Anemia de c��lulas falciformes na idade pedi��trica : contribui����o para o estudo das suas principais complica����es e indicadores de progn��stico

RESMO: Introdu����o: A anemia de c��lulas falciformes doen��a heredit��ria, com repercuss��o multi-org��nica, tem grande variabilidade na sua express��o cl��nica. Da�� o interesse do estudo de indicadores de progn��stico. A investiga����o realizada foi precedida de um resumo hist��rico incidindo sobre a compreens��o de aspectos fundamentais da doen��a ao longo dos tempos. Na primeira parte do estudo e ap��s revis��o bibliogr��fica, foram referidos dados da fisiopatologia como base para os estudos que integram a presente disserta����o. Abordou-se o estado da arte relativamente ��s complica����es, aos indicadores de progn��stico e �� terap��utica utilizada. Objectivos: Constitu��ram objectivos deste estudo realizado numa amostra populacional representativa: identificar as les��es a n��vel dos sistemas cardio-respirat��rio e nervoso central, avaliando-se as respectivas repercuss��es; avaliar a presen��a de indicadores de progn��stico entre as vari��veis seleccionadas; estudar a efic��cia e toxicidade da HU nos doentes com as formas graves da ACF. Para a prossecu����o destes objectivos foram delineados para al��m do estudo global tr��s estudos espec��ficos: Estudo 1- repercuss��o no sistema cardio-respirat��rio; Estudo 2- repercuss��o no sistema nervoso central; Estudo 3- terap��utica com hidroxiureia. Doentes e m��todos: Procedeu-se a um estudo prospectivo e multi-institucional durante um per��odo de tr��s anos tendo-se seleccionado para a amostra, e de acordo com crit��rios pr��-definidos, 30 doentes com ACF na fase est��vel da doen��a, com idades compreendidas entre os sete e os 18 anos, todos de origem africana �� excep����o de um caucasiano. O diagn��stico baseou-se em t��cnicas de electroforese e estudo molecular que definiu o genotipo da doen��a e a presen��a da delec����o da ���-talass��mia assim como os haplotipos da amostra populacional. Foram utilizadas diferentes metodologias para avaliar a exist��ncia de les��o pulmonar e cerebral. Atrav��s do estudo estat��stico foram seleccionadas diversas vari��veis como hipot��ticos indicadores de progn��stico. Estudo 1. Para determinar a exist��ncia de les��o a n��vel pulmonar usaram-se duas metodologias diferentes, a avalia����o da fun����o pulmonar com estudo da satura����o da Hb em O2 no sangue arterial e a tomografia computadorizada de alta resolu����o. Estudou-se tamb��m a poss��vel disfun����o card��aca como repercuss��o da les��o pulmonar, atrav��s do ecocardiograma, e os indicadores de progn��stico com significado estat��stico para a les��o encontrada. Estudo 2. O desenho deste estudo foi sobrepon��vel ao anterior, mas com metodologia adequada para o SNC. Procedeu-se ao estudo das les��es cerebrais por meio de exames imagiol��gicos, (RMN-CE e DTC) e de testes psicol��gicos. Correlacionaram-se as tr��s metodologias utilizadas e a import��ncia de cada uma para a decis��o de atitudes terap��uticas preventivas. Estudo 3. Consistiu num estudo aberto prospectivo n��o controlado com nove crian��as e adolescentes com formas graves de ACF, com o objectivo de avaliar a efic��cia da terap��utica com hidroxiureia, durante um per��odo de 24 meses. Todos os doentes completaram no m��nimo 15 meses de terap��utica, com uma dose final m��dia de 19���4 mg/K/dia. Resultados globais: Durante o per��odo anterior �� investiga����o caracterizou-se a amostra populacional estudada quanto ao fenotipo gen��tico, cl��nico e hematol��gico de acordo com os crit��rios utilizados por outros investigadores. Verificou-se: predom��nio do haplotipo Bantu na forma homozig��tica em 53% dos doentes; n��mero total de EVO ���3/ano em 87,5% dos doentes; crises de sequestra����o em 18,75%; dactilites no primeiro ano de vida em 31,2%; quadro de s��psis grave apenas num doente; crises de hiper-hem��lise em 50%; e STA em 59,38% dos doentes. Quanto ao fenotipo hematol��gico evidenciaram-se como factores de risco reticulocitose (13,1x103/���l) e hiperbilirrubin��mia (2,5 mg/dl) e como factores de bom progn��stico a presen��a de delec����o de um gene da ���-talass��mia em 46,9% dos doentes e valor m��dio de Hb 8,1 g/dl. Resultados dos estudos parcelares: Estudo 1. Deste estudo infere-se que a DPR ligeira foi diagnosticada em 70% dos doentes, uma vez que as altera����es da difus��o n��o foram estatisticamente significativas, o estudo dos gases no sangue n��o evidenciaram resultados anormais e a TCAR evidenciou altera����es em 43,3% dos doentes. Apenas num doente se verificou doen��a pulmonar obstrutiva relacionada com maior n��mero da STA.O estudo da disfun����o card��aca encontrada em 86,7% dos doentes n��o reflecte a repercuss��o da DPR a n��vel card��aco, podendo estar associada ��s altera����es fisiopatol��gicas da pr��pria anemia cr��nica. Encontraram-se indicadores de progn��stico hematol��gicos e cl��nicos. Entre os primeiros, valores de Hb ���8,5 g/dl e de HbF ���13% foram considerados indicadores de bom progn��stico para a les��o pulmonar. Em rela����o aos par��metros cl��nicos, as STA n��o foram consideradas indicadoras de progn��stico para a DPR ao contr��rio do que se verificou com o n��mero de EVO. Pela an��lise dos par��metros gen��ticos e socio-econ��micos provou-se a aus��ncia de rela����o estatisticamente significativa com les��o pulmonar. Estudo 2. Pela RMN-CE foram diagnosticados ES em 33,3% com uma localiza����o preferencial na subst��ncia branca profunda em 26,6% dos doentes. Relativamente aos par��metros hematol��gicos seleccionados, o valor m��dio da HbF 8,6% constitu��u um indicador de bom progn��stico para o aparecimento de ES, enquanto o valor m��dio de leuc��citos 12.39x103/��l foi considerado um indicador de mau progn��stico. No estudo do DTC apenas um doente apresentou aumento da velocidade do fluxo cerebral na ACM igual a 196 cm/segundos, associado a vasculopatia grave. Os testes psicol��gicos alterados em 80% dos doentes mostraram ser o m��todo mais sens��vel para detectar altera����es do neurodesenvolvimento, mas sem correla����o com os ES em 10% dos doentes. Real��a-se a baixa percentagem de DTC patol��gicos encontrados neste estudo em rela����o ao n��mero elevado de ES e de testes psicol��gicos alterados, n��o se verificando concord��ncia entre os tr��s exames. Dos indicadores de progn��stico estudados a ���-talass��mia foi considerada um factor de protec����o para o coeficiente de intelig��ncia da escala de Wechsler. Em rela����o a par��metros cl��nicos estudados os doentes com maior n��mero de EVO, tem em m��dia valores inferiores nos testes psicol��gicos. Estudo 3. Neste estudo verificou-se que o valor m��dio da HbF aumentou significativamente de 7,0��4% para 13,7��5,3% (p=0,028) ao fim de 15 meses de terap��utica com hidroxiureia. Clinicamente todos os doentes responderam significativamente com uma redu����o de 80% no n��mero de EVO, 69% no n��mero de internamentos, 76% no n��mero de dias de hospitaliza����o e 67% no n��mero de transfus��es. Deste modo comprovou-se n��o s�� a efic��cia desta terap��utica neste grupo pedi��trico como tamb��m a falta de efeitos secund��rios significativos. Considera-se a necessidade de estudos mais prolongados e em grande s��ries, para com seguran��a se usar a HU antes que a les��o org��nica se estabele��a, portanto logo nos primeiros anos de vida. Conclus��o: Na amostra populacional estudada foram evidenciadas les��es pulmonares e cerebrais na grande maioria dos doentes que condicionaram a sua qualidade de vida. Foram identificados indicadores de progn��stico que poder��o eventualmente ditar medidas terap��uticas precoces com o objectivo de diminuir a morbilidade e a mortalidade neste grupo et��rio. Demonstrou-se que a terap��utica com a HU foi eficaz e bem tolerada----------ABSTRACT: Background: Sickle cell anemia (SCA), a hereditary disease characterized by pain and lifetime multi-organic lesion, is a challenge for all that work with carriers of this disease. The clinical expression variability of SCA is a constant reality and a problem to be solved in the current world of investigation, for which the knowledge of prognostic indicators responsible for the different aspects of clinical evolution diversity wiil be an added value. The study is preceded by a historical summary of the most important factors in the evolution of SCA, which are in themselves, an incentive for future research. In the first part of the study, after an extensive bibliographical revision, physiopathology data is referred to in general and specifically regarding the target organs, that constituted the base for the studies presented in the dissertation. The state of the art for the complications to be studied, the choice of prognostic indicators and the therapeutics application, were approached for the renewed interest in the theme. Aims: In regard to the investigation, the objective was to study the lesions in the most affected organs of a chosen pediatric group, to investigate prognostic indicators for lung and cerebral lesions and to evaluate the protective effect of hydroxyurea in children with severe outcomes. Patients and methods: A prospective and multi-institutional study was carried out during a three-year period, February 1998 to March 2001, with children and adolescents followed up at a Immunohematology Outpatient Clinic of Dona Estef��nia's Hospital, Lisbon. Based in predefined criteria, 30 children with SCA were selected in a stable phase of the disease, aged from seven to 18 years old, all of whom were of African origin with exception of one who was Caucasian. The diagnosis was based on electrophoresis techniques and molecular study that allowed to define the genotype, the presence of deletional alpha-thalassemia as well as haplotypes in the population. Different methodologies were used to evaluate the existence of lung and cerebral lesion. Statistical study of the different variables selected the prognostic indicators. In Study 1, to determine the existence of lung lesion two different methodologies were used: pulmonar function study with arterial blood gases determination; and high resolution computerized tomography. Heart dysfunction as a repercussion of lung lesion was also studied through echocardiography, and prognostic indicators were statistically significant for lesions found. The design of Study 2 was similar to Study 1, but with the appropriate methodology for CNS. After neurological examination, which was normal in all patients (control group), cerebral lesions were studied with imagiologic exams (MRN-CE and TCD) and psychological tests. These three methodologies were correlated and the importance of each one in the decision of the therapeutic profilactic attitudes. Study 3 consisted of a controlled prospective open study in children with severe forms of SCA, with the aim of the evaluating therapeutic effectiveness of hydroxyurea, during a period of 24 months. Results: In the global overall study preceding the Studies 1,2 and 3, there were a prevalence of haplotype Bantu (53%) and other risk factors, namely the number of VOC (87,5%), sequestration crisis (18,75%), dactilytis in first year of life(31,2%), hyperhemolysis crisis (50%) and ATC in more than half of the patients (59,38%). This group of bad prognostic indicators, associated with the population of the lower class according to the Graffar scale, demonstrates the importance of primary health care services, information provided to the children and their relatives, as well as the interest in prophylactic therapeutics, specific screening and prenatal diagnosis. Study 1. It was evident from this study that slight RPD was diagnosed in 70% of the patients, because alterations of the diffusion had no statistical significance and arterial blood gases determinations were normal. Only one patient had restrictive lung disease related with numerous ACS. However ACS was not considered a prognostic indicator for RPD, contrary to the number of EVO. HRTC revealed discreet fibrotic lines that could be related with slight RPD, but the lack of correlation of these two exams (33%) supports the value of lung function tests for precocious diagnosis of RPD. Heart dysfunction was found in 86,7% of patients, does not reflect the repercussion of RPD, but with the physiopathology of chronic anemia. Hematologic and clinical prognostic indicators were found. Good prognostic indicators for the non-evolution of RPD with average Hb values of ��� 8,5 g/dl and average HbF values of ���13%, respectively. The genetic and social-economic factors had no statistical significance; nevertheless, they were more prevalent among Bantu haplotype (53,3%) in patients with RPD. Study 2. RMN-CE detected SI in 33,3% of the patients, with preferential location in deep white substance in 26,6% and in front lobe in 20%. This distribution can be related to structural aspects of the brain and with the high sensibility of this organ to hypoxia. From the hematological parameters selected, average HbF value 8,6% and average leucocyte count 12.39x103/��l were prognostic indicators with different meaning to SI. The increase in the total bilirubin related to hyperhemolysis clinically explains the genesis of SI In the TCD study, only one patient had increased cerebral flow speed >196 cm/sec in CMA, which corresponded to serious vasculopathy in AngioMR. This patient never present previously neurological symptoms and had several hyperhemolysis crisis and VOC as risk factors. Low percentage of pathological TCD in this study, in relation to the high number of SI and altered tests, although without correlation among the three exams, is probably attributed to factors related to the methodology, aspects of cerebral physiopathology or perhaps a sign of good prognostic if the duration of study had not been so short. TCD should be used as a screening method in the age groups with higher risk of AVC and should never be considered separately in prophylactic therapeutics indication. Psychological tests were the most sensitive method to detect neurodevelopment impairment; in 80% of patients the neuropsychologics tests were altered, but without correlation with SI (10%). Since SI can become evident during the first two years of life and develop with time, the first psychological tests should be carried out between 3 and 5 years of age to timely be referred to special education and stimulation programs. Prognostic indicators to psychological tests were also found: alpha-thalassemia was found to be a protection factor of the IQ, just as other hematologic factors (hematocrit, MGCV and erythrocytes count). In relation to clinical parameters, although without statistical significance, patients with larger number of VOC had average lower scores versus the average in tests, except in TP. Results from different studies were conclusive as to the type of lesion found and the importance of prognostic indicators. Study 3. All the patients completed a minimum of 15 months therapeutic treatment with the final average daily dose of 19��4 mg/kg/day. The average value of the fetal hemoglobin increased significantly from 7,0��3,9% to 13,7��5,3% (p=0.028). The HbF average values increased from 6% to 15% after 15 months of therapeutic treatment. Clinically there was a reduction of 80% in the number of VOE , 69% in the number of hospitalization, 76% in the number of days of hospitalization and 67% in the number of transfusions. Once again the effectiveness of this treatment in this pediatric group, as well as the lack of any significant secondary effects, was evident. The study confirms the need for further detailed research in order to safely effect the appropriate treatment prior to the development of organic lesions, which ideally should be in the first year of life. Conclusions: These results allow us to clarify the importance of either pulmonary lesions or either nervous central system impairment among patients, children and adolescents, with sickle cell anemia. These lesions were demonstrated in most of the patients studied compromising their quality of life and the mortality. The treatment with HU is proved to be effective and having low toxicity.

Epidemiological aspects of the Brazilian spotted fever: serological survey of dogs and horses in an endemic area in the State of S��o Paulo, Brazil

In order to obtain information on Brazilian spotted fever, a study in domestic animals was performed in the County of Pedreira, State of S��o Paulo, Brazil, where 17 human cases had been notified. Serum samples obtained from animals were tested by indirect immunofluorescence for detectable antibodies to spotted fever-group rickettsiae. Seropositivity was revealed in 12 (36.4%) of 33 dogs and seven (77.8%) of nine horses from the endemic area. For comparison, blood samples from dogs and horses from non endemic area were tested and four (12.9%) of 31 dogs and three (27.3%) of 11 horses were positive. The highest titers of antibodies by IFA (IgG > 1:1024) were found only in three dogs and six horses from endemic area. The results suggest that dogs as horses may serve as environmental sentinels for estabilishing the prevalence of foci of spotted fever in Brazil.

Epidemiological and clinical aspects of snAkebite in Belo Horizonte, Southeast Brazil

Epidemiologic and clinical aspects of 310 hospitalized snakebite patients and 310 matched controls were described, over a seven years period, from an emergency hospital in Belo Horizonte, Southeast Brazil. The diagnosis was based upon clinical picture or actual snake identification. Fifty six percent of victims were bitten by the snakes of genus Bothrops, 32.0% by Crotalus, 1.0% by Lachesis and 10.0% undetermined. During the study period, stable number of cases and marked seasonal variation were noted. In comparing cases of snakebite and controls, those from a rural area or who were involved in agricultural labor activity were identified as a high risk group, with an odds ratio (OR) of 14.7 and 6.7, respectively, in favor of being bitten. Upon treatment, snakebite patients were 13.5 times more likely to have had early anaphylactic reactions than their controls, with a higher association in the age group <FONT FACE="Symbol">��</font> 20 years (OR = 30.3). Increased risks were also detected for pyrexia (OR = 11.7), with a marked association in the group under 19 years old (OR = 16.6). Severe cases of snakebite are an important treatable cause of morbidity in Brazil but therapy may be potentially life threatening. The higher case-fatality ratio encountered, compared to national statistics may be due the representativeness of the more severe cases who sought hospitalization. Preventing snakebite and early referral of those who are bitten is proposed

Some aspects of dermatophytoses seen at University Hospital in Florian��polis, Santa Catarina, Brazil

Dermatophytoses comprise mycoses which are very frequently diagnosed in the routine of clinical laboratories of Florian��polis, like any other Brazilian cities. However, no clinical or epidemiological studies data have been published for that city so far. To partially clarify these questions, we carried out a study on this subject on patients who sought the mycology services of Hospital of Federal University of Santa Catarina, from January 1995 to November 1996. The most prevalent dermatophyte was Trichophyton rubrum (58.6%), followed by T. mentagrophytes (25.3%), Epidermophyton floccosum (7.2%), Microsporum canis (4.8%), T. tonsurans (1.6%) T. violaceum (1.6%) and M. gypseum (0.8%). The prevalence of T. mentagrophytes was significantly higher for females than for males, with a frequency of 37.3% and 16.0% respectively, which could be explained by higher infection of T. mentagrophytes in feet and nails, which were percentually more affected in females than in males. These results suggest that, in general, the clinical and epidemiological characteristics of dermatophytoses of our study have similar patterns of those occurring in other southern and southeastern Brazilian cities

Autochthonous acute Chagas�� disease in S��o Paulo State, Brazil: Epidemiological aspects

Since the beginning of the seventies the natural transmission of Chagas�� infection has been considered to be under control in the State of S��o Paulo and not even a case of American Trypanosomiasis, transmitted by triatomine bugs, has been detected by the epidemiological surveillance system. This situation justifies the report of a case of acute Chagas�� disease that occurred in a forest area considered free of domiciliary triatomines along the Southern seacoast of S��o Paulo State. In May, 1995 the presence of trypomastigote forms of Trypanosoma cruzi had been diagnosed in a retired 57 year-old male patient, born and living in Santos (S��o Paulo State), complaining of fever, fatigue and malaise. The patient reported that 40 days before he had participated with 17 friends in a 7-day excursion in a forest area of the municipalities of Itanha��m and Peru��be. During this period the group had been lodged in three houses located within the forest. Eight days after the end of the excursion the patient began to have fever, malaise and fatigue. During the next 31 days he had received medical care both as an inpatient and an outpatient, without any significant improvement. After the detection of T. cruzi trypomastigotes in his blood stream the patient began to be treated with benzonidazole in a hospital but died 8 days after the beginning of treatment. The epidemiological investigation carried out showed no signs of the presence of triatomine bugs in the three houses where the group had been lodged, or any indication of Chagas' infection in other excursionists

Engineering Temporal and Spatial Aspects in OWL using Patterns

WWW is a huge, open, heterogeneous system, however its contents data is mainly human oriented. The Semantic Web needs to assure that data is readable and ���understandable��� to intelligent software agents, though the use of explicit and formal semantics. Ontologies constitute a privileged artifact for capturing the semantic of the WWW data. Temporal and spatial dimensions are transversal to the generality of knowledge domains and therefore are fundamental for the reasoning process of software agents. Representing temporal/spatial evolution of concepts and their relations in OWL (W3C standard for ontologies) it is not straightforward. Although proposed several strategies to tackle this problem but there is still no formal and standard approach. This work main goal consists of development of methods/tools to support the engineering of temporal and spatial aspects in intelligent systems through the use of OWL ontologies. An existing method for ontology engineering, Fonte was used as framework for the development of this work. As main contributions of this work Fonte was re-engineered in order to: i) support the spatial dimension; ii) work with OWL Ontologies; iii) and support the application of Ontology Design Patterns. Finally, the capabilities of the proposed approach were demonstrated by engineering time and space in a demo ontology about football.

Periodontal aspects of the juvenile form of paracoccidioidomycosis

Three cases of the juvenile form of paracoccidioidomycosis are reported. Emphasis has been given to the oral manifestations, particularly the periodontal involvement. The main periodontal findings were: generalized and progressive alveolar bone destruction leading to gingival recession with exposure of the tooth roots, and spontaneous tooth losses. The gingival mucosa was predominantly smooth, erithematous and slightly swollen. These aspects, although rare, may be the earliest signs of the disease and sometimes its only manifestation.

Hantavirus pulmonary syndrome in Brazil: clinical aspects of three new cases

Hantavirus pulmonary syndrome (HPS) has been recognized recently in Brazil, where 28 cases have been reported as of September 1999. We report here the clinical and laboratory findings of three cases whose diagnoses were confirmed serologically. All the patients were adults who presented a febrile illness with respiratory symptoms that progressed to respiratory failure that required artificial ventilation in two of them. Laboratory findings were most of the time consistent with those reported in the United States in patients infected with the Sin Nombre virus, and included elevated hematocrit and thrombocytopenia; presence of atypical lymphocytes was observed in one patient. The chest radiological findings observed in all the patients were bilateral, diffuse, reticulonodular infiltrates. Two patients died. Histopathological examination of the lungs of these patients revealed interstitial and alveolar edema, alveolar hemorrhage, and mild interstitial pneumonia characterized by infiltrate of immunoblasts and mononuclear cells. In the epidemiologic investigation of one of the cases, serologic (ELISA) tests were positive in 3 (25%) out of 12 individuals who shared the same environmental exposure. HPS should be included in the differential diagnosis of interstitial pneumonia progressing to acute respiratory failure.

Fibrotic sequelae in pulmonary paracoccidioidomycosis: histopathological aspects in BALB/c mice infected with viable and non-viable Paracoccidioides brasiliensis propagules

Patients with paracoccidioidomycosis often present pulmonary fibrosis and exhibit important respiratory limitations. Based on an already established animal model, the contribution of viable and non-viable P. brasiliensis propagules to the development of fibrosis was investigated. BALB/c male mice, 4-6 weeks old were inoculated intranasally either with 4x10(6 )viable conidia (Group I), or 6.5x10(6) fragmented yeast cells (Group II). Control animals received PBS. Six mice per period were sacrificed at 24, 48, 72h (initial) and 1, 2, 4, 8, 12 and 16 weeks post-challenge (late). Paraffin embedded lungs were sectioned and stained with H&E, trichromic (Masson), reticulin and Grocott��s. During the initial period PMNs influx was important in both groups and acute inflammation involving 34% to 45% of the lungs was noticed. Later on, mononuclear cells predominated. In group I, the inflammation progressed and granulomas were formed and by the 12th week they fussed and became loose. Thick collagen I fibers were observed in 66.6% and 83.3% of the animals at 8 and 12 weeks, respectively. Collagen III, thick fibers became apparent in some animals at 4weeks and by 12 weeks, 83% of them exhibited alterations in the organization and thickness of these elements. In group II mice, this pattern was different with stepwise decrease in the number of inflammatory foci and lack of granulomas. Although initially most animals in this group had minor alterations in thin collagen I fibers, they disappeared by the 4th week. Results indicate that tissue response to fragmented yeast cells was transitory while viable conidia evoked a progressive inflammatory reaction leading to granuloma formation and to excess production and/or disarrangement of collagens I and III; the latter led to fibrosis.

Congenital cytomegalovirus infection in a neonatal intensive care unit in Brazil evaluated by PCR and association with perinatal aspects

Cytomegalovirus (CMV) infection is the most common congenital infection, affecting 0.4% to 2.3% newborns. Most of them are asymptomatic at birth, but later 10% develop handicaps, mainly neurological disturbances. Our aim was to determine the prevalence of CMV shed in urine of newborns from a neonatal intensive care unit using the polymerase chain reaction (PCR) and correlate positive cases to some perinatal aspects. Urine samples obtained at first week of life were processed according to a PCR protocol. Perinatal data were collected retrospectively from medical records. Twenty of the 292 cases (6.8%) were CMV-DNA positive. There was no statistical difference between newborns with and without CMV congenital infection concerning birth weight (p=0.11), gestational age (p=0.11), Apgar scores in the first and fifth minutes of life (p=0.99 and 0.16), mother's age (p=0.67) and gestational history. Moreover, CMV congenital infection was neither related to gender (p=0.55) nor to low weight (<2,500g) at birth (p=0.13). This high prevalence of CMV congenital infection (6.8%) could be due to the high sensitivity of PCR technique, the low socioeconomic level of studied population or the severe clinical status of these newborns.

Clinical and diagnostic aspects of intestinal microsporidiosis in HIV-infected patients with chronic diarrhea in Rio de Janeiro, Brazil

The objectives of this study were to determine both the prevalence of microsporidial intestinal infection and the clinical outcome of the disease in a cohort of 40 HIV-infected patients presenting with chronic diarrhea in Rio de Janeiro, Brazil. Each patient, after clinical evaluation, had stools and intestinal fragments examined for viral, bacterial and parasitic pathogens. Microsporidia were found in 11 patients (27.5%) either in stools or in duodenal or ileal biopsies. Microsporidial spores were found more frequently in stools than in biopsy fragments. Samples examined using transmission electron microscopy (n=3) or polymerase chain reaction (n=6) confirmed Enterocytozoon bieneusi as the causative agent. Microsporidia were the only potential enteric pathogens found in 5 of the 11 patients. Other pathogens were also detected in the intestinal tract of 21 patients, but diarrhea remained unexplained in 8. We concluded that microsporidial infection is frequently found in HIV infected persons in Rio de Janeiro, and it seems to be a marker of advanced stage of AIDS.

Pancreatic involvement in co-infection visceral leishmaniasis and HIV: histological and ultrastructural aspects

The involvement of the gastrointestinal tract in the co-infection of HIV and Leishmania is rarely reported. We report the case of an HIV-infected adult man co-infected with a disseminated form of leishmaniasis involving the liver, lymph nodes, spleen and, as a feature reported for the first time in the English literature, the pancreas. Light microscopy showed amastigote forms of Leishmania in pancreatic macrophages and immunohistochemical staining revealed antigens for Leishmania and also for HIV p24. Microscopic and ultrastructural analysis revealed severe acinar atrophy, decreased zymogen granules in the acinar cytoplasm and also nuclear abnormalities such as pyknosis, hyperchromatism and thickened chromatin. These findings might correspond to the histologic pattern of protein-energy malnutrition in the pancreas as shown in our previous study in pancreas with AIDS and no Leishmania. In this particular case, the protein-energy malnutrition may be due to cirrhosis, or, Leishmania or HIV infection or all mixed. We believe that this case represents the morphologic substratum of the protein energy malnutrition in pancreas induced by the HIV infection. Further studies are needed to elucidate these issues.

Molecular aspects of hepatic carcinogenesis

Exogenous agents correlated with hepatocellular carcinoma (HCC) have been identified and well characterized. These agents, including the different viruses that cause chronic hepatitis and cirrhosis, can lead to regenerative nodules and dysplastic nodules/adenomatous hyperplasia. These conditions associated with several molecular alterations of hepatocyte ultimately culminate in hepatocellular carcinoma. Recently, there has been a great progress in the identification of somatic and germinative mutations that may be correlated with the development of HCC, justifying a review on the subject. Hence, the factors involved in the process of hepatic carcinogenesis, such as infection by the hepatitis B and C viruses, with a special focus in the molecular alterations described in recent years are discussed herein, pointing out areas potentially relevant for clinical development.

Quelques Aspects de la Reforme Carolingienne du rituel eucharistique. Les cas exemplaires de la "Fractio" et l"'Immixtio"

pp. 359-365

Caracteriza����o e Impacte das quedas de doentes, como indicador de qualidade, num hospital E.P.E.

RESUMO - Introdu����o: As quedas dos doentes s��o um dos principais eventos adversos que podem ocorrer em contexto hospitalar, levando por um lado, ao aumento de encargos econ��micos e sociais, e por outro a consequ��ncias f��sicas e psicol��gicas nos doentes e respectiva fam��lia. Para a sua preven����o, �� necess��rio investir na seguran��a do doente atrav��s de uma avalia����o e consequente gest��o do risco de quedas. Este trabalho insere-se na estrat��gia de melhorar a seguran��a do doente e a qualidade dos cuidados prestados. Objectivos: Avaliar em que medida o formul��rio existente responde ��s actuais necessidades de gest��o do risco de quedas e suas consequ��ncias. Por outro lado, com base numa extensa revis��o da literatura nacional e internacional, e tendo em conta as din��micas de qualidade e seguran��a do doente que t��m sido criadas no hospital em estudo, propor um formul��rio mais eficaz que permita responder aos desafios que se colocam nos dias de hoje. Metodologia: Tratou-se de um estudo descritivo explorat��rio assente no paradigma quantitativo. A popula����o do estudo foi constitu��da por 98 doentes que sofreram quedas durante o internamento no ano de 2010, num hospital E.P.E. (Entidade P��blica Empresarial) Conclus��o: As quedas ocorreram mais frequentemente em indiv��duos do sexo masculino com doen��as c��rebro-vasculares e infecciosas, sendo que na maioria das vezes n��o resultaram em consequ��ncias graves. O formul��rio que aqui se recomenda tem a vantagem de ser informatizado e caracterizar aspectos relacionados com os custos. ---------------- ABSTRACT - Introduction: Falls of patients are one of the main adverse events that may occur in a hospital context, leading on the one hand, to an increase of economic and social burden, and, on the other hand, physical and psychological consequences for patients and their families. For its prevention, we need to invest in patient safety through an assessment and consequent management of the fall risk. This work is inserted in the strategy to improve the Patient safety and the quality of health care. Objectives: To assess the extent to which the form responds to current needs of managing the fall risk and their consequences. On the other hand, on the basis of an extensive review of national and international literature, and taking into account the dynamics of quality and safety of the patient that are created at the hospital in study, to propose a form more efficient in order to respond to the challenges that we face nowadays. Methodology: It was an exploratory descriptive study based on the quantitative paradigm. The population study was constituted by 98 patients who had suffered falls during hospitalization in the year 2010, in a hospital E.P.E. Conclusion: Falling occurred more frequently in male individuals with cerebral-vascular and infectious diseases, and in most of the time, falls have not resulted in serious consequences. The form recommended here has the advantage of being computerized and characterize aspects related with costs.