Chronic phase of Chagas disease: why should it be treated? A comprehensive review

The pathogenesis and evolutive pattern of Chagas disease suggests that the chronic phase should be more widely treated in order to (i) eliminate Trypanosoma cruzi and prevent new inflammatory foci and the extension of tissue lesions, (ii) promote tissue regeneration to prevent fibrosis, (iii) reverse existing fibrosis, (iv) prevent cardiomyopathy, megaoesophagus and megacolon and (v) reduce or eliminate cardiac block and arrhythmia. All cases of the indeterminate chronic form of Chagas disease without contraindications due to other concomitant diseases or pregnancy should be treated and not only cases involving children or recently infected cases. Patients with chronic Chagas cardiomyopathy grade II of the New York Heart Association classification should be treated with specific chemotherapy and grade III can be treated according to medical-patient decisions. We are proposing the following new strategies for chemotherapeutic treatment of the chronic phase of Chagas disease: (i) repeated short-term treatments for 30 consecutive days and interval of 30-60 days for six months to one year and (ii) combinations of drugs with different mechanisms of action, such as benznidazole + nifurtimox, benznidazole or nifurtimox + allopurinol or triazole antifungal agents, inhibition of sterol synthesis.

A single nucleotide polymorphism, rs129679860, in the IL28B locus is associated with the viral kinetics and a sustained virological response in a chronic, monoinfected hepatitis C virus genotype-1 Brazilian population treated with pegylated interferon-ribavirin

Single nucleotide polymorphisms (SNPs) in the interleukin (IL)28B locus have been associated with a sustained virological response (SVR) in interferon-ribavirin (IFN-RBV)-treated chronic hepatitis C virus (HCV)-infected patients in European and African populations. In this study, the genotype frequency of two IL28B SNPs (rs129679860 and rs8099917) in a cohort of chronic HCV-monoinfected patients in Brazil was evaluated and the SNP sufficient to predict the treatment response outcome was determined. A total of 66 naïve genotype-1 chronic HCV-infected patients were genotyped and the associated viral kinetics and SVR were assessed. The overall SVR was 38%. Both the viral kinetics and SVR were associated with rs129679860 genotypes (CC = 62% vs. CT = 33% vs. TT = 18%, p = 0.016). However, rs8099917 genotypes were only associated with SVR (TT = 53% vs. TG = 33% vs. GG = 18%; p = 0.032). In this population, the analysis of a single SNP, rs12979860, successfully predicts SVR in the IFN-RBV treatment of HCV.

Variability and resistance mutations in the hepatitis C virus NS3 protease in patients not treated with protease inhibitors

The goal of treatment of chronic hepatitis C is to achieve a sustained virological response, which is defined as exhibiting undetectable hepatitis C virus (HCV) RNA levels in serum following therapy for at least six months. However, the current treatment is only effective in 50% of patients infected with HCV genotype 1, the most prevalent genotype in Brazil. Inhibitors of the serine protease non-structural protein 3 (NS3) have therefore been developed to improve the responses of HCV-infected patients. However, the emergence of drug-resistant variants has been the major obstacle to therapeutic success. The goal of this study was to evaluate the presence of resistance mutations and genetic polymorphisms in the NS3 genomic region of HCV from 37 patients infected with HCV genotype 1 had not been treated with protease inhibitors. Plasma viral RNA was used to amplify and sequence the HCV NS3 gene. The results indicate that the catalytic triad is conserved. A large number of substitutions were observed in codons 153, 40 and 91; the resistant variants T54A, T54S, V55A, R155K and A156T were also detected. This study shows that resistance mutations and genetic polymorphisms are present in the NS3 region of HCV in patients who have not been treated with protease inhibitors, data that are important in determining the efficiency of this new class of drugs in Brazil.

A serological, parasitological and clinical evaluation of untreated Chagas disease patients and those treated with benznidazole before and thirteen years after intervention

The etiological treatment of Chagas disease is recommended for all patients with acute or recent chronic infection, but controversies remain regarding the benefit of chemotherapy and interpretations of the parasitological cure after etiological treatment. This study compares the laboratory and clinical evaluations of Chagas disease patients who were diagnosed 13 years earlier. Fifty-eight Chagas disease patients (29 treated with benznidazole and 29 untreated) were matched at the time of treatment based on several variables. Conventional serology revealed the absence of seroconversion in all patients. However, lower serological titres were verified in the treated group, primarily among patients who had the indeterminate form of the disease. Haemoculture performed 13 years after the intervention was positive for 6.9% and 27.6% of the treated and untreated patients, respectively. Polymerase chain reaction tests were positive for 44.8% and 13.8% of the treated and untreated patients, respectively. Patients who presented with the indeterminate form of the disease at the beginning of the study exhibited less clinical progression (17.4%) compared with the untreated group (56.5%). Therefore, this global analysis revealed that etiological treatment with benznidazole may benefit patients with respect to the clinical progression of Chagas disease and the prognosis, particularly when administered to patients with the indeterminate form of the disease.

Tissue distribution of residual antimony in rats treated with multiple doses of meglumine antimoniate

Meglumine antimoniate (MA) and sodium stibogluconate are pentavalent antimony (SbV) drugs used since the mid-1940s. Notwithstanding the fact that they are first-choice drugs for the treatment of leishmaniases, there are gaps in our knowledge of their toxicological profile, mode of action and kinetics. Little is known about the distribution of antimony in tissues after SbV administration. In this study, we evaluated the Sb content of tissues from male rats 24 h and three weeks after a 21-day course of treatment with MA (300 mg SbV/kg body wt/d, subcutaneous). Sb concentrations in the blood and organs were determined by inductively coupled plasma-mass spectrometry. In rats, as with in humans, the Sb blood levels after MA dosing can be described by a two-compartment model with a fast (t1/2 = 0.6 h) and a slow (t1/2 >> 24 h) elimination phase. The spleen was the organ that accumulated the highest amount of Sb, while bone and thyroid ranked second in descending order of tissues according to Sb levels (spleen >> bone, thyroid, kidneys > liver, epididymis, lungs, adrenals > prostate > thymus, pancreas, heart, small intestines > skeletal muscle, testes, stomach > brain). The pathophysiological consequences of Sb accumulation in the thyroid and Sb speciation in the liver, thyroid, spleen and bone warrant further studies.

Pharmacokinetic and pharmacodynamic responses in adult patients with Chagas disease treated with a new formulation of benznidazole

Pharmacological treatment of Chagas disease with benznidazole (BNZ) is effective in children in all stages, but it is controversial in chronically infected adults. We report the pharmacokinetics and pharmacodynamics in six adult patients with Chagas disease treated with the new BNZ formulation (ABARAX®) in doses between 2.5-5.5 mg/Kg/day. All but one patient had plasmatic BNZ concentrations within the expected range. All patients finalised treatment with nondetectable Trypanosoma cruziquantitative polymerase chain reaction, which remained nondetectable at the six month follow-up. Our data suggests parasitological responses with the new BNZ and supports the hypothesis that treatment protocols with lower BNZ doses may be effective.

Serological based monitoring of a cohort of patients with chronic Chagas disease treated with benznidazole in a highly endemic area of northern Argentina

This study aimed to evaluate well-documented diagnostic antigens, named B13, 1F8 and JL7 recombinant proteins, as potential markers of seroconversion in treated chagasic patients. Prospective study, involving 203 patients treated with benznidazole, was conducted from endemic areas of northern Argentina. Follow-up was possible in 107 out of them and blood samples were taken for serology and PCR assays before and 2, 3, 6, 12, 24 and 36 months after treatment initiation. Reactivity against Trypanosoma cruzi lysate and recombinant antigens was measured by ELISA. The rate of decrease of antibody titers showed nonlinear kinetics with an abrupt drop within the first three months after initiation of treatment for all studied antigens, followed by a plateau displaying a low decay until the end of follow-up. At this point, anti-B13, anti-1F8 and anti-JL7 titers were relatively close to the cut-off line, while anti-T. cruzi antibodies still remained positive. At baseline, 60.8% (45/74) of analysed patients tested positive for parasite DNA by PCR and during the follow-up period in 34 out of 45 positive samples (75.5%) could not be detected T. cruzi DNA. Our results suggest that these antigens might be useful as early markers for monitoring antiparasitic treatment in chronic Chagas disease.

Scenarios for the milk production chain in Brazil in 2020

Brazilian milk production has grown steadily and in 2004 the country became self-sufficient in dairy production. This article develops possible scenarios for the milk production chain in Brazil for the year 2020 in order to contribute to decisions that must be made by stakeholders. A literature review on foresight and the use of scenarios was conducted, and a scenario writing approach based on Wright and Spers (2006) was adopted, which includes the use of the Delphi method, Michael Porter's Five Competitive Forces model, Interpretative Structural Modeling (ISM) (WRIGHT, 1991) and quantitative projections. This methodology provided four scenarios, with quantitative and qualitative elements: two exploratory scenarios ("milk, the new agribusiness star" and "a wasted future"), a most probable scenario ("continuous but uneven growth") and a desired scenario ("competitive family agriculture"). Overall, it is possible to note many market opportunities, as well as niche markets and the strengthening of cooperatives. Future prospects are also favorable to the dairy industry in general, but nearly all scenarios point to a concentration in the industrial sphere.

Human milk for neonatal pain relief during ophthalmoscopy

Ophthalmoscopy performed for the early diagnosis of retinopathy of prematurity (ROP) is painful for preterm infants, thus necessitating interventions for minimizing pain. The present study aimed to establish the effectiveness of human milk, compared with sucrose, for pain relief in premature infants subjected to ophthalmoscopy for the early diagnosis of ROP. This investigation was a pilot, quasi-experimental study conducted with 14 premature infants admitted to the neonatal intensive care unit (NICU) of a university hospital. Comparison between the groups did not yield a statistically significant difference relative to the crying time, salivary cortisol, or heart rate (HR). Human milk appears to be as effective as sucrose in relieving acute pain associated with ophthalmoscopy. The study’s limitations included its small sample size and lack of randomization. Experimental investigations with greater sample power should be performed to reinforce the evidence found in the present study.

CO2, CH4 and N2O fluxes in an Ultisol treated with sewage sludge and cultivated with castor bean

Organic residue application into soil alter the emission of gases to atmosphere and CO2, CH4, N2O may contribute to increase the greenhouse effect. This experiment was carried out in a restoration area on a dystrophic Ultisol (PVAd) to quantify greenhouse gas (GHG) emissions from soil under castor bean cultivation, treated with sewage sludge (SS) or mineral fertilizer. The following treatments were tested: control without N; FertMin = mineral fertilizer; SS5 = 5 t ha-1 SS (37.5 kg ha-1 N); SS10 = 10 t ha-1 SS (75 kg ha-1 N); and SS20 = 20 t ha-1 SS (150 kg ha-1 N). The amount of sludge was based on the recommended rate of N for castor bean (75 kg ha-1), the N level of SS and the mineralization fraction of N from SS. Soil gas emission was measured for 21 days. Sewage sludge and mineral fertilizers altered the CO2, CH4 and N2O fluxes. Soil moisture had no effect on GHG emissions and the gas fluxes was statistically equivalent after the application of FertMin and of 5 t ha-1 SS. The application of the entire crop N requirement in the form of SS practically doubled the Global Warming Potential (GWP) and the C equivalent emissions in comparison with FertMin treatments.

Water-dispersible clay in soils treated with sewage sludge

A by-product of Wastewater Treatment Stations is sewage sludge. By treatment and processing, the sludge is made suitable for rational and environmentally safe use in agriculture. The aim of this study was to assess the influence of different doses of limed sewage sludge (50 %) on clay dispersion in soil samples with different textures (clayey and medium). The study was conducted with soil samples collected from native forest, on a Red Latosol (Brazilian classification: Latossolo Vermelho distroférrico) loamy soil in Londrina (PR) and a Red-Yellow Latosol (BC: Latossolo Vermelho-Amarelo distrófico) medium texture soil in Jaguapitã (PR). Pots were filled with 3 kg of air-dried fine earth and kept in greenhouse. The experiment was arranged in a randomized block design with six treatments: T1 control, and treatments with limed sewage sludge (50 %) as follows: T2 (3 t ha-1), T3 (6 t ha-1), T4 (12 t ha-1), T5 (24 t ha-1) and T6 (48 t ha-1) and five replications. The incubation time was 180 days. At the end of this period, the pots were opened and two sub-samples per treatment collected to determine pH-H2O, pH KCl (1 mol L-1), organic matter content, water-dispersible clay, ΔpH (pH KCl - pH-H2O) and estimated PZC (point of zero charge): PZC = 2 pH KCl - pH-H2O, as well as the mineralogy of the clay fraction, determined by X ray diffraction. The results showed no significant difference in the average values for water-dispersible clay between the control and the other treatments for the two soil samples studied and ΔpH was the variable that correlated best with water-dispersible clay in both soils.

Plant availability of trace elements in sewage sludge-treated soils: methodology¹

Synthetic root exudates were formulated based on the organic acid composition of root exudates derived from the rhizosphere of aseptically grown corn plants, pH of the rhizosphere, and the background chemical matrices of the soil solutions. The synthetic root exudates, which mimic the chemical conditions of the rhizosphere environment where soil-borne metals are dissolved and absorbed by plants, were used to extract metals from sewage-sludge treated soils 16 successive times. The concentrations of Zn, Cd, Ni, Cr, and Cu of the sludge-treated soil were 71.74, 0.21, 15.90, 58.12, and 37.44 mg kg-1, respectively. The composition of synthetic root exudates consisted of acetic, butyric, glutaric, lactic, maleic, propionic, pyruvic, succinic, tartaric, and valeric acids. The organic acid mixtures had concentrations of 0.05 and 0.1 mol L-1 -COOH. The trace elements removed by successive extractions may be considered representative for the availability of these metals to plants in these soils. The chemical speciation of the metals in the liquid phase was calculated; results showed that metals in sludge-treated soils were dissolved and formed soluble complexes with the different organic acid-based root exudates. The most reactive organic acid ligands were lactate, maleate, tartarate, and acetate. The inorganic ligands of chloride and sulfate played insignificant roles in metal dissolution. Except for Cd, free ions did not represent an important chemical species of the metals in the soil rhizosphere. As different metals formed soluble complexes with different ligands in the rhizosphere, no extractor, based on a single reagent would be able to recover all of the potentially plant-available metals from soils; the root exudate-derived organic acid mixtures tested in this study may be better suited to recover potentially plant-available metals from soils than the conventional extractors.

Chemical and microbiological attributes of an oxisol treated with successive applications of sewage sludge¹

Studies on sewage sludge (SS) have confirmed the possibilities of using this waste as fertilizer and/or soil conditioner in crop production areas. Despite restrictions with regard to the levels of potentially toxic elements (PTE) and pathogens, it is believed that properly treated SS with low PTE levels, applied to soil at adequate rates, may improve the soil chemical and microbiological properties. This study consisted of a long-term field experiment conducted on a Typic Haplorthox (eutroferric Red Latosol) treated with SS for seven successive years for maize production, to evaluate changes in the soil chemical and microbiological properties. The treatments consisted of two SS rates (single and double dose of the crop N requirement) and a mineral fertilizer treatment. Soil was sampled in the 0-0.20 m layer and analyzed for chemical properties (organic C, pH, P, K, Ca, Mg, CEC, B, Cu, Fe, Mn, Zn, Cd, Ni, and Pb) and microbiological properties (basal respiration, microbial biomass activity, microbial biomass C, metabolic quotient, microbial quotient, and protease and dehydrogenase enzyme activities). Successive SS applications to soil increased the macro- and micronutrient availability, but the highest SS dose reduced the soil pH significantly, indicating a need for periodic corrections. The SS treatments also affected soil microbial activity and biomass negatively. There were no significant differences among treatments for maize grain yield. After seven annual applications of the recommended sludge rate, the heavy metal levels in the soil had not reached toxic levels.

Chemical properties of soils treated with biological sludge from gelatin industry

The impact of agro-industrial organic wastes in the environment can be reduced when used in agriculture. From the standpoint of soil fertility, residue applications can increase the organic matter content and provide nutrients for plants. This study evaluated the effect of biological sludge from gelatin industry on the chemical properties of two Ultisols (loamy sand and sandy clay) and an Oxisol (clay). The experiment lasted 120 days and was carried out in laboratory in a completely randomized design with factorial arrangement, combining the three soils and six biological sludge rates (0, 100, 200, 300, 400, and 500 m³ ha-1), with three replications. Biological sludge rates of up to 500 m³ ha-1 decreased soil acidity and increased the effective cation exchange capacity (CEC) and N, Ca, Mg, and P availability, without exceeding the tolerance limit for Na. The increase in exchangeable base content, greater than the effective CEC, indicates that the major part of cations added by the sludge remains in solution and can be lost by leaching.

Phosphorus transformation in poultry litter and litter-treated Oxisol of Brazil assessed by 31P-NMR and wet chemical fractionation

Large quantities of poultry litter are being produced in Brazil, which contain appreciable amounts of phosphorus (P) that could be of environmental concern. To assess the immediate environmental threat, five poultry litters composed of diverse bedding material were incubated for 43 days under greenhouse conditions. The litters consisted of: coffee bean husk (CH); wood chips (WC); rice husk (RH); ground corn cobs (CC) and ground napier grass (NG) (Pennisetum purpureum Schum.), in which the change in forms of soluble P was evaluated using 31P NMR spectroscopy. On average, 80.2 and 19.8 % of the total P in the extract, respectively, accounted for the inorganic and organic forms before incubation and 48 % of the organic P was mineralized to inorganic P in 43 days of incubation. Wide variation in the organic P mineralization rate (from 82 % -WC to 4 % - NG) was observed among litters. Inorganic orthophosphate (99.9 %) and pyrophosphate (0.1 %) were the only inorganic P forms, whereas the organic P forms orthophosphate monoesters (76.3 %) and diester (23.7 %) were detected. Diester P compounds were mineralized almost completely in all litters, except in the CH litter, within the incubation period. Pyrophosphates contributed with less than 0.5% and remained unaltered during the incubation period. Wood-chip litter had a higher organic P (40 %) content and a higher diester: monoester ratio; it was therefore mineralized rapidly, within the first 15 days, achieving steady state by the 29th day. Distinct mineralization patterns were observed in the litter when incubated with a clayey Oxisol. The substantial decrease observed in the organic P fraction (Po) of the litter types followed the order: CH (45 %) > CC (25 %) > RH (13 %) ≈ NG (12 %) > WC (5 %), whereas the Pi fraction increased. Incubation of RH litter in soil slowed down the mineralization of organic P.