Evaluation of the diagnostic value of the tourniquet test in predicting severe dengue cases in a population from Belo Horizonte, State of Minas Gerais, Brazil

Introduction Dengue is prevalent in many tropical and sub-tropical regions. The clinical diagnosis of dengue is still complex, and not much data are available. This work aimed at assessing the diagnostic accuracy of the tourniquet test in patients with suspected dengue infection and its positivity in different classifications of this disease as reported to the Information System for Notifiable Disease in Belo Horizonte, State of Minas Gerais, Brazil between 2001 and 2006. Methods Cross-section analysis of the diagnostic accuracy of the tourniquet test for dengue, using IgM-anti-DENV ELISA as a gold standard. Results We selected 9,836 suspected cases, of which 41.1% were confirmed to be dengue. Classic dengue was present in 95.8%, dengue with complications in 2.5% and dengue hemorrhagic fever in 1.7%. The tourniquet test was positive in 16.9% of classic dengue cases, 61.7% of dengue cases with complications and 82.9% of cases of dengue hemorrhagic fever. The sensitivity and specificity of the tourniquet test were 19.1% and 86.4%, respectively. Conclusions A positive tourniquet test can be a valuable tool to support diagnosis of dengue where laboratory tests are not available. However, the absence of a positive test should not be read as the absence of infection. In addition, the tourniquet test was demonstrated to be an indicator of dengue severity.

Development of a fundus camera for analysis of photoreceptor directionality in the healthy retina

The Stiles-Crawford effect (SCE) is the well-known phenomenon in which the brightness of light perceived by the human eye depends upon its entrance point in the pupil. This physiological characteristic is due to the directional sensitivity of the cone photoreceptors in the retina and it displays an approximately Gaussian dependency which is altered in a number of pathologies. Retinal imaging, a widely spread clinical practice, may be used to evaluate the SCE and thus serve as diagnostic tool. Nonetheless, its use for such a purpose is still underdeveloped and far from the clinical reality. In this project a fundus camera was built and used to assess the cone photoreceptor directionality by reflective imaging of the retina in healthy individuals. The physical and physiological implications of its development are addressed in detail in the text: the optical properties of the human eye, illumination issues, acquiring a retinal image formed by the eye, among others. A full description of the developmental process that led to the final measuring method and results is also given. The developed setup was successfully used to obtain high quality images of the eye fundus and in particular the parafoveal cone photoreceptors. The SCE was successfully observed and characterized. Even though considerable improvements could be done to the measurement method, the project showed the feasibility of using retinal imaging to evaluate the SCE thus motivating its usage in a clinical environment.

Diagnosing schistosomiasis: where are we?

In light of the World Health Organization's initiative to extend schistosomiasis morbidity and mortality control programs by including a disease elimination strategy in low endemic settings, this paper reviews diagnostic tools described during the last decades and provide an overview of ongoing efforts in making an efficient diagnostic tool available worldwide. A literature search on PubMed using the search criteria schistosomiasis and diagnosis within the period from 1978 to 2013 was carried out. Articles with abstract in English and that used laboratory techniques specifically developed for the detection of schistosomiasis in humans were included. Publications were categorized according to the methodology applied (parasitological, immunological, or molecular) and stage of development (in house development, limited field, or large scale field testing). The initial research generated 4,535 publications, of which only 643 met the inclusion criteria. The vast majority (537) of the publications focused on immunological techniques; 81 focused on parasitological diagnosis, and 25 focused on molecular diagnostic methods. Regarding the stage of development, 307 papers referred to in-house development, 202 referred to limited field tests, and 134 referred to large scale field testing. The data obtained show that promising new diagnostic tools, especially for Schistosoma antigen and deoxyribonucleic acid (DNA) detection, which are characterized by high sensitivity and specificity, are being developed. In combination with international funding initiatives these tools may result in a significant step forward in successful disease elimination and surveillance, which is to make efficient tests accessible and its large use self-sustainable for control programs in endemic countries.

Laboratory diagnosis of amebiasis in a sample of students from southeastern Brazil and a comparison of microscopy with enzyme-linked immunosorbent assay for screening of infections with Entamoeba sp.

Introduction: Epidemiological studies on amebiasis have been reassessed since Entamoeba histolytica and E. dispar were first recognized as distinct species. Because the morphological similarity of these species renders microscopic diagnosis unreliable, additional tools are required to discriminate between Entamoeba species. The objectives of our study were to compare microscopy with ELISA kit (IVD®) results, to diagnose E. histolytica infection, and to determine the prevalence of amebiasis in a sample of students from southeastern Brazil. Methods: In this study, diagnosis was based on microscopy due to its capacity for revealing potential cysts/trophozoites and on two commercial kits for antigen detection in stool samples. Results: For 1,403 samples collected from students aged 6 to 14 years who were living in Divinópolis, Minas Gerais, Brazil, microscopy underestimated the number of individuals infected with E. histolytica/E. dispar (5.7% prevalence) compared with the ELISA kit (IVD®)-based diagnoses (15.7% for E. histolytica/E. dispar). A comparison of the ELISA (IVD®) and light microscopy results returned a 20% sensitivity, 97% specificity, low positive predictive value, and high negative predictive value for microscopy. An ELISA kit (TechLab®) that was specific for E. histolytica detected a 3.1% (43/1403) prevalence for E. histolytica infection. Conclusions: The ELISA kit (IVD®) can be used as an alternative screening tool. The high prevalence of E. histolytica infection detected in this study warrants the implementation of actions directed toward health promotion and preventive measures.

Thrombocytopenia as a surrogate marker of hepatosplenic schistosomiasis in endemic areas for Schistosomiasis mansoni

Introduction This study aimed to evaluate whether a low platelet count is a good surrogate marker of hepatosplenic schistosomiasis (HSS) in a rural area of Brazil. A small district in southeastern Brazil, with a population of 1,543 individuals and a 23% prevalence of schistosomiasis, was selected for this investigation. Methods In July 2012, 384 volunteers were subjected to clinical, ultrasonography (US), and laboratory examinations, including stool sample analysis. The HSS patients were classified into four groups: Group 1 consisted of patients with a spleen >13cm and liver fibrosis; Group 2 consisted of patients with a palpable spleen and spleen>13cm measured by US; Group 3 consisted of patients with a spleen >13cm measured by US; and Group 4 consisted of patients with a palpable spleen. Results Eight patients were in Group 1 (2.1%), twenty-one were in Group 2 (5.5%), eight were in Group 3 (2.1%), and eighteen were in Group 4 (4.7%). A significant difference in the mean platelet counts was observed between the patients with and without HSS (p<0.01). Based on the receiver operating characteristic (ROC) curve (platelet count <143,000/mm3), the sensitivity was greater than 92% in all groups, and the specificity varied from 44.4% to 75%. Conclusions We concluded that in endemic areas, thrombocytopenia demonstrates good sensitivity for detecting HSS and may be used as a screening tool to identify patients with HSS.

Evaluation of diagnostic tests for Wuchereria bancrofti infection in Brazilian schoolchildren

Introduction Since the launch of the Global Programme to Eliminate Lymphatic Filariasis, more than 70% of the endemic countries have implemented mass drug administration (MDA) to interrupt disease transmission. The monitoring of filarial infection in sentinel populations, particularly schoolchildren, is recommended to assess the impact of MDA. A key issue is choosing the appropriate tools for these initial assessments (to define the best intervention) and for monitoring transmission. Methods This study compared the pre-MDA performance of five diagnostic methods, namely, thick film test, Knott's technique, filtration, Og4C3-ELISA, and the AD12-ICT card test, in schoolchildren from Brazil. Venous and capillary blood samples were collected between 11 pm and 1 am. The microfilarial loads were analyzed with a negative binomial regression, and the prevalence and associated 95% confidence intervals were estimated for all methods. The accuracies of the AD12-ICT card and Og4C3-ELISA tests were assessed against the combination of parasitological test results. Results A total of 805 schoolchildren were examined. The overall and stratified prevalence by age group and gender detected by Og4C3-ELISA and AD12-ICT were markedly higher than the prevalence estimated by the parasitological methods. The sensitivity of the AD12-ICT card and Og4C3-ELISA tests was approximately 100%, and the positive likelihood ratios were above 6. The specificity of the Og4C3-ELISA was higher than that of the AD12-ICT at different prevalence levels. Conclusions The ICT card test should be the recommended tool for monitoring school-age populations living in areas with ongoing or completed MDA.

Impact of insecticide resistance on the field control of Aedes aegypti in the State of São Paulo

IntroductionThe need to control dengue transmission by means of insecticides has led to the development of resistance to most of the products used worldwide against mosquitoes. In the State of São Paulo, the Superintendência de Controle de Endemias(SUCEN) has annually monitored the susceptibility of Aedes aegypti to insecticides since 1996; since 1999, surveys were conducted in collaboration with the National Network of Laboratories (MoReNAa Network) and were coordinated by the Ministry of Health. In this study, in addition to the biological characterization of insecticide resistance in the laboratory, the impact of resistance on field control was evaluated for vector populations that showed resistance in laboratory assays.MethodsField efficacy tests with larvicides and adulticides were performed over a 13-year period, using World Health Organization protocols.ResultsData from the field tests showed a reduction in the residual effect of temephos on populations with a resistance ratio of 3. For adults, field control was less effective in populations characterized as resistant in laboratory qualitative assays, and this was confirmed using qualitative assays and field evaluation.ConclusionsOur results indicated that management of resistance development needs to be adopted when insect populations show reduced susceptibility. The use of insecticides is a self-limiting tool that needs to be applied cautiously, and dengue control requires more sustainable strategies.

Using mobile technology to conduct epidemiological investigations

INTRODUCTION : The aim of this study was to report the experience of an epidemiological field survey for which data were collected and analyzed using tablets. METHODS : The devices used Epi Info 7 (Android version), which has been modeled a database with variables of the traditional form. RESULTS : Twenty-one households were randomly selected in the study area; 75 residents were registered and completed household interviews with socioeconomic and environmental risk variables. CONCLUSIONS : This new technology is a valuable tool for collecting and analyzing data from the field, with advantageous benefits to epidemiological surveys.

Comparative study of lymphocytes from individuals that were vaccinated and unvaccinated against the pandemic 2009-2011 H1N1 influenza virus in Southern Brazil

ABSTRACTINTRODUCTION:While no single factor is sufficient to guarantee the success of influenza vaccine programs, knowledge of the levels of immunity in local populations is critical. Here, we analyzed influenza immunity in a population from Southern Brazil, a region with weather conditions that are distinct from those in the rest of country, where influenza infections are endemic, and where greater than 50% of the population is vaccinated annually.METHODS:Peripheral blood mononuclear cells were isolated from 40 individuals. Of these, 20 had received the H1N1 vaccine, while the remaining 20 were unvaccinated against the disease. Cells were stimulated in vitro with the trivalent post-pandemic influenza vaccine or with conserved major histocompatibility complex I (MHC I) peptides derived from hemagglutinin and neuraminidase. Cell viability was then analyzed by [3-(4,5-dimethylthiazol-2-yl)-2,5- diphenyltetrazolium bromide)]-based colorimetric assay (MTT), and culture supernatants were assayed for helper T type 1 (Th1) and Th2-specific cytokine levels.RESULTS:Peripheral blood lymphocytes from vaccinated, but not unvaccinated, individuals exhibited significant proliferation in vitro in the presence of a cognate influenza antigen. After culturing with vaccine antigens, cells from vaccinated individuals produced similar levels of interleukin (IL)-10 and interferon (IFN)-γ, while those from unvaccinated individuals produced higher levels of IFN-γ than of IL-10.CONCLUSIONS:Our data indicate that peripheral blood lymphocytes from vaccinated individuals are stimulated upon encountering a cognate antigen, but did not support the hypothesis that cross-reactive responses related to previous infections can ameliorate the immune response. Moreover, monitoring IL-10 production in vaccinated individuals could comprise a valuable tool for predicting disease evolution.

Geographic weighted regression: applicability to epidemiological studies of leprosy

Abstract: INTRODUCTION: Geographic information systems (GIS) enable public health data to be analyzed in terms of geographical variability and the relationship between risk factors and diseases. This study discusses the application of the geographic weighted regression (GWR) model to health data to improve the understanding of spatially varying social and clinical factors that potentially impact leprosy prevalence. METHODS: This ecological study used data from leprosy case records from 1998-2006, aggregated by neighborhood in the Duque de Caxias municipality in the State of Rio de Janeiro, Brazil. In the GWR model, the associations between the log of the leprosy detection rate and social and clinical factors were analyzed. RESULTS: Maps of the estimated coefficients by neighborhood confirmed the heterogeneous spatial relationships between the leprosy detection rates and the predictors. The proportion of households with piped water was associated with higher detection rates, mainly in the northeast of the municipality. Indeterminate forms were strongly associated with higher detections rates in the south, where access to health services was more established. CONCLUSIONS: GWR proved a useful tool for epidemiological analysis of leprosy in a local area, such as Duque de Caxias. Epidemiological analysis using the maps of the GWR model offered the advantage of visualizing the problem in sub-regions and identifying any spatial dependence in the local study area.

Detection of canine visceral leishmaniasis by conjunctival swab PCR

Abstract: INTRODUCTION: Conjunctival swab PCR was evaluated as a tool to diagnose visceral leishmaniasis in dogs. METHODS: Conjunctival swab PCR was compared to indirect immunofluorescence antibody test and blood PCR. RESULTS: Indirect immunofluorescence was significantly correlated with conjunctival swab PCR (p < 0.05), but not with blood PCR (p > 0.05). In addition, conjunctival swab PCR was significantly associated with presence of clinical symptoms (p < 0.05), whereas blood PCR was associated with absence of clinical symptoms (p < 0.05). CONCLUSIONS: Results indicate that conjunctival swab PCR is useful in epidemiological surveys of canine visceral leishmaniasis.

Extraction of Trypanosoma cruzi DNA from food: a contribution to the elucidation of acute Chagas disease outbreaks

Abstract: INTRODUCTION: Before 2004, the occurrence of acute Chagas disease (ACD) by oral transmission associated with food was scarcely known or investigated. Originally sporadic and circumstantial, ACD occurrences have now become frequent in the Amazon region, with recently related outbreaks spreading to several Brazilian states. These cases are associated with the consumption of açai juice by waste reservoir animals or insect vectors infected with Trypanosoma cruzi in endemic areas. Although guidelines for processing the fruit to minimize contamination through microorganisms and parasites exist, açai-based products must be assessed for quality, for which the demand for appropriate methodologies must be met. METHODS: Dilutions ranging from 5 to 1,000 T. cruzi CL Brener cells were mixed with 2mL of acai juice. Four Extraction of T. cruzi DNA methods were used on the fruit, and the cetyltrimethyl ammonium bromide (CTAB) method was selected according to JRC, 2005. RESULTS: DNA extraction by the CTAB method yielded satisfactory results with regard to purity and concentration for use in PCR. Overall, the methods employed proved that not only extraction efficiency but also high sensitivity in amplification was important. CONCLUSIONS: The method for T. cruzi detection in food is a powerful tool in the epidemiological investigation of outbreaks as it turns epidemiological evidence into supporting data that serve to confirm T. cruzi infection in the foods. It also facilitates food quality control and assessment of good manufacturing practices involving acai-based products.

Experience with the first Internet-based course at the Faculty of Medicine, University of São Paulo

PURPOSE: The Internet expands the range and flexibility of teaching options and enhances the ability to process the ever-increasing volume of medical knowledge. The aim of this study is to describe and discuss our experience with transforming a traditional medical training course into an Internet-based course. METHOD: Sixty-nine students were enrolled for a one-month course. They answered pre- and post-course questionnaires and took a multiple-choice test to evaluate the acquired knowledge. RESULTS: Students reported that the primary value for them of this Internet-based course was that they could choose the time of their class attendance (67%). The vast majority (94%) had a private computer and were used to visiting the Internet (75%) before the course. During the course, visits were mainly during the weekends (35%) and on the last week before the test (29%). Thirty-one percent reported that they could learn by reading only from the computer screen, without the necessity of printed material. Students were satisfied with this teaching method as evidenced by the 89% who reported enjoying the experience and the 88% who said they would enroll for another course via the Internet. The most positive aspect was freedom of scheduling, and the most negative was the lack of personal contact with the teacher. From the 80 multiple-choice questions, the mean of correct answers was 45.5, and of incorrect, 34.5. CONCLUSIONS: This study demonstrates that students can successfully learn with distance learning. It provides useful information for developing other Internet-based courses. The importance of this new tool for education in a large country like Brazil seems clear.

Phage display as a tool for generation of bio-therapeutic agents for breast cancer

Notch is a conserved signalling pathway, which plays a crucial role in a multiple cellular processes such as stem cell self-renewal, cell division, proliferation and apoptosis. In mammalian, four Notch receptors and five ligands are described, where interaction is achieved through their extracellular domains, leading to a transcription activation of different target genes. Increased expression of Notch ligands has been detected in several types of cancer, including breast cancer suggesting that these proteins represent possible therapeutic targets. The goal of this work was to generate quality protein targets and, by phage display technology, select function-blocking antibodies specific for Notch ligands. Phage display is a powerful technique that allows the generation of highly specific antibodies to be used for therapeutics, and it has also proved to be a reliable approach in identifying and validating new cancer-related targets. Also, we aimed at solving the tri-dimensional structure of the Notch ligands alone and in complex with selected antibodies. In this work, the initial phase focused on the optimization of the expression and purification of a human Delta-like 1 ligand mutant construct (hDLL1-DE3), by refolding from E. coli inclusion bodies. To confirm the biological activity of the produced recombinant protein cellular functional studies were performed, revealing that treatment with hDLL1-DE3 protein led to a modulation of Notch target genes. In a second stage of this study, Antibody fragments (Fabs) specific for hDLL1-DE3 were generated by phage display, using the produced protein as target, in which one good Fab candidate was selected to determine the best expression conditions. In parallel, multiple crystallization conditions were tested with hDLL1-DE3, but so far none led to positive results.

Necrolytic migratory erythema associated with glucagonoma syndrome: a case report

Necrolytic migratory erythema is a rare skin condition that consists of migrating areas of erythema with blisters that heal with hyperpigmentation. It usually occurs in patients with an alpha islet cell tumor of the pancreas-or glucagonoma-and when associated with glucose intolerance, anemia, hyperglucagonemia, and weight loss defines the glucagonoma syndrome. We describe a 52-year-old female patient with necrolytic migratory erythema associated with glucagonoma syndrome who had metastatic disease at presentation and passed away one week after her admission. The autopsy showed a tumor in the body of the pancreas, which was diagnosed as a neuroendocrine tumor and confirmed by immunohistochemistry. The diagnosis of necrolytic migratory erythema is a matter of great importance, since it might be an auxiliary tool for the early detection of glucagonoma.