Enhancing health care for type 2 diabetes in Northern Brazil: A pilot study of pharmaceutical care in community pharmacy

To evaluate the impact of a medication therapy management (MTM) program on the clinical outcomes and the quality of life (QoL) of a group of elderly patients with type 2 diabetes mellitus (DM). The study was conducted in a community pharmacy in Aracaju, Brazil, from February to November 2009. A quasi-experimental, longitudinal, prospective study was conducted by intervention. The group patients received medication therapy management from a clinical pharmacist. A sample of convenience was obtained for patients of both genders aged from 60 to 75 years. Monthly visits were scheduled over 10 months. At these consultations, sociodemographic, clinical data were obtained. QoL assessment was conducted using a generic instrument-the Medical Outcomes Studies 36-item Short Form Survey (SF-36 (R)). In total, 34 completed the study. The mean age of the patients was 65.9 (4.7) years. In total, 117 DRPs were identified. Patients' baseline and final evaluation measures for glycosylated hemoglobin, capillary blood glucose, blood pressure, and waist circumference were significantly different (p < 0.05). The domains of QoL assessed by the SF-36 (R) also shows significant differences between patients' baseline and final evaluation scores. The co-responsibility and active participation on the part of the elderly may have helped pharmacotherapy achieve its clinical and humanistic aims.

Perimedullary arteriovenous fistulas in children: report on six cases

Background Perimedullary arteriovenous fistulas (PMAVFs) are rare spinal lesions and even more uncommon in children. Objective The aim of this study was to document rare occurrences of this type of arteriovenous malformation in six children treated at our institution. Methods The clinical data, radiological findings, and treatment in six cases of PMAVFs were reviewed. Six patients with PMAVFs were managed at our institution over a 5-year period. The patients (four girls and two boys), ranging in age from 6 to 15 years, presented with initially fluctuating, and eventually permanent and progressive, sudden-onset paraparesis, sensory disturbances, and sphincter dysfunction. The duration of symptoms before diagnosis ranged from 1 week to 13 years. Results All the patients underwent magnetic resonance imaging and spinal selective angiography, which demonstrated the characteristic imaging of an arteriovenous fistula. Embolization of the arteriovenous fistula was initially attempted in three patients with successful occlusion of the fistula in two. For the remaining cases, open surgery was performed, with complete occlusion of the fistula. There was no morbidity, regardless of the treatment performed. All the patients experienced neurological improvement after treatment. Conclusions No specific clinical or radiological characteristic of PMAVFs in the pediatric population was observed when our series was compared with a general series. Early diagnosis and timing of the therapeutic intervention seemed to avoid the development of irreversible ischemic myeloradiculopathy and prevented hemorrhage. Treatment for PMAVFs is difficult to standardize because these are extremely rare lesions with different angioarchitecture configurations.

Analytical Processing Over XML and XLink

Current commercial and academic OLAP tools do not process XML data that contains XLink. Aiming at overcoming this issue, this paper proposes an analytical system composed by LMDQL, an analytical query language. Also, the XLDM metamodel is given to model cubes of XML documents with XLink and to deal with syntactic, semantic and structural heterogeneities commonly found in XML documents. As current W3C query languages for navigating in XML documents do not support XLink, XLPath is discussed in this article to provide features for the LMDQL query processing. A prototype system enabling the analytical processing of XML documents that use XLink is also detailed. This prototype includes a driver, named sql2xquery, which performs the mapping of SQL queries into XQuery. To validate the proposed system, a case study and its performance evaluation are presented to analyze the impact of analytical processing over XML/XLink documents.

Oral leukoplakia manifests differently in smokers and non-smokers

Oral leukoplakias (OL) are potentially malignant lesions that are typically white in color. Smoking is considered a risk factor for developing OL, and dysplastic lesions are more prone to malignant transformation. The aim of this study was to describe the clinical features observed in dysplastic and non-dysplastic OL in both smokers and nonsmokers. A total of 315 cases of OL were retrieved and separated into either dysplastic or non-dysplastic lesions, and these cases were further categorized as originating in either smokers or non-smokers. Frequencies of the type of OL lesion, with respect to whether the patients smoked, were established. The results demonstrated that 131 cases of OL were dysplastic (74 smokers and 57 non-smokers), and 184 were non-dysplastic (96 smokers and 88 non-smokers). For OL cases in smokers for which information about alcohol consumption was also available (84 cases), the results revealed no significant difference in the amount of dysplastic and non-dysplastic lesions. Dysplastic lesions were more frequent in male smokers and in non-smoking females. The median age of smokers with cases of OL was significantly lower than in non-smokers; the lowest median ages were observed for female smokers with dysplastic OL. The most frequent anatomical sites of dysplastic lesions were the floor of the mouth in smokers and the tongue in non-smokers. Dysplastic lesions in smokers were significantly smaller than non-dysplastic lesions in non-smokers. Being a male smoker, being female, being younger, and having smaller lesions were associated with dysplastic features in OL. These clinical data may be important for predicting OL malignant transformation.

Diagnostic utility of immunohistochemistry in distinguishing trichoepithelioma and basal cell carcinoma: evaluation using tissue microarray samples

Trichoepithelioma is a benign neoplasm that shares both clinical and histological features with basal cell carcinoma. It is important to distinguish these neoplasms because they require different clinical behavior and therapeutic planning. Many studies have addressed the use of immunohistochemistry to improve the differential diagnosis of these tumors. These studies present conflicting results when addressing the same markers, probably owing to the small number of basaloid tumors that comprised their studies, which generally did not exceed 50 cases. We built a tissue microarray with 162 trichoepithelioma and 328 basal cell carcinoma biopsies and tested a panel of immune markers composed of CD34, CD10, epithelial membrane antigen, Bcl-2, cytokeratins 15 and 20 and D2-40. The results were analyzed using multiple linear and logistic regression models. This analysis revealed a model that could differentiate trichoepithelioma from basal cell carcinoma in 36% of the cases. The panel of immunohistochemical markers required to differentiate between these tumors was composed of CD10, cytokeratin 15, cytokeratin 20 and D2-40. The results obtained in this work were generated from a large number of biopsies and resulted in the confirmation of overlapping epithelial and stromal immunohistochemical profiles from these basaloid tumors. The results also corroborate the point of view that trichoepithelioma and basal cell carcinoma tumors represent two different points in the differentiation of a single cell type. Despite the use of panels of immune markers, histopathological criteria associated with clinical data certainly remain the best guideline for the differential diagnosis of trichoepithelioma and basal cell carcinoma. Modern Pathology (2012) 25, 1345-1353; doi: 10.1038/modpathol.2012.96; published online 8 June 2012

A rigorous approach to facilitate and guarantee the correctness of the genetic testing management in human genome information systems

Abstract Background Recent medical and biological technology advances have stimulated the development of new testing systems that have been providing huge, varied amounts of molecular and clinical data. Growing data volumes pose significant challenges for information processing systems in research centers. Additionally, the routines of genomics laboratory are typically characterized by high parallelism in testing and constant procedure changes. Results This paper describes a formal approach to address this challenge through the implementation of a genetic testing management system applied to human genome laboratory. We introduced the Human Genome Research Center Information System (CEGH) in Brazil, a system that is able to support constant changes in human genome testing and can provide patients updated results based on the most recent and validated genetic knowledge. Our approach uses a common repository for process planning to ensure reusability, specification, instantiation, monitoring, and execution of processes, which are defined using a relational database and rigorous control flow specifications based on process algebra (ACP). The main difference between our approach and related works is that we were able to join two important aspects: 1) process scalability achieved through relational database implementation, and 2) correctness of processes using process algebra. Furthermore, the software allows end users to define genetic testing without requiring any knowledge about business process notation or process algebra. Conclusions This paper presents the CEGH information system that is a Laboratory Information Management System (LIMS) based on a formal framework to support genetic testing management for Mendelian disorder studies. We have proved the feasibility and showed usability benefits of a rigorous approach that is able to specify, validate, and perform genetic testing using easy end user interfaces.

Severe lower respiratory tract infection in infants and toddlers from a non-affluent population: viral etiology and co-detection as risk factors

Abstract Background Lower respiratory tract infection (LRTI) is a major cause of pediatric morbidity and mortality, especially among non-affluent communities. In this study we determine the impact of respiratory viruses and how viral co-detections/infections can affect clinical LRTI severity in children in a hospital setting. Methods Patients younger than 3 years of age admitted to a tertiary hospital in Brazil during the months of high prevalence of respiratory viruses had samples collected from nasopharyngeal aspiration. These samples were tested for 13 different respiratory viruses through real-time PCR (rt-PCR). Patients were followed during hospitalization, and clinical data and population characteristics were collected during that period and at discharge to evaluate severity markers, especially length of hospital stay and oxygen use. Univariate regression analyses identified potential risk factors and multivariate logistic regressions were used to determine the impact of specific viral detections as well as viral co-detections in relation to clinical outcomes. Results We analyzed 260 episodes of LRTI with a viral detection rate of 85% (n = 222). Co-detection was observed in 65% of all virus-positive episodes. The most prevalent virus was Respiratory Syncytial Virus (RSV) (54%), followed by Human Metapneumovirus (hMPV) (32%) and Human Rhinovirus (HRV) (21%). In the multivariate models, infants with co-detection of HRV + RSV stayed 4.5 extra days (p = 0.004), when compared to infants without the co-detection. The same trends were observed for the outcome of days of supplemental oxygen use. Conclusions Although RSV remains as the main cause of LRTI in infants our study indicates an increase in the length of hospital stay and oxygen use in infants with HRV detected by RT-PCR compared to those without HRV. Moreover, one can speculate that when HRV is detected simultaneously with RSV there is an additive effect that may be reflected in more severe clinical outcome. Also, our study identified a significant number of children infected by recently identified viruses, such as hMPV and Human Bocavirus (HBov), and this is a novel finding for poor communities from developing countries.

Septic shock in older people: a prospective cohort study

Abstract Background Septic shock is the first cause of death in Intensive Care Units. Despite experimental data showing increased inflammatory response of aged animals following infection, the current accepted hypothesis claims that aged patients are immunocompromised, when compared to young individuals. Results Here, we describe a prospective cohort study designed to analyze the immune profile of this population. Conclusion Older people are as immunocompetent as the young individual, regarding the cytokines, chemokines and growth factors response to devastating infection.

Hipoglicemia hiperinsulinêmica da infância: Análise de dados clínicos de uma amostra brasileira

OBJETIVO: Rever a apresentação dos casos de hipoglicemia hiperinsulinêmica da infância (HHI), tratamento e histologia nos serviços de endocrinologia pediátrica no Brasil. MATERIAIS E MÉTODO: Os serviços receberam protocolo para resgatar dados de nascimento, resultados laboratoriais, tipo de tratamento instituído, necessidade de pancreatectomia e histologia. RESULTADOS: Vinte e cinco casos de HHI de seis centros foram resgatados, 15 do sexo masculino, 3/25 nascidos de parto normal. A mediana de idade do diagnóstico foi 10,3 dias. As dosagens de glicose e insulina na amostra sérica crítica apresentaram mediana de 24,7 mg/dL e 26,3 UI/dL. A velocidade de infusão de glicose endovenosa foi superior a 10 mg/kg/min em todos os casos (M:19,1). Diazóxido foi utilizado em 15/25, octreotide em 10, corticoide em 8, hormônio de crescimento em 3, nifedipina em 2 e glucagon em 1. Quarenta por cento (10/25) foram pancreatectomizados, nos quais a análise histológica revelou a forma difusa da patologia. CONCLUSÃO: Primeira análise crítica de uma amostra brasileira de portadores de HHI congênita. Arq Bras Endocrinol Metab. 2012;56(9):666-71

Treino cognitivo e intervenção psicoeducativa para indivíduos hipertensos: efeitos na cognição

OBJETIVOS: Avaliar a possibilidade de aliar o treino cognitivo à intervenção psicoeducativa de oito sessões sobre hipertensão visando melhor manejo desta condição crônica em idosos. MÉTODOS: Participaram 64 idosos que se declararam como hipertensos, divididos em grupo experimental (GE, n=35) e grupo controle (GC, n=29). O grupo controle recebeu treino após o pós teste. O protocolo incluiu dados sócio-demográficos e clínicos, o Mini-Exame do Estado Mental (MEEM), Escala de Depressão Geriátrica (EDG), Teste Comportamental de Memória de Rivermead (RBMT), Fluência Verbal categoria animais (FV) e Short Cognitive Test (SKT). RESULTADOS: Pôde-se observar que o GE apresentou melhor desempenho cognitivo, quando comparado ao GC, após a intervenção. CONCLUSÕES: Podem ocorrer ganhos cognitivos associados a uma intervenção psicoeducativa para idosos hipertensos.

Prior history of sexually transmitted diseases in women living with AIDS in São Paulo, Brazil

OBJECTIVES: To describe the epidemiological profile, risk behaviors, and the prior history of sexually transmitted diseases (STDs) in women living with acquired immunodeficiency syndrome (AIDS). METHODS: Cross-sectional study, performed at the Centro de Referência e Treinamento em DST/AIDS of São Paulo. The social, demographic, behavioral, and clinical data such as age, schooling, marital status, age at first sexual intercourse, number of sexual partners, parity, use of drugs, time of HIV diagnosis, CD4 count, and viral load determination were abstracted from the medical records of women living with AIDS who had gynecological consultation scheduled in the period from June 2008 to May 2009. RESULTS: Out of 710 women who were scheduled to a gynecological consultation during the period of the study, 598 were included. Previous STD was documented for 364 (60.9%; 95% CI: 56.9%-64.8%) women. The associated factors with previous STDs and their respective risks were: human development index (HDI) < 0.50 (ORaj = 5.5; 95% CI: 2.8-11.0); non-white race (ORaj = 5.2; 95% CI: 2.5-11.0); first sexual intercourse at or before 15 years of age (ORaj = 4.4; 95% CI: 2.3-8.3); HIV infection follow-up time of nine years or more (ORaj = 4.2; 95% CI: 2.3-7.8)]; number of sexual partners during the entire life between three and five partners (ORaj = 2.2; 95% CI: 1.1-4.6), and six or more sexual partners (ORaj = 3.9; 95% CI: 1.9-8.0%); being a sex worker (ORaj = 1.9; 95% CI: 1.1-3.1). CONCLUSIONS: A high prevalence of a prior history of STDs in the studied population was found. It is essential to find better ways to access HIV infection prevention, so that effective interventions can be more widely implemented.

MicroRNA expression profile in head and neck cancer: HOX-cluster embedded microRNA-196a and microRNA-10b dysregulation implicated in cell proliferation

Abstract Background Current evidence implicates aberrant microRNA expression patterns in human malignancies; measurement of microRNA expression may have diagnostic and prognostic applications. Roles for microRNAs in head and neck squamous cell carcinomas (HNSCC) are largely unknown. HNSCC, a smoking-related cancer, is one of the most common malignancies worldwide but reliable diagnostic and prognostic markers have not been discovered so far. Some studies have evaluated the potential use of microRNA as biomarkers with clinical application in HNSCC. Methods MicroRNA expression profile of oral squamous cell carcinoma samples was determined by means of DNA microarrays. We also performed gain-of-function assays for two differentially expressed microRNA using two squamous cell carcinoma cell lines and normal oral keratinocytes. The effect of the over-expression of these molecules was evaluated by means of global gene expression profiling and cell proliferation assessment. Results Altered microRNA expression was detected for a total of 72 microRNAs. Among these we found well studied molecules, such as the miR-17-92 cluster, comprising potent oncogenic microRNA, and miR-34, recently found to interact with p53. HOX-cluster embedded miR-196a/b and miR-10b were up- and down-regulated, respectively, in tumor samples. Since validated HOX gene targets for these microRNAs are not consistently deregulated in HNSCC, we performed gain-of-function experiments, in an attempt to outline their possible role. Our results suggest that both molecules interfere in cell proliferation through distinct processes, possibly targeting a small set of genes involved in cell cycle progression. Conclusions Functional data on miRNAs in HNSCC is still scarce. Our data corroborate current literature and brings new insights into the role of microRNAs in HNSCC. We also show that miR-196a and miR-10b, not previously associated with HNSCC, may play an oncogenic role in this disease through the deregulation of cell proliferation. The study of microRNA alterations in HNSCC is an essential step to the mechanistic understanding of tumor formation and could lead to the discovery of clinically relevant biomarkers.

Frequency of Toxocara infection in children attended by the health public service of Maringá, south Brazil.

The lack of specific laboratorial diagnosis methods and precise symptoms makes the toxocariasis a neglected disease in Public Health Services. This study aims to determine the frequency of Toxocara spp. infection in children attended by the Health Public Service of Hospital Municipal de Maringá, South Brazil. To evaluate the association of epidemiological and clinical data, and observational and cross-section study was carried out. From 14,690 attended children/year aged from seven month to 12 years old, 450 serum samples were randomly collected from September/2004 to September/2005. A questionnaire was used to evaluate epidemiological, clinical and hematological data. An ELISA using Toxocara canis larval excretory-secretory products as antigen detected 130 (28.8%) positive sera, mainly between children from seven month to five years old (p = 0.0016). Significant correlation was observed between positive serology for Toxocara, and frequent playing in sandbox at school or daycare center (p = 0.011) and the presence of a cat at home (p = 0.056). From the families, 50% were dog owners which exposed soil backyards. Eosinophilia (p = 0.776), and signs and symptoms analyzed (fever p = 0.992, pneumonia p = 0.289, cold-like symptoms p = 0.277, cough p =0.783, gastrointestinal problems p = 0.877, migraine p = 0.979, abdominal pain p = 0.965, joint pain p = 0.686 and skin rash p = 0.105) could not be related to the presence of anti-Toxocara antibodies. Therefore, two asthmatics children showed titles of1:10,240 and accentuated eosinophilia (p = 0.0001). The authors emphasize the needs of prevention activities.

Profilo molecolare dei linfomi post-trapianto

Fifty-two cases of monomorphic post-transplant lymphoproliferative disorders (M-PTLD), developed in patients undergone solid organ or bone marrow transplantation, were studied by the application of the tissue micro-array (TMA) technology. They included 50 cases of diffuse large B-cell lymphomas (DLBCL) and 2 Burkitt lymphomas (BL). In order to evaluate the immune-profile a large panel of antibodies was applied including several new markers (Cyclin D2, Cyclin D3, p27, PKC-β, FOXP-1 and Survivin) identified as negative prognostic factors in DLBCL of the immunocompetent patient. Out of 50 DLBCL, 23 cases (46%) had an Activated B Cell (ABC) phenotype, 8 (16%) a Germinal Centre B-cell (GCB) phenotype, and 11 (22%) an Unclassified (UC) phenotype. In 8 cases (16%) the subtype was not demonstrable due to sub-optimal preservation or loss of the tissue core. FISH analysis detected BCL2 gene amplification and MYC rearrangement. EBV was identified in 32 cases (64%) performing immunohistochemistry (LMP-1) and in situ hybridization (EBER). Clinical data and follow-up were available in all cases of malignant lymphomas but one. Thirty-two patients died for progression of disease or complications related to transplant (bleeding, bacterial infections, and multi-organ failure); 17 patients are actually alive and disease-free. M-PTLD are aggressive lymphomas characterized by very poor outcome. The neoplastic process is stimulated by a prolonged immunosuppressive status which is capable to induce alterations of the immune system and allow EBV reactivation in previously infected patients. Indeed EBV infection seems to be the most significant risk factor to predict the development of a PTLD while age, sex, site of involvement and type of transplant do not have significant correlation. Furthermore DLBCL arisen in a setting of immunodeficiency share phenotypic and molecular features with DLBCL of the immunocompetent patient. In particular, the former shows a high incidence of BCL2 gene amplification and this aberration typically correlates with “non-GCB” phenotype. Also M-PTLD do express prognostic markers (PKC-β, cyclin D2, FOXP-1, and Survivin): notably, in our study, PKC-β and FOXP-1 were frequently expressed and they were predictive of a shorter overall survival even in lymphomas recognized to have a good prognosis (GCB-type). Given the fact that such molecules are detectable at the time of the diagnosis, we postulate whether a “tailored” or more specific therapy might be applied in the management of the immune-compromised patient.

Evaluation of fluid transport processes in dental enamel. Methods to assess the relevance of enamel permeability in caries prevention and etching treatments.

This thesis evaluated in vivo and in vitro enamel permeability in different physiological and clinical conditions by means of SEM inspection of replicas of enamel surface obtained from polyvinyl siloxane impressions subsequently later cast in polyether impression ma-terial. This technique, not invasive and risk-free, allows the evaluation of fluid outflow from enamel surface and is able to detect the presence of small quantities of fluid, visu-alized as droplets. Fluid outflow on enamel surface represents enamel permeability. This property has a paramount importance in enamel physiolgy and pathology although its ef-fective role in adhesion, caries pathogenesis and prevention today is still not fully under-stood. The aim of the studies proposed was to evaluate enamel permeability changes in differ-ent conditions and to correlate the findings with the actual knowledge about enamel physiology, caries pathogenesis, fluoride and etchinhg treatments. To obtain confirmed data the replica technique has been supported by others specific techniques such as Ra-man and IR spectroscopy and EDX analysis. The first study carried out visualized fluid movement through dental enamel in vivo con-firmed that enamel is a permeable substrate and demonstrated that age and enamel per-meability are closely related. Examined samples from subjects of different ages showed a decreasing number and size of droplets with increasing age: freshly erupted permanent teeth showed many droplets covering the entire enamel surface. Droplets in permanent teeth were prominent along enamel perikymata. These results obtained through SEM inspection of replicas allowed innovative remarks in enamel physiology. An analogous testing has been developed for evaluation of enamel permeability in primary enamel. The results of this second study showed that primary enamel revealed a substantive permeability with droplets covering the entire enamel sur-face without any specific localization accordingly with histological features, without changes during aging signs of post-eruptive maturation. These results confirmed clinical data that showed a higher caries susceptibility for primary enamel and suggested a strong relationship between this one and enamel permeability. Topical fluoride application represents the gold standard for caries prevention although the mechanism of cariostatic effect of fluoride still needs to be clarified. The effects of topical fluoride application on enamel permeability were evaluated. Particularly two dif-ferent treatments (NaF and APF), with different pH, were examined. The major product of topical fluoride application was the deposition of CaF2-like globules. Replicas inspec-tion before and after both treatments at different times intervals and after specific addi-tional clinical interventions showed that such globule formed in vivo could be removed by professional toothbrushing, sonically and chemically by KOH. The results obtained in relation to enamel permeability showed that fluoride treatments temporarily reduced enamel water permeability when CaF2-like globules were removed. The in vivo perma-nence of decreased enamel permeability after CaF2 globules removal has been demon-strated for 1 h for NaF treated teeth and for at least 7 days for APF treated teeth. Important clinical consideration moved from these results. In fact the caries-preventing action of fluoride application may be due, in part, to its ability to decrease enamel water permeability and CaF2 like-globules seem to be indirectly involved in enamel protection over time maintaining low permeability. Others results obtained by metallographic microscope and SEM/EDX analyses of or-thodontic resins fluoride releasing and not demonstrated the relevance of topical fluo-ride application in decreasing the demineralization marks and modifying the chemical composition of the enamel in the treated area. These data obtained in both the experiments confirmed the efficacy of fluoride in caries prevention and contribute to clarify its mechanism of action. Adhesive dentistry is the gold standard for caries treatment and tooth rehabilitation and is founded on important chemical and physical principles involving both enamel and dentine substrates. Particularly acid etching of dental enamel enamel has usually employed in bonding pro-cedures increasing microscopic roughness. Different acids have been tested in the litera-ture suggesting several etching procedures. The acid-induced structural transformations in enamel after different etching treatments by means of Raman and IR spectroscopy analysis were evaluated and these findings were correlated with enamel permeability. Conventional etching with 37% phosphoric acid gel (H3PO4) for 30 s and etching with 15 % HCl for 120 s were investigated. Raman and IR spectroscopy showed that the treatment with both hydrochloric and phosphoric acids induced a decrease in the carbonate content of the enamel apatite. At the same time, both acids induced the formation of HPO42- ions. After H3PO4 treatment the bands due to the organic component of enamel decreased in intensity, while in-creased after HCl treatment. Replicas of H3PO4 treated enamel showed a strongly reduced permeability while replicas of HCl 15% treated samples showed a maintained permeability. A decrease of the enamel organic component, as resulted after H3PO4 treatment, involves a decrease in enamel permeability, while the increase of the organic matter (achieved by HCl treat-ment) still maintains enamel permeability. These results suggested a correlation between the amount of the organic matter, enamel permeability and caries. The results of the different studies carried out in this thesis contributed to clarify and improve the knowledge about enamel properties with important rebounds in theoretical and clinical aspects of Dentistry.