New prevalence estimate of TT virus (TTV) infection in low- and high-risk population from São Paulo, Brazil

The prevalence of TT virus (TTV) infection was investigated by Polymerase Chain Reaction (PCR) in low- (blood donors and healthy children/adolescents) and high-risk (hemophiliacs) groups from São Paulo, Brazil. Primers based on the untranslated region (UTR) of the viral genome proved to be much more ubiquitous, leading to much higher frequencies for both groups ( > or = 81%) than the earlier N22-PCR directed to the open reading frame 1 (blood donors, 5.5%, and hemophiliacs, 42.3%). The UTR-PCR also revealed an interesting profile for healthy children/adolescents: very high prevalence at the early years and significant decrease in male teenagers. The N22-PCR, in turn, demonstrated higher frequency in hemophiliacs treated with fresh blood products (58%), than in those treated with virus-inactivated clotting factors (9.4%) and blood donors (5.5%).

Home visitors and child health in England: advances and challenges

There is increasing interest in the early years as a focus for reducing health inequalities as well as one that is important for the children themselves. This paper describes the introduction in England of Sure Start Local Programmes, which included home visiting within a community development approach, and an intensive home visiting programme, the Nurse-Family partnership, for disadvantaged teenage mothers. It reflects on changes and challenges in service provision to mothers and their pre-school children in England, explaining that a long tradition of home visiting was, paradoxically, reduced as attention focused on the newer initiatives. This is now being addressed, with attention to a range of evidence based programmes and a specific focus on heath visitor provision.

Uma interpretação das causas da desaceleração econômica do Brasil

The paper aims at explaining why Brazil's GDP growth plunged after 1980. Brazil's GDP grew at 7% yearly from 1940 to 1980 but at only 2.5% per year since then. Increases in the relative price of investment that reduced the purchasing power of savings, associated to declines in the productivity of capital, seem to have been the most important factors behind the observed loss of dynamism. The tentative conclusion is that inward-oriented economic policies since the 1970s and, perhaps, even as early as the 1950s, had negative long-run growth implications that were aggravated by populist policies in the early years of the post-1984 redemocratization.

Early infection and asymptomatic spread of hepatitis A virus in a public child care center in Rio de Janeiro, Brazil: should attending children under two years of age be vaccinated?

A cross-sectional study was conducted in order to identify hepatitis A virus (HAV) serological markers in 418 individuals (mean age, 16.4 years; range, 1 month-80 years) at a public child care center in Rio de Janeiro, Brazil, as well as to analyze risk factors and determine circulating genotypes. Serum samples were tested using an enzyme immunoassay. Reverse transcription polymerase chain reaction (RT-PCR) was used to detect and characterize HAV RNA, and sequencing was performed. Anti-HAV antibodies and IgM anti-HAV antibodies were detected, respectively, in 89.5% (374/418) and 10.5% (44/418) of the individuals tested. Acute HAV infection in children was independently correlated with crawling (p < 0.05). In 56.8% (25/44) of the IgM anti-HAV-positive individuals and in 33.3% (5/15) of the IgM anti-HAV-negative individuals presenting clinical symptoms, HAV RNA was detected. Phylogenetic analysis revealed co-circulation of subgenotypes IA and IB in 93.3% (28/30) of the amplified samples. In present study, we verify that 79% (30/38) of children IgM anti-HAV-positive were asymptomatic. In child care centers, this asymptomatic spread is a more serious problem, promoting the infection of young children, who rarely show signs of infection. Therefore, vaccinating children below the age of two might prevent the asymptomatic spread of hepatitis A.

Growth patterns in early childhood and the onset of menarche before age twelve

OBJECTIVE: To examine the relationship between growth patterns in early childhood and the onset of menarche before age 12. METHODS: The study included 2,083 women from a birth cohort study conducted in the city of Pelotas, Southern Brazil, starting in 1982. Anthropometric, behavioral, and pregnancy-related variables were collected through home interviews. Statistical analyses were performed using Pearson's chi-square and chi-square test for linear trends. A multivariable analysis was carried out using Poisson regression based on a hierarchical model. RESULTS: Mean age of menarche was 12.4 years old and the prevalence of menarche before age 12 was 24.3%. Higher weight-for-age, height-for-age, and weight-for-height z-scores at 19.4 and 43.1 months of age were associated with linear tendencies of increased prevalence and relative risks of the onset of menarche before age 12. Girls who experienced rapid growth in weight-for-age z-score from birth to 19.4 months of age and in weight-for-age or height-for-age z-scores from 19.4 to 43.1 months of age also showed higher risk of menarche before age 12. Higher risk was seen when rapid growth in weight-for-age z-score was seen during these age intervals and the highest risk was found among those in the first tertile of Williams' curve at birth. Rapid growth in weight-for-height z-score was not associated with menarche before age 12. CONCLUSIONS: Menarche is affected by nutritional status and growth patterns during early childhood. Preventing overweight and obesity during early childhood and keeping a "normal" growth pattern seem crucial for the prevention of health conditions during adulthood.

Evaluation of the ELISA-F29 test as an early marker of therapeutic efficacy in adults with chronic Chagas disease

This work compared the time at which negative seroconversion was detected by conventional serology (CS) and by the ELISA-F29 test on a cohort of chronic chagasic patients treated with nifurtimox or benznidazole. A retrospective study was performed using preserved serum from 66 asymptomatic chagasic adults under clinical supervision, and bi-annual serological examinations over a mean follow-up of 23 years. Twenty nine patients received trypanocide treatment and 37 remained untreated. The ELISA-F29 test used a recombinant antigen which was obtained by expressing the Trypanosoma cruzi flagellar calcium-binding protein gene in Escherichia coli. Among the untreated patients, 36 maintained CS titers. One patient showed a doubtful serology in some check-ups. ELISA-F29 showed constant reactivity in 35 out of 37 patients and was negative for the patient with fluctuating CS. The treated patients were divided into three groups according to the CS titers: in 13 they became negative; in 12 they decreased and in four they remained unchanged. ELISA-F29 was negative for the first two groups. The time at which negativization was detected was significantly lower for the ELISA-F29 test than for CS, 14.5 ± 5.7 and 22 ± 4.9 years respectively. Negative seroconversion was observed in treated patients only. The results obtained confirm that the ELISA-F29 test is useful as an early indicator of negative seroconversion in treated chronic patients.

Dura mater mitral and tricuspid bioprostheses: 30 years of follow-up

PURPOSE: The dura mater bioprosthesis was developed in the Department of Cardiopneumology of the Hospital das Clínicas of the University of São Paulo Medical School in 1971. Here, we present the clinical results of the dura mater bioprosthesis over 30 years of follow-up. METHODS: We studied 70 consecutive patients who underwent mitral or tricuspid valve replacement with a dura mater bioprosthesis between January 1971 and August 1972. RESULTS: The early mortality was 10% (7 patients). The follow-up was 87% complete (9 patients were lost to follow-up). Two patients were alive and asymptomatic 30 years after valve replacement; 33 patients underwent reoperations due to valve dysfunction, and 19 died during the follow-up period. At 30 years, the actuarial survival was 49.2 ± 8.6%; freedom from rupture, 27.0 ± 10.2%; freedom from calcification, 78.8 ± 8.6%; and freedom from reoperation, 18.8 ± 7.5%. CONCLUSIONS: The dura mater bioprosthesis played an important role in the treatment of patients with mitral and tricuspid valve disease. The low rate of thromboembolism and the long period of follow-up without evidence of valve dysfunction, which occurred for several of our patients, are important characteristics of these bioprosthesis.

Transmyocardial laser revascularization. Early clinical experience

OBJECTIVE: To analyze the initial clinical experience of transmyocardial laser revascularization (TMLR) in patients with severe diffuse coronary artery disease. METHODS: Between February, 1998 and February, 1999, 20 patients were submitted to TMLR at the Heart Institute (InCor), University of São Paulo Medical School, Brazil, isolated or in association with conventional coronary artery bypass graft (CABG). All patients had severe diffuse coronary artery disease, with angina functional class III/IV (Canadian Cardiovascular Society score) unresponsive to medical therapy. Fourteen patients were submitted to TMLR as the sole therapy, whereas 6 underwent concomitant CABG. Fifty per cent of the patients had either been previously submitted to a CABG or to a percutaneous transluminal coronary angioplasty (PTCA). Mean age was 60 years, ranging from 45 to 74 years. RESULTS: All patients had three-vessel disease, with normal or mildly impaired left ventricular global function. Follow-up ranged from 1 to 13 months (mean 6.6 months), with no postoperative short or long term mortality. There was significant symptom improvement after the procedure, with 85% of the patients free of angina, and the remaining 15 % of the patients showing improvement in functional class, as well as in exercise tolerance. CONCLUSION: This novel technique can be considered a low risk alternative for a highly selected group of patients not suitable for conventional revascularization procedures.

Mechanical versus biological aortic valve implants in the elderly. A comparison of early and mid-term results

OBJECTIVE: Our aim was to compare, in a non randomized study, the surgical outcome in elderly patients with mechanical (Group 1; n=83) and bioprosthetic valve implants (Group 2; n=136). METHODS: During a three year period, 219 patients >75 years underwent Aortic Valve Replacement. The groups matched according to age, sex, comorbidity, valve pathology and concomitant Coronary Artery Bypass Surgery. Follow-up was a total of 469 patient-years (mean follow-up 2.1 years, maximum 4,4 years). RESULTS: Operative mortality was zero and the overall early mortality was 2.3 % (within 30 days). Actuarial survival was 87.5 ± 4.0% and 66.1 ± 7.7% (NS) at 4 years in Group 1 and Group 2, respectively. Freedom from valve-related death was 88.9 ± 3.8% in Group 1 and 69.9±7.9% (NS) in Group 2 at 4 years. CONCLUSION: Aortic Valve Replacement in the elderly (>75 years) is a safe procedure even in cases where concomitant coronary artery revascularization is performed. Only a few anticoagulant-related complications were reported and this may indicate that selected groups of elderly patients with significant life expectancy may benefit from mechanical implants .

Distribution of risk factors in parents and siblings of patients with early coronary artery disease

OBJECTIVE: Early coronary artery disease (CAD) is associated with risk factors (RF). Offspring of parents with a RF have a greater prevalence of them. However, the distribution of RF in parents and siblings of patients with early CAD is unknown. METHODS: The study comprised the parents and siblings of 42 patients with early CAD (< 45 years), 29 males. Their mean age was 39.5±3.7 years. The following major RF were analyzed: smoking (> 5 cigarretes/day), hypercholesterolemia (total cholesterol > 200 mg/dL), hypertension (diastolic blood pressure > 90 mmHg), and diabetes (glycemia > 126 mg/dL). RESULTS: Of a total of 102 RF, 4, 3, 2, and 1 were observed in, respectively, 5, 15, 15, and 7 patients with early CAD, the most prevalent being smoking (86%) and hypercholesterolemia (83%). Diabetes was observed in 15 (36%) and hypertension in 16 (38%) patients. Smoking was more prevalent in the fathers (76%) and hypercholesterolemia in the mothers (30%). In 183 siblings, 131 RF were observed (1 patient with the disease had a mean of 4.7 siblings). The prevalences of smoking, hypertension, hypercholesterolemia, and diabetes in the siblings were, respectively, 32%, 18%, 14%, and 9%. The incidence of RF was as follows: 72 (39%) siblings had 1 RF, 25 (14%) siblings had 2 RF, and 3 (2%) siblings had 3 RF. In parents and their offspring, smoking was moderately correlated (r=0.43; P=0.02) with CAD. CONCLUSION: Smoking habit of parents is passed on to offspring, and, in association with hypercholesterolemia, it was the major cause of early CAD in offspring. High prevalence of smoking in offspring shows the potential responsibility of parents in the incidence of the disease in offspring.

Blood Pressure Variation Throughout Pregnancy According to Early Gestational BMI: A Brazilian Cohort

Background: The maternal cardiovascular system undergoes progressive adaptations throughout pregnancy, causing blood pressure fluctuations. However, no consensus has been established on its normal variation in uncomplicated pregnancies. Objective: To describe the variation in systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels during pregnancy according to early pregnancy body mass index (BMI). Methods: SBP and DBP were measured during the first, second and third trimesters and at 30-45 days postpartum in a prospective cohort of 189 women aged 20-40 years. BMI (kg/m2) was measured up to the 13th gestational week and classified as normal-weight (<25.0) or excessive weight (≥25.0). Longitudinal linear mixed-effects models were used for statistical analysis. Results: A decrease in SBP and DBP was observed from the first to the second trimester (βSBP=-0.394; 95%CI: -0.600- -0.188 and βDBP=-0.617; 95%CI: -0.780- -0.454), as was an increase in SBP and DBP up to 30-45 postpartum days (βSBP=0.010; 95%CI: 0.006-0.014 and βDBP=0.015; 95%CI: 0.012-0.018). Women with excessive weight at early pregnancy showed higher mean SBP in all gestational trimesters, and higher mean DBP in the first and third trimesters. Excessive early pregnancy BMI was positively associated with prospective changes in SBP (βSBP=7.055; 95%CI: 4.499-9.610) and in DBP (βDBP=3.201; 95%CI: 1.136-5.266). Conclusion: SBP and DBP decreased from the first to the second trimester and then increased up to the postpartum period. Women with excessive early pregnancy BMI had higher SBP and DBP than their normal-weight counterparts throughout pregnancy, but not in the postpartum period.

Cardiac Sympathetic Hyperactivity after Chemotherapy: Early Sign of Cardiotoxicity?

Background:Chemotherapy with anthracyclines and trastuzumab can cause cardiotoxicity. Alteration of cardiac adrenergic function assessed by metaiodobenzylguanidine labeled with iodine-123 (123I-mIBG) seems to precede the drop in left ventricular ejection fraction.Objective:To evaluate and to compare the presence of cardiovascular abnormalities among patients with breast cancer undergoing chemotherapy with anthracyclines and trastuzumab, and only with anthracycline.Methods:Patients with breast cancer were analyzed clinical, laboratory, electrocardiographic and echocardiographic and cardiac sympathetic activity. In scintigraphic images, the ratio of 123I-mIBG uptake between the heart and mediastinum, and the washout rate were calculated. The variables were compared between patients who received anthracyclines and trastuzumab (Group 1) and only anthracyclines (Group 2).Results:Twenty patients, with mean age 57 ± 14 years, were studied. The mean left ventricular ejection fraction by echocardiography was 67.8 ± 4.0%. Mean washout rate was 28.39 ± 9.23% and the ratio of 123I-mIBG uptake between the heart and mediastinum was 2.07 ± 0.28. Of the patients, 82% showed an increased in washout rate, and the ratio of 123I-mIBG uptake between the heart and mediastinum decreased in 25%. Concerning the groups, the mean washout rate of Group 1 was 32.68 ± 9.30% and of Group 2 was 24.56 ± 7.72% (p = 0,06). The ratio of 123I-mIBG uptake between the heart and mediastinum was normal in all patients in Group 2, however, the Group 1, showed 50% the ratio of 123I-mIBG uptake between the heart and mediastinum ≤ 1.8 (p = 0.02).Conclusion:In women with breast cancer undergoing chemotherapy, assessment of cardiac sympathetic activity with 123I-mIBG appears to be an early marker of cardiotoxicity. The combination of chemotherapy showed higher risk of cardiac adrenergic hyperactivity.

Early Markers of Atherosclerotic Disease in Individuals with Excess Weight and Dyslipidemia

Abstract Background: Excessive weight is a cardiovascular risk factor since it generates a chronic inflammatory process that aggravates the endothelial function. Objective: To evaluate the endothelial function in individuals with excess weight and mild dyslipidemia using brachial artery flow-mediated dilation (BAFMD), and the association of endothelial function with anthropometric and biochemical variables. Methods: Cross-sectional study that included 74 individuals and evaluated anthropometric variables (body mass index [BMI], waist-hip ratio [WHR], waist circumference [AC], and percentage of body fat [PBF]), biochemical (blood glucose, insulinemia, ultrasensitive C-reactive protein, fibrinogen, total cholesterol, HDL-cholesterol, triglycerides, and LDL-cholesterol) and endothelial function (BAFMD, evaluated by ultrasound). The statistical analysis was performed with SPSS, version 16.0. To study the association between the variables, we used chi-square, Student's t and Mann-Whitney tests, and Pearson's correlation. Logistic regression analyzed the independent influence of the factors. Values of p < 0.05 were considered significant. Results: The participants had a mean age of 50.8 years, and 57% were female. BMI, WC, WHR, and PBF showed no significant association with BAFMD. The male gender (p = 0.02) and higher serum levels of fibrinogen (p = 0.02) were significantly and independently associated with a BAFMD below 8%. Conclusions: In individuals with excess weight and mild untreated dyslipidemia, male gender and higher levels of fibrinogen were independently associated with worse BAFMD.

Evolution of the clinical and epidemiological knowledge about Chagas disease 90 years after its discovery

Three different periods may be considered in the evolution of knowledge about the clinical and epidemiological aspects of Chagas disease since its discovery: (a) early period concerning the studies carried out by Carlos Chagas in Lassance with the collaboration of other investigators of the Manguinhos School. At that time the disease was described and the parasite, transmitters and reservoirs were studied. The coexistence of endemic goiter in the same region generated some confusion about the clinical forms of the disease; (b) second period involving uncertainty and the description of isolated cases, which lasted until the 1940 decade. Many acute cases were described during this period and the disease was recognized in many Latin American countries. Particularly important were the studies of the Argentine Mission of Regional Pathology Studies, which culminated with the description of the Romaña sign in the 1930 decade, facilitating the diagnosis of the early phase of the disease. However, the chronic phase, which was the most important, continued to be difficult to recognize; (c) period of consolidation of knowledge and recognition of the importance of Chagas disease. Studies conducted by Laranja, Dias and Nóbrega in Bambuí updated the description of Chagas heart disease made by Carlos Chagas and Eurico Villela. From then on, the disease was more easily recognized, especially with the emphasis on the use of a serologic diagnosis; (d) period of enlargement of knowledges on the disease. The studies on denervation conducted in Ribeirão Preto by Fritz Köberle starting in the 1950 decade led to a better understanding of the relations between Chagas disease and megaesophagus and other visceral megas detected in endemic areas.

Predictors of local malaria outbreaks: an approach to the development of an early warning system in Colombia

Risk factor surveillance is a complementary tool of morbidity and mortality surveillance that improves the likelihood that public health interventions are implemented in a timely fashion. The aim of this study was to identify population predictors of malaria outbreaks in endemic municipalities of Colombia with the goal of developing an early warning system for malaria outbreaks. We conducted a multiple-group, exploratory, ecological study at the municipal level. Each of the 290 municipalities with endemic malaria that we studied was classified according to the presence or absence of outbreaks. The measurement of variables was based on historic registries and logistic regression was performed to analyse the data. Altitude above sea level [odds ratio (OR) 3.65, 95% confidence interval (CI) 1.34-9.98], variability in rainfall (OR 1.85, 95% CI 1.40-2.44) and the proportion of inhabitants over 45 years of age (OR 0.17, 95% CI 0.08-0.38) were factors associated with malaria outbreaks in Colombian municipalities. The results suggest that environmental and demographic factors could have a significant ability to predict malaria outbreaks on the municipal level in Colombia. To advance the development of an early warning system, it will be necessary to adjust and standardise the collection of required data and to evaluate the accuracy of the forecast models.