Prevalence of discordant immunologic and virologic responses in patients with AIDS under antiretroviral therapy in a specialized care center in Brazil

Some patients under antiretroviral therapy (ART) do not reach immune recovery when the viral load becomes undetectable. This is called discordant immunologic and virologic responses. Its prevalence varies between 8% and 24%. This study describes its prevalence and the characteristics of the affected subjects in the outpatient clinic of a Brazilian specialized-care center. Of 934 patients on ART, 536 had undetectable viral loads. Prevalence was 51/536 or 9% (95% confidence interval: 6.6% to 11.4%). Median age at the beginning of ART was 37 years (interquartile range - IQR: 31 to 45). Male gender and mixed race predominated (76.5% and 47.1% respectively). AIDS-defining illnesses were absent at the beginning of ART in 60.8%. Fifty-one percent were taking protease inhibitors, 43.2% Efavirenz and 5.8% both. Median time on ART was 36 months (IQR: 17-81 months). Irregular treatment was recorded for 21.6%. ART had been modified for 63% prior to the study, and 15.7% had used monotherapy or double therapy. Median CD4 count was 255 cells/mm³ (IQR: 200-284). Median viral load before ART was 4.7 log10 copies/mL (IQR: 4.5-5.2). Discordant responders were not different from AIDS patients in general, but there was a high frequency of multiple schedules of treatment.

Potential utility of hyperbaric oxygen therapy and propolis in enhancing the leishmanicidal activity of glucantime

In this study we investigated the efficacy of hyperbaric oxygen (HBO) therapy, alone or combined with the pentavalent antimonial glucantime on Leishmania amazonensis infection. In parallel, the effect of Brazilian red propolis gel (propain) alone or combined with glucantime on L. amazonensis infection was evaluated. The inhibition of the infection in macrophages treated with glucantime in combination with HBO exposition was greater than that of macrophages treated with glucantime alone or HBO alone. The susceptible mouse strain BALB/c infected in the shaved rump with L. amazonensis treated with glucantime and exposed to HBO showed: time points in the course of the disease in which lesions were smaller than those of mice treated with glucantime alone and revascularization of the skin in the lesion site; interferon-gamma (IFN-g) levels were not elevated in lymph node cells from these animals. Propain alone was not efficient against lesions, although less exudative lesions were observed in animals treated with propain alone or combined with glucantime. These results reveal the potential value of HBO and red propolis in combination with glucantime for treating cutaneous leishmaniasis and encourage further studies on the effect of more aggressive HBO, propolis and glucantime therapies on different mouse models of leishmaniasis.

Acute gouty arthritis as a manifestation of immune reconstitution inflammatory syndrome after initiation of antiretroviral therapy

Immune reconstitution inflammatory syndrome (IRIS) in HIV-infected subjects initiating antiretroviral therapy most commonly involves new or worsening manifestations of previously subclinical or overt infectious diseases. Reports of non-infectious IRIS are much less common but represent important diagnostic and treatment challenges. We report on a 34-year-old HIV-infected male patient with no history of gout who developed acute gouty arthritis in a single joint one month after initiating highly active antiretroviral therapy.

Inferior Vena Cava Filter Placement During Pregnancy: an Adjuvant Option When Medical Therapy Fails

The authors present a case of a 27-year-old multiparous woman, with multiple thrombophilia, whose pregnancy was complicated with deep venous thrombosis requiring placement of a vena cava filter. At 15th week of gestation, following an acute deep venous thrombosis of the right inferior limb, anticoagulant therapy with low-molecular-weight heparin (LMWH) was instituted without improvement in her clinical status. Subsequently, at 18 weeks of pregnancy, LMWH was switched to warfarin. At 30th week of gestation, the maintenance of high thrombotic risk was the premise for placement of an inferior vena cava filter for prophylaxis of pulmonary embolism during childbirth and postpartum. There were no complications and a vaginal delivery was accomplished at 37 weeks of gestation. Venal placement of inferior vena cava filters is an attractive option as prophylaxis for pulmonary embolism during pregnancy.

Efetividade da Terapia Manual Ortopédica num Caso de Lombalgia – Estudo de Caso

Introdução: A lombalgia crônica é uma patologia que pode afetar a sua qualidade de vida de todo o tipo de indivíduos e apresenta grandes custos socioeconómicos. Objetivo: Analisar a efetividade de um programa de fisioterapia num caso de lombalgia crônica, na dor, funcionalidade e qualidade de vida. Métodos: Estudo observacional descritivo tipo estudo de caso de um homem de 56 anos, com lombalgia crônica. Para a avaliação foram utilizados testes ortopédicos, goniometria, a escala visual analógica (EVA), índice de incapacidade Oswestry para a lombalgia, o questionário de estado de saúde SF-36v2 e a classificação internacional de funcionalidade, incapacidade e saúde. Foi efetuada 10 sessões, ao longo de 2 semanas recorrendo a terapia manual, exercícios de terapêuticos e educação. Resultados: Na escala visual analógica, o utente no final apresenta a dor lombar direita após 20 minutos se classifica como (2/10 na EVA) e a dor irradiada para o membro inferior direito na região posterior da perna e pé (0/10 na EVA). No índice de incapacidade Oswestry para a lombalgia, o utente obteve uma pontuação de 6% (incapacidade mínima), demostrando melhoria. No questionário de estado de saúde SF-36v2 o utente apresenta uma melhoria nas seguintes categorias: capacidade funcional (53%); limitação por aspetos físicos (54%); dor (51%); estado geral de saúde (48%); vitalidade (65%); aspetos sociais (57%); limitação por aspetos emocionais (56%) e saúde mental (57%). Os dados da classificação internacional de funcionalidade, incapacidade e saúde demonstraram melhoria do utente. Conclusão: Demonstrou-se que o processo de raciocínio clínico efetuado na intervenção, utilizando uma abordagem centrada no utente, baseada na evidência científica e na experiência clínica anterior, obteve os resultados positivos indo encontro aos objetivos iniciais e evidenciam que o programa de fisioterapia teve efeitos na dor, funcionalidade e qualidade de vida.

Efetividade da Terapia Manual Ortopédica num Caso de Cervicalgia – Estudo de caso

Introdução: Existem diversas causas e/ou estruturas responsáveis pela dor cervical, pelo que o sucesso do tratamento depende do diagnóstico diferencial e da escolha do tratamento mais adequado a cada situação. Objetivo: Descrever um plano de intervenção em fisioterapia num caso clínico de cervicalgia com base na terapia manual e exercícios terapêuticos. Métodos: Este estudo de caso refere-se a uma utente do sexo feminino, 47 anos, que foi encaminhada aos serviços de fisioterapia após um acidente de carro do qual fraturou C6 e C7, a clavícula e o úmero (1/3 proximal). A utente foi avaliada na primeira semana de tratamento e seis semanas após o início da intervenção. Como instrumentos de avaliação foram utilizadas a Escala Numérica da Dor (END) e o questionário Neck Disability Index. A utente apresenta um quadro clínico de cefaleia cervicogénica (6/10 END), dor cervical com mais incidência no lado esquerdo (6/10 END) e dor no ombro direito (4/10 END). A intervenção inclui técnicas de terapia manual, exercícios terapêuticos e instrução da paciente. O foco principal é determinar se o treino da musculatura flexora profunda da cervical com feedback visual, utilizando o Stabilizer®, tem influência positiva na diminuição da dor, das cefaleias e na estabilidade cervical. Resultados: Após as seis semanas de tratamento a paciente apresentou evidente melhoria, e diminuição dos sintomas. Conclusão: A cervicalgia está associada a alterações da estabilidade dos músculos cervicais e à falta de propriocetividade do pescoço e ombros. As evidências sugerem que esta disfunção deve-se principalmente à dor, que consequentemente vai agravando a condição do paciente. A abordagem terapêutica foi fundamentada pela anatomia, biomecânica e raciocínio clínico, à luz da evidência científica e fatores biopsicossociais. Tendo em conta o sucesso da intervenção, conclui-se que o plano de tratamento aplicado foi adequado para este caso clínico.

Efetividade da Terapia Manual na Síndrome de Conflito Subacromial

Introdução: A síndrome do conflito subacromial representa uma das causas mais comuns de dor no ombro. Neste tipo de conflito existe comprometimento do espaço subacromial, na maioria das vezes provocada pela compressão mecânica da coifa dos rotadores, especialmente da inserção do tendão do músculo supra-espinhoso, contra a superfície antero-inferior do acrómio. A etiologia desta condição tem sido debatida ao longo dos anos e muitos autores defendem que a sua causa é multi-fatorial. Estudos associam a terapia manual e os exercícios terapêuticos como forma de melhorar a eficiência do tratamento e o tempo de recuperação. Objectivo(s): descrever a intervenção da fisioterapia manual num paciente com diagnóstico de conflito subacromial. Métodos: estudo de caso de um paciente que desenvolveu um quadro doloroso no ombro direito no início de Janeiro de 2015 e em que a intervenção de fisioterapia teve início no princípio de Março de 2015. Foi utilizado como instrumentos de avaliação a escala numérica de dor, a escala DASH e a goniometria. Foi aplicado uma variedade de técnicas musculares, articulares e exercícios terapêuticos. O tratamento foi realizado em dias alternados e teve a duração total de nove sessões. Resultados: no final da primeira sessão o paciente referiu melhoria na dor e movimentos ativos. A regressão dos sintomas foi relativamente rápida até à completa remissão no fim da nona sessão. Conclusão: o processo de raciocínio clínico desenvolvido pelo fisioterapeuta durante de tratamento foi salientado. Após a recolha dos dados relativos à história e sua interpretação levantaram-se hipóteses o qual poderia estar na origem numa queixa do ombro com estas características. No exame objetivo foram realizados testes para permitir a obtenção do diagnóstico diferencial – conflito subacromial; elaborou-se então um plano de intervenção em colaboração com o paciente, nomeadamente com técnicas de terapia manual, que se mostrou eficaz, com excelentes resultados.

Elaboração de um manual de fabrico de gelado

Dissertação para obtenção do Grau de Mestre em Tecnologia e Segurança Alimentar – perfil Qualidade Alimentar

Zinc Therapy of Neurological Wilson's Disease in a Woman with Two Foetus with Agenesis of the Corpus Callosum

8A>C>86A G:EDGI: A patient diagnosed Wilson’s disease (WD) 22 years previously, successfully treated initially with zinc, developed neuropsychiatric disease after years of irregular therapy. Reassuming zinc therapy was successful. After a normal pregnancy, she had two therapeutic abortions for corpus callosum agenesis, and a missed abortion. We review the genetics, physiopathology, clinics and imagiologic response to zinc therapy, the problems of pregnancy in WD, advising to maintain therapy. A hypothetic cause for fetus brain anomaly would be hypocupremia due to zinc therapy, confronting with two other possibilities, one related to Wilson’s disease in itself, other due to a congenital syndrome of agenesis of the corpus callosum, impossible to diagnose by our available diagnostic methods.

Host-induced changes in the cell surface N-linked glycoproteins, from Aspergillus fumigatus. Search for specific targets with potential for clinical therapy and/or diagnosis.

This dissertation is presented to obtain a Master degree in Structural and Functional Biochemistry

Long-Term Evaluation of Recurrence after Photodynamic Therapy with Topical Methyl Aminolevulinate for Non-Melanoma Skin Cancer: a Hospital-Based Study

Introduction & Objectives: Several factors may influence the decision to pursue nonsurgical modalities for the treatment of non-melanoma skin cancer. Topical photodynamic therapy (PDT) is a non-invasive alternative treatment reported to have a high efficacy when using standardized protocols in Bowen’s disease (BD), superficial basal cell carcinoma (BCC) and in thin nodular BCC. However, long-term recurrence studies are lacking. The aim of this study was to evaluate the long-term efficacy of PDT with topical methylaminolevulinate (MAL) for the treatment of BD and BCC in a dermato-oncology department. Materials & Methods: All patients with the diagnosis of BD or BCC, treated with MAL-PDT from the years 2004 to 2008, were enrolled. Treatment protocol included two MAL-PDT sessions one week apart repeated at three months when incomplete response, using a red light dose of 37-40 J/cm2 and an exposure time of 8’20’’. Clinical records were retrospectively reviewed, and data regarding age, sex, tumour location, size, treatment outcomes and recurrence were registered. Descriptive analysis was performed using chi square tests, followed by survival analysis with the Kaplan-Meier and Cox regression models. Results: Sixty-eight patients (median age 71.0 years, P25;P75=30;92) with a total of 78 tumours (31 BD, 45 superficial BCC, 2 nodular BCC) and a median tumour size of 5 cm2 were treated. Overall, the median follow-up period was 43.5 months (P25;P75=0;100), and a total recurrence rate of 33.8% was observed (24.4 % for BCC vs. 45.2% for BD). Estimated recurrence rates for BCC and BD were 5.0% vs. 7.4% at 6 months, 23.4% vs. 27.9% at 12 months, and 30.0% vs. 72.4% at 60 months. Both age and diagnosis were independent prognostic factors for recurrence, with significantly higher estimated recurrence rates in patients with BD (p=0.0036) or younger than 58 years old (p=0.039). The risk of recurrence (hazard ratio) was 2.4 times higher in patients with BD compared to superficial BCC (95% CI:1.1-5.3; p=0.033), and 2.8 times higher in patients younger than 58 years old (95% CI:1.2-6.5; p=0.02). Conclusions: In the studied population, estimated recurrence rates are higher than those expected from available literature, possibly due to a longer follow-up period. To the authors’ knowledge there is only one other study with a similar follow-up period, regarding BCC solely. BD, as an in situ squamous cell carcinoma, has a higher tendency to recur than superficial BCC. Despite greater cosmesis, PDT might no be the best treatment option for young patients considering their higher risk of recurrence.

Vulvar Lichen Sclerosus: Efficacy of Photodynamic Therapy Under Conscious Sedation with Inhaled 50% Nitrous Oxide and Oxygen Mixture

Anogenital lichen sclerosus is a chronic, inflammatory, mucocutaneous disorder of significant morbidity. Common symptoms include pruritus, pain, dysuria, and dyspareunia, frequently of difficult control. Photodynamic therapy (PDT) may be an effective therapeutic option in selected cases refractory to first--‐line treatment options. However, procedure--‐related pain is a limiting factor in patient adherence to treatment. Conscious sedation and analgesia with a ready--‐to--‐use gas mixture of nitrous oxide and oxygen is useful in short--‐term procedures. It provides a rapid, effective, and short--‐lived effect, without the need for anesthesiology support. A 75--‐year--‐old woman presented with a highly symptomatic, histologically confirmed vulvar lichen sclerosus, with at least 15 years of evolution. Pain, pruritus, and dysuria were intense and disabling. Treatment with ultrapotent topical corticosteroids proved to be ineffective despite patient compliance. She was then referred for PDT. A total of 3 sessions were performed, held at a mean interval of 9 weeks, and under the analgesic and sedative effect of nitrous oxide/oxygen gas. Response to treatment was evaluated through a daily, self--‐reported pain rating scale. Dysuria remitted completely after the first PDT session. An 80% reduction in pruritus and pain was observed after the third session, and has been sustained for the past six months without further need for topical corticotherapy. Treatment sessions were well tolerated and pain-- free, with no side effects to report. PDT appears to be effective in the symptomatic treatment of vulvar lichen sclerosus. To the authors’ knowledge this is the first case reporting the use of inhaled nitrous oxide/oxygen gas mixture during PDT performed in the genital area. Its analgesic and sedative effects may increase patients’ adherence to this painful procedure. Furthermore, given its safety, it can be easily managed in outpatient clinics by trained dermatologists.

ASSOCIATION BETWEEN SMOKING, CRACK COCAINE ABUSE AND THE DISCONTINUATION OF COMBINATION ANTIRETROVIRAL THERAPY IN RECIFE, PERNAMBUCO, BRAZIL

Despite the effectiveness of combination antiretroviral therapy in the treatment of people living with HIV/AIDS (PLWHA), nonadherence to medication has become a major threat to its effectiveness. This study aimed to estimate the prevalence of self-reported irregular use of antiretroviral therapy and the factors associated with such an irregularity in PLWHA. A cross-sectional study of PLWHA who attended two referral centers in the city of Recife, in Northeastern Brazil, between June 2007 and October 2009 was carried out. The study analyzed socioeconomic factors, social service support and personal habits associated with nonadherence to antiretroviral therapy, adjusted by multivariable logistic regression analysis. The prevalence of PLWHA who reported irregular use of combination antiretroviral therapy (cART) was 25.7%. In the final multivariate model, the irregular use of cART was associated with the following variables: being aged less than 40 years (OR = 1.66, 95%-CI: 1.29-2.13), current smokers (OR = 1.76, 95%-CI: 1.31-2.37) or former smokers (OR = 1.43, 95%-CI: 1.05-1.95), and crack cocaine users (OR = 2.79, 95%-CI: 1.24-6.32). Special measures should be directed towards each of the following groups: individuals aged less than 40 years, smokers, former smokers and crack cocaine users. Measures for giving up smoking and crack cocaine should be incorporated into HIV-control programs in order to promote greater adherence to antiretroviral drugs and thus improve the quality of life and prolong life expectancy.

RISK FACTORS OF HIV-1 VERTICAL TRANSMISSION (VT) AND THE INFLUENCE OF ANTIRETROVIRAL THERAPY (ART) IN PREGNANCY OUTCOME

In the absence of intervention, the rate of vertical transmission of HIV can range from 15-45%. With the inclusion of antiretroviral drugs during pregnancy and the choice of delivery route this amounts to less than 2%. However ARV use during pregnancy has generated several questions regarding the adverse effects of the gestational and neonatal outcome. This study aims to analyze the risk factors for vertical transmission of HIV-1 seropositive pregnant women living in Rio Grande and the influence of the use of ARVs in pregnancy outcome. Among the 262 pregnant women studied the rate of vertical transmission of HIV was found to be 3.8%. Regarding the VT, there was a lower risk of transmission when antiretroviral drugs were used and prenatal care was conducted at the referral service. However, the use of ART did not influence the outcome of pregnancy. However, initiation of prenatal care after the first trimester had an influence on low birth weight, as well as performance of less than six visits increased the risk of prematurity. Therefore, the risk factors analyzed in this study appear to be related to the realization of inadequate pre-natal and maternal behavior.

Renal Replacement Therapy in Critically Ill Patients - What Modality Should We Choose?

A lesão renal aguda é uma complicação comum nas unidades de cuidados intensivos. A mortalidade do doente crítico que requer diálise é extremamente elevada, apesar dos avanços significativos dos cuidados prestados a estes doentes. Há várias décadas que se discute o tipo de modalidade dialítica a oferecer a estes doentes (continua ou intermitente) e os principais fatores que pesam na decisão clínica são os meios e a experiência do centro, bem como a condição clínica do doente. Vários estudos tentaram estabelecer a melhor abordagem ao doente crítico com lesão renal aguda e necessidade dialítica, em termos de sobrevida do doente e recuperação renal. Nesta revisão tentarei resumir as evidências disponíveis sobre este tema.