to five weeks.