Clinical presentation of parvovirus B19 infection in HIV-infected patients with and without AIDS

Human parvovirus B19 replicates in erythrocyte precursors. Usually, there are no apparent hematological manifestations. However, in individuals with high erythrocyte turnover, as in patients with sickle-cell disease and in the fetus, the infection may lead to severe transient aplasia and hydrops fetalis, respectively. In AIDS patients, persistent infection may result in chronic anemia. By contrast, in HIV-positive patients without AIDS the infection evolves as a mild exanthematous disease. Two clinical descriptions exemplify these forms of presentation. In the first, an AIDS patient presented with bone marrow failure that responded to immunoglobulin. In the second, an HIV-positive patient without AIDS had a morbilliform rash, and needed no treatment. Knowing that an AIDS patient has chronic B19 anemia lessens concern about drug anemia; protects the patient from invasive diagnostic maneuvers; and prevents the patient from disseminating the infection. In AIDS patients with pure red cell aplasia, a search for parvovirus B19 DNA in the serum or in the bone marrow is warranted.

Clinical and laboratorial evidence of Rickettsia felis infections in Latin America

After the discovery and initial characterization of Rickettsia felis in 1992 by Azad and cols, and the subsequent first description of a human case of infection in 1994, there have been two communications of human rickettsiosis cases caused by Rickettsia felis in Latin America. The first one was published in 2000 by Zavala-Velazquez and cols in Mexico. In 2001 Raoult and cols described the occurrence of two human cases of Rickettsia felis rickettsiosis in Brazil. In the present discussion these two articles were compared and after the description of the principal signs and symptoms, it was concluded that more studies are needed with descriptions of a greater number of patients to establish the true frequency of the clinical signs and symptoms present in Rickettsia felis rickettsiosis.

Multivariate analysis applied to clinical analysis data

Dissertação para obtenção do Grau de Mestre em Engenharia e Gestão Industrial

Comparative clinical and ultrasound study of egg-negative and egg-positive individuals from Schistosoma mansoni low morbidity endemic areas, and hospitalized patients with hepatosplenic disease

Two hundred and twenty three subjects from a Schistosoma mansoni low morbidity endemic area and nine hospitalized hepatosplenic patients were submitted to stool test and clinical examination and abdomen ultrasound assessments. According to stool examination and ultrasound results, they were grouped as follows: G1 - 63 Schistosoma mansoni egg-negative individuals; G2 - 141 egg-positive patients and without evidence of periportal fibrosis; G3 - 19 egg-positive patients with periportal echogenicity (3-6mm); and G4 - 9 hepatosplenic patients with periportal echogenicity (> 6mm). Hepatomegaly detected by physical examination of the abdomen evaluated in the midclavicular line was verified in G1, G2 and G3, respectively, in 11.1, 12.1 and 26.3%. In G1, G2 and G3, periportal thickening occurred only in schistosomal patients (8.5%). Mild pathological alterations in patients that cannot yet be detected by clinical examination were detectable in the liver by ultrasound and can be due to fibrosis. The degree of mild periportal fibrosis was diminished in 57.9% of patients 12 months after treatment of schistosomiasis with oxamniquine. At ultrasonography, the mean liver left lobe measurement of G3 was larger than that of G1, and that of G4 larger than that of G1 and G2. The mean size of the spleen of G4 was significantly larger than that of the other three groups, and that of G3 larger than that of G1 and G2.

Longitudinal clinical and serological survey of abdominal angiostrongyliasis in Guaporé, southern Brazil, from 1995 to 1999

Abdominal angiostrongyliasis is a zoonotic infection caused by Angiostrongylus costaricensis, a nematode with an intra-vascular location in the mesentery. Our objective was to address several aspects of the natural history of this parasitosis, in a longitudinal clinical and seroepidemiological study. A total of 179 individuals living in a rural area with active transmission in southern Brazil were followed for five years (1995-1999) resulting in yearly prevalence of 28.2%, 4.2%, 10%, 20.2% and 2.8% and incidences of 0%, 5.9%, 8% and 1.5%, respectively. Both men and woman were affected with higher frequencies at age 30-49 years. In 32 individuals serum samples were collected at all time points and IgG antibody reactivity detected by ELISA was variable and usually persisting not longer than one year. Some individual antibody patterns were suggestive of re-infection. There was no association with occurrence of abdominal pain or of other enteroparasites and there was no individual with a confirmed (histopathologic) diagnosis. Mollusks were found with infective third-stage larvae in some houses with an overall prevalence of 16% and a low parasitic burden. In conclusion, abdominal angiostrongyliasis in southern Brazil may be a frequent infection with low morbidity and a gradually decreasing serological reactivity.

Retrospective study of the occurrence of Cyclospora cayetanensis at Clinical Hospital of the University of São Paulo Medical School, SP

Cyclospora cayetanensis causes watery diarrhea in tropical countries, among travelers and after ingestion of contaminated water and food. Very little is known about its epidemiology, pathogenic aspects and reservoirs. In Brazil, its prevalence is unknown and to date there have been reports of three outbreaks. We report here a retrospective study of 5,015 stool samples from 4,869 patients attended at Clinical Hospital of the University of São Paulo Medical School, SP, Brazil between April 1996 and January 2002, with 14 cases of Cyclospora cayetanensis being detected there was a prevalence of 0.3%. Of the 14 infected patients, the mean age was 38 years and 71.4% were female. Ten patients presented symptoms; six presented levels of immunological markers and five patients were immunodeficient.

Clinical and laboratory findings related to a favorable evolution of hantavirus pulmonary syndrome

The medical records of 27 patients with hantavirus pulmonary syndrome were analyzed according to the need for invasive mechanical ventilation in relation to the following data up on hospital admission: age, gender, fever, cough, dyspnea, systolic arterial blood pressure, heart rate, levels of hemoglobin, hematocrit, leukocytes, lymphocytes, platelets, creatinine and arterial blood gases. The volume infused during the first 24 hours after admission, the use of inotropic agents, the use of corticosteroids and the patient outcomes were also evaluated. A favorable outcome was related to systolic blood pressure³ 100mmHg, heart rate lower than 100 beats per minute, creatinine below 1.6mg/dl, arterial blood pH³ 7.35, bicarbonate higher than 15mEq/dl, oxygen saturation higher than 84.1%, lower rehydration volume in the first 24 hours of hospitalization and no use of inotropic agents. Absence of clinical and laboratory signs of circulatory shock up on admission was associated with a favorable outcome of the patients.

Clinical and laboratorial evaluation of urinary schistosomiasis in Brazilians after staying in Mozambique

We examined 87 Brazilian individuals of a group of 132 that, on July and November 1994, participated in a peace mission in Mozambique. They served in an endemic area for haematobic schistosomiasis, where they swum in Licungo river during leisure time. Their arithmetic mean age was 31 year and all of them were male. Their urine test showed that 30 (34.5%) eliminated S. haematobium eggs and 55 (63.2%) presented positive serology by the enzime-linked immunoelectrotransfer blot test with purified microsomal antigen of S. haematobium adult worms. Eosinophilia was found in 30 (34.5%), haematuria in 26 (29.9%), dysuria in 32 (36.8%) and lombar pain in 36 (41.4%). All of those that eliminated eggs through urine had positive serology. Among the 25 patients with positive serology and without S. haematobium eggs in the urine test, 13 were symptomatic and 12 assymptomatic. The treatment with praziquantel for the 30 patients, with urine positive to S. haematobium eggs, presented 70% of parasitological cure.

An assessment of the integration of the mental health component into the care of women affected by intimate partner violence in Peru

RESUMO: A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica. legislação com base no género, saúde, guias, prevenção e mujeres 6 RESUMO (PORTUGUESE) A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica.-----------------ABSTRACT: Violence against women (VAW) is a public health problem and a human rights violation. It is highly prevalent in Latin America and the Caribbean; the Multi-country Study on Violence against Women by the World Health Organization identified rural Peruvian women as suffering the highest rates of VAW. The country is party to CEDAW and Belen Do Para Conventions, which set forth recommendations to overcome this form of discrimination and describe the role of the health sector. Peruvian law defines violence as a mental health issue. Objective: The Ministry of Health’s three technical guidelines were reviewed to assess the integration of mental health into the care of women affected by violence Method: The protection of the woman’s mental health was ascertained in the conventions mentioned above. The recognition of the mental health consequences of VAW and the inclusion of its evaluation and care were assessed in pertinent Peruvian legislation. Using these international and national parameters, the three guidelines for the attention of violence were subject to content analysis to see whether they conform to the conventions and integrate mental health care. Outcome: These guidelines are too extensive and do not clearly define the responsibility of health workers. They do not include a mental health exam in the evaluation of the victim and are vague in the description of the actions to be carried out by the health care provider. Guidelines prescribe universal screening using an outdated instrument and moreover, WHO Guidelines do not recommend screening. Conclusion: These multiple guidelines do not provide useful guidance for health care providers, particularly for the assessment of mental health sequelae, and unnecessarily stigmatize survivors of violence as mentally ill. It is recommended that the World Health Organization’s document Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) be used as a blueprint for only one technical instrument that incorporates evidence -based national policy and guidelines.

Developing clinical trials in the portuguese family medicine : challenges and opportunities in the European context

RESUMO: Introdução: A hipótese colocada nesta tese é a de que poderia haver um número bastante mais elevado de ensaios clínicos na medicina familiar portuguesa se os obstáculos fossem removidos e as oportunidades exploradas de modo adequado. Contexto: Em Portugal existe uma nova geração de Médicos de Família que está a assumir postos de trabalho um pouco por todo o país e que é aceite como sendo a mais bem preparada geração de sempre. Métodos: Busca na MEDLINE. Leitura de artigos na única publicação científica dedicada à Medicina Geral e Familiar – RPMGF. Consulta em livros portugueses de política da saúde e acerca do Plano Nacional de Saúde. O INFARMED foi contactado e relatórios seus sobre ensaios clínicos foram analisados. Os Médicos de Família portugueses foram contactados e convidados a responder a questionários. Além disso, quinze personalidades da Medicina Portuguesa foram chamadas a sugerir soluções. Resultados: De acordo com dados do INFARMED, de 2006 a 2011 houve apenas quatro centros de saúde envolvidos em ensaios clínicos. Em Portugal: Existe um número pouco significativo de ensaios académicos; Praticamente não há infraestruturas de suporte ou treino; Os registos clínicos eletrónicos são usados de forma ineficiente; a investigação é fracamente ligada às carreiras médicas; há isolamento interno e externo; a já complexa regulamentação da União Europeia é complicada ainda mais; há um subfinanciamento da Investigação Clínica. Os Médicos de Família portugueses estão disponíveis para participar ativamente numa mudança. Discussão: Com os presentes resultados o diagnóstico para a presente situação é claramente negativo. Felizmente existem muito boas oportunidades para melhorar. Conclusão/Recomendações: Tempo, dinheiro e apoio têm de ser fornecidos aos Médicos de Família portugueses. É nesse sentido que são fornecidas vinte recomendações para obter uma verdadeira mudança no panorama dos Ensaios Clínicos na Medicina Familiar portuguesa.-------------ABSTRACT: Introduction: The hypothesis of this thesis is that there could be a much greater number of Clinical Trials in Portuguese Family Medicine if obstacles were removed and opportunities explored properly. Background: In Portugal there is a new generation of Family Doctors that is assuming permanent positions all over the country and is accepted to be the most well prepared generation ever. Methods: Search on MEDLINE. Relevant articles were also identified in the only jornal dedicated to Portuguese Family Medicine, RPMGF. A search was made on Portuguese health policy textbooks and national health plan policy. INFARMED was also contacted and their reports about Clinical Trials were analysed. Portuguese Family Doctors themselves were contacted and invited to answer questionnaires. Besides that, fifteen key opinion leaders related to Portuguese Medicine were approached for solutions. Results: According to INFARMED data, from 2006 to 2011 there were only four health centres involved in clinical trials. In Portugal there is: A negligible number of academic trials; almost no support infrastructures or training; inefficiently used electronic health records; a research weakly linked to medical careers; an uninformed isolation internally and externally; an already complex European Union regulation that is compounded even more; Scarce funding for clinical research. Portuguese Family Doctors are keen to actively participate in a change. Discussion: With the present results the diagnosis for the current situation is clearly negative. Fortunately there are very good opportunities to improve. Conclusion/Recommendations: Time, money and support must be given to Portuguese Family Doctors. In this context, twenty recommendations are provided intending to promote a true change in Portuguese Family Medicine Clinical Trials panorama.

Trypanocide treatment among adults with chronic Chagas disease living in Santa Fe city (Argentina), over a mean follow-up of 21 years: parasitological, serological and clinical evolution

The efficacy of treatment with nifurtimox and/or benznidazole among adults with chronic Chagas disease with no previous electrocardiographic disturbances was evaluated over a mean follow-up of 21 years, by means of conventional serology, xenodiagnosis, clinical examination, electrocardiograms and chest X-ray. One hundred and eleven patients, between 17 and 46 years old, were studied: 54 underwent treatment (nifurtimox 27, benznidazole 27) and 57 remained untreated (control group). Xenodiagnosis was performed on 65% of them: 36/38 of the treated and 9/34 of the untreated patients had previous positive xenodiagnosis. Post-treatment, 133 xenodiagnoses were performed on 41 patients, all resulting negative. In the control group, 29 xenodiagnoses were performed on 14 patients; 2 resulted positive. Sera stored during the follow-up were simultaneously analyzed through conventional serology tests (IHA; DA-2ME; IIF). The serological evolution in the treated group was: a) 37% underwent negative seroconversion (nifurtimox 11, benznidazole 9); b) 27.8% decreased titers (nifurtimox 9, benznidazole 6), 9 showed inconclusive final serology (nifurtimox 7, benznidazole 2); c) 35.2% remained positive with constant titers (nifurtimox 7; benznidazole 12). The control group conserved the initial antibody levels during the follow-up. In the clinical evolution, 2/54 (3.7%) of the treated and 9/57 (15.8%) of the untreated patients showed electrocardiographic disturbances attributable to Chagas myocardiopathy, with a statistically relevant difference (p<0.05). Treatment caused deparasitation in at least 37% of the chronically infected adults and a protective effect on their clinical evolution.

Clinical and ultrasound findings before and after praziquantel treatment among Venezuelan schistosomiasis patients

Abdominal ultrasound can be a useful tool for diagnosing periportal fibrosis related to Schistosoma mansoni infection, and also for planning and monitoring the evolution of hepatic morbidity following control measures. We evaluated the standardized ultrasound methodology proposed by the World Health Organization for detecting periportal fibrosis and portal hypertension, among patients from an endemic area in Venezuela, and the impact of praziquantel treatment 3-5 years later. After chemotherapy, complete reversal of periportal lesions was observed in 28.2% of the cases and progression of the disease in 5.1%. Improvement in the hepatic disease started with a reduction in the periportal thickening followed by a decrease in the size of the left hepatic lobe, spleen and mesenteric and spleen veins. Ultrasound confirmed the clinical findings after chemotherapy among the patients with reversal of the disease. However, in patients with more advanced disease, these findings were contradictory. There was no correlation between evolution of the disease seen on ultrasound and age, intensity of infection or serological findings.

Clinical and radiographic features of HIV-related pulmonary tuberculosis according to the level of immunosuppression

Medical charts and radiographs from 38 HIV-infected patients with positive cultures for Mycobacterium tuberculosis from sputum or bronchoalveolar lavage were reviewed in order to compare the clinical, radiographic, and sputum bacilloscopy characteristics of HIV-infected patients with pulmonary tuberculosis according to CD4+ lymphocyte count (CD4). The mean age of the patients was 32 years and 76% were male. The median CD4 was 106 cells/mm³ and 71% had CD4 < 200 cells/mm³. Sputum bacilloscopy was positive in 45% of the patients. Patients with CD4 < 200 cells/mm³ showed significantly less post-primary pattern (7% vs. 63%; p = 0.02) and more frequently reported weight loss (p = 0.04). Although not statistically significant, patients with lower CD4 showed lower positivity of sputum bacilloscopy (37% vs. 64%; p = 0.18). HIV-infected patients with culture-confirmed pulmonary tuberculosis had a high proportion of non-post-primary pattern in thoracic radiographs. Patients with CD4 lower than 200 cells/mm³ showed post-primary patterns less frequently and reported weight loss more frequently.

Clinical, epidemiological and laboratory aspects of patients with American cutaneous leishmaniasis in the State of Pernambuco

The diagnosis for American cutaneous leishmaniasis is based on an association of clinical, epidemiological and laboratory characteristics. The present study identified the circulating species of Leishmania in the State of Pernambuco, described its clinical-epidemiological characteristics and diagnosed the disease. Nineteen patients presenting active lesions who had been diagnosed through clinical evaluation and laboratory tests were selected. The tests included direct investigation, in vitro culturing, Montenegro skin test, indirect immunofluorescence and polymerase chain reaction. The Montenegro Skin Test showed positive results in 89% of the patients; indirect immunofluorescence, in 79%; direct investigation, in 58%; and polymerase chain reaction in 75%. Seven Leishmania (Viannia) braziliensis samples were isolated from these patients and were characterized by means of specific monoclonal antibodies. These data confirm that a combination of different diagnosis techniques is needed in order to obtain efficient results and that, so far, Leishmania (Viannia) braziliensis is the only species responsible for American cutaneous leishmaniasis infection in Pernambuco. Thus, it is essential to identify the parasite species involved in cases of human disease in an endemic area in order to determine the clinical and epidemiological characteristics, especially with regard to diagnosis, therapy development and disease prognosis.

Clinical and epidemiological study of leprosy cases in the University Hospital of Brasília: 20 years - 1985 to 2005

Hansen's disease, also known as leprosy, is an infectious disease still prevalent in Brazil. It is a chronic illness with acute immunological phenomena known as leprosy reactions. In the Federal District of Brazil, the University Hospital of Brasília is the reference centre for leprosy care. The study aimed to characterize the clinical and epidemiological profile of Hansen's disease patients at the University Hospital of Brasília, by descriptive, retrospective analysis of 1,124 patients over the period from 1985 to 2005. The pattern of leprosy in this study demonstrated that type 2 leprosy reactions were common, especially in the lepromatous form and presented a direct correlation with the bacilloscopic index. The prevalence and frequency of severe complications, such as leprosy reactions, emphasize the importance of the ongoing study of leprosy and the need for continual improvement in the scope of knowledge concerning its treatment.