Risk factors for hepatitis C virus infection in Inland Brazil: an analysis of pooled epidemiological sectional studies.

In order to assess the contribution of different parenteral routes as risk exposure to the hepatitis C virus (HCV), samples from nine surveys or cross-sectional studies conducted in two Brazilian inland regions were pooled, including a total of 3,910 subjects. Heterogeneity among the study results for different risk factors was tested and the results were shown to be homogeneous. Anti-HCV antibodies were observed in 241 individuals, of which 146 (3.7%, 95% CI = 3.2-4.4) had HCV exposure confirmed by immunoblot analysis or PCR test. After adjustment for relevant variables, a correlation between confirmed HCV exposure and injection drug use, tattooing, and advance age was observed. In a second logistic model that included exposures not searched in all nine studies, a smaller sample was analyzed, revealing an independent HCV association with past history of surgery and males who have sex with other males, in addition to repeated injection drug use. Overall, these analyses corroborate the finding that injection drug use is the main risk factor for HCV exposure and spread, in addition to other parenteral routes.

Biofilms, infection, and parenteral nutrition therapy.

Parenteral nutrition therapy is used in patients with a contraindication to the use of the gastrointestinal tract, and infection is one of its frequent and severe complications. The objective of the present study was to detect the presence of biofilms and microorganisms adhering to the central venous catheters used for parenteral nutrition therapy by scanning electron microscopy. Thirty-nine central venous catheters belonging to patients with clinical signs of infection (G1) and asymptomatic patients (G2) and patients receiving central venous catheters for clinical monitoring (G3) were analyzed by semiquantitative culture and scanning electron microscopy. The central venous catheters of G1 presented more positive cultures than those of G2 and G3 (81% vs 50% and 0%, respectively). However, biofilms were observed in all catheters used and 55% of them showed structures that suggested central venous catheters colonization by microorganisms. Approximately 53% of the catheter infections evolved with systemic infection confirmed by blood culture. The authors conclude that the presence of a biofilm is frequent and is an indicator of predisposition to infection, which may even occur in patients who are still asymptomatic.

Hepatitis C among former athletes: association with the use of injectable stimulants in the past.

This study was performed with the purpose of testing the hypothesis that the high prevalence of hepatitis C among former athletes is associated with their past use of injectable stimulants. The study involved the participation of 208 former professional and amateur soccer and basketball players from the region of Ribeirão Preto, Brazil, who answered a questionnaire regarding their exposure to risk factors, including the use of injectable stimulants in the time they were engaged in sporting activities. ELISA tests were used to detect infection by the hepatitis C virus, and confirmed with PCR and genotyping for the positive cases. It was observed that the former use of injectable stimulants was a practice disseminated among the participants (24.5%), reaching 50.8% in the professionals. The overall prevalence for hepatitis C was 7.2%, with values of 11% among professionals and 5.5% among amateurs. In both categories, the presence of infection was markedly higher among those who admitted past use of injectable stimulants when compared to those who denied such practice (36% and 0.8% among amateurs; 21.9% and 0% among professionals, respectively). Multivariate analysis showed that the use of those substances was the only variable associated with the risk of hepatitis C. This confirms previous observations, performed with reduced sample sizes and without comparison groups, which indicated that the use of injectable vitamins was a risk factor of hepatitis C among former athletes.

L. (L.) chagasi in AIDS and visceral leishmaniasis (kala-azar) co-infection.

Concomitant skin lesions in visceral leishmaniasis (VL) or kala-azar are rare, being more common the description of post-kala-azar dermal leishmaniasis occurring post treatment of kala-azar. Skin lesions caused by Leishmania donovani are frequently seen in the aids-VL co-infection. In Brazil cutaneous or mucosal forms of tegumentary leishmaniasis concomitant with aids are more commonly registered. Here we present a case of aids-VL co-infection, with unusual cutaneous and digestive compromising attributed to L. (L.) chagasi, with special attention to ecthymatous aspect of the lesion, allied to the absence of parasite on the histological skin biopsy.

Ocular problems in Brazilian patients with AIDS before and in highly active antiretroviral therapy (HAART) era.

This study determined the total frequency of patients with AIDS and ophthalmologic problems before and after the introduction of combined highly active antiretroviral therapy (HAART), regardless of the use of this treatment; it also determined the frequency of external ocular diseases, intraocular infections and inflammations, and problems of the anterior portion of the optic nerve in these two groups of patients; and it determined the differences in the frequency of ophthalmologic problems in patients receiving HAART or not. This was a retrospective study of 207 patients examined using the same protocol, from June 1995 to February 1998 (n=58, pre-HAART era) and from March 1998 to May 2005 (n=149, HAART era). The frequency of ophthalmologic problems was significantly higher in the pre-HAART group, with a predominance of intraocular infections and inflammations. Comparison of patients receiving HAART or not revealed that ocular involvement tended to be reduced in the treated group and that treatment was effective in preventing infectious diseases; however, the prevalence of external ocular diseases was similar in the patients receiving HAART or not. As a consequence of HAART, we observed a reduction in the frequency of ocular problems, especially intraocular infections and inflammations. However, this benefic influence was less important in the ocular surface or in external ocular disease.

Autoimmune hemolytic anemia in HCV/HIV coinfected patients during treatment with pegylated alpha-2a interferon plus ribavirin.

Two cases of autoimmune hemolytic anemia that occurred during the treatment of chronic hepatitis C with pegylated alpha-2a interferon and ribavirin, in HIV coinfected patients, are presented and described. The late occurrence (after six months of therapy) of this severe hemolytic anemia leads to the recommendation that hemoglobin levels should be monitored throughout the treatment period, even among patients who presented stable hemoglobin levels in the preceding months.

[Ophthalmologic conditions of AIDS patients with long-term follow-up]. / Condições oftalmológicas de pacientes com síndrome da imunodeficiência adquirida com longo tempo de seguimento.

PURPOSE: To evaluate the ophthalmologic conditions of patients with AIDS, with long-term follow-up, previously evaluated by an ophthalmologist, considering general conditions related with AIDS. METHODS: Observational study of 42 patients with AIDS divided into two groups: Group I: 8 patients with previous AIDS-related cytomegalovirus retinitis, Group II: 34 patients with AIDS without cytomegalovirus retinitis. Each patient had been submitted to one ophthalmologic examination. General data of the patients were obtained from the medical records. RESULTS: The majority of the patients presented visual acuity in the best eye between logMAR 0.0 (68.3%) and 0.1 (26.9%). Optic prescription for refractive errors benefited 39.4% of the patients in Group II but none of the patients in Group I. Presbyopia was corrected in 27.3% of Group II and in 12.5% of Group I patients. No current ocular AIDS-related manifestations were detected in any group. Ocular posterior segment alterations, all of them consisting of retinitis / retinochoroiditis scars, were found in 10 patients, 7 (16.7%) belonging to Group I and 3 (7.1%) to Group II. CONCLUSION: Ten (24.4%) patients presented visual alteration due to age. Except for the patients presenting previous retinitis and retinochoroiditis, all the other patients were in good ophthalmic conditions and most of them were in immunologic recovery due to the use of highly active antiretroviral therapy.

Sensitivity of an immunoenzymatic test for detection of anti-L. brasiliensis antibodies compared to other tests used for the diagnosis of American cutaneous leishmaniasis.

The diagnosis of American cutaneous leishmaniasis (ACL) is frequently based on clinical and epidemiological data associated with the results of laboratory tests. Some laboratory methods are currently being applied for the diagnosis of ACL, among them the indirect immunofluorescence reaction (IIFR), the Montenegro skin test (MST), histopathological examination, and the polymerase chain reaction (PCR). The performance of these methods varies in a considerable proportion of patients. After the standardization of an immunoenzymatic test (ELISA) for the detection of IgG in the serum of patients with ACL using a crude Leishmania braziliensis antigen, the results obtained were compared to those of other tests routinely used for the diagnosis. The tests revealed the following sensitivity, when analyzed separately: 85% for ELISA IgG, 81% for PCR, 64.4% for MST, 58.1% for IIFR, and 34% for the presence of parasites in the biopsy. ELISA was positive in 75% of patients with ACL presenting a negative MST, in 84.8% of ACL patients with negative skin or mucous biopsies for the presence of the parasite, and in 100% of cases with a negative PCR. Thus, ELISA presented a higher sensitivity than the other tests and was useful as a complementary method for the diagnosis of ACL.

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 pressure(3) 100 mmHg, heart rate lower than 100 beats per minute, creatinine below 1.6 mg/dl, arterial blood pH(3) 7.35, bicarbonate higher than 15 mEq/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.

[Acute renal failure related to intravenous acyclovir]. / Insuficiência renal aguda associada ao uso de aciclovir endovenoso.

OBJECTIVE: The aim of this study was to evaluate the incidence and outcome of acute renal failure (ARF) in patients submitted to intravenous (IV) acyclovir treatment. METHODS: All patients over 13 years of age that used intravenous acyclovir for 5 or more days were retrospectively analyzed. When serum creatinine levels, previously in the normal range, increased above 2 mg/dl, the case was considered an ARF. Treatment and outcome of patients that developed ARF were analyzed. RESULTS: Eighty-five patients received IV acyclovir during the study period. Forty-one patients were included in the study. ARF developed in 8 out of 41 patients (19.5%). In the ARF cases, after beginning of treatment, the average time for increase of the serum creatinine levels was 4.2 days. Creatinine levels reached their peak in a mean time of 7.1 days (ranging from 3 to 14 days). Recovery of the renal function, evaluated by decrease of the creatinine level, varied from 1 to 7 days (mean of 3.6 days). ARF had a good outcome with hydration, lengthening of drug infusion time and adjustment of the drug dosage. CONCLUSION: Acyclovir induced ARF in 19.5% of the patients. All patients had a positive response with return to a normal renal function after hydration, lengthening of drug infusion time and adjustment of the drug dosage. None of the patients required treatment with hemodialysis. Acyclovir is a safe drug when administered with certain preventive measures.

Evaluation of intrathecal synthesis of specific IgG antibodies against Toxoplasma gondii in the diagnosis assessment of presumptive toxoplasma encephalitis in AIDS patients.

The diagnosis of neurotoxoplasmosis in patients with acquired immunodeficiency syndrome is mainly based on tomographic or magnetic resonance findings and on the response to specific treatment. We studied 55 patients with AIDS and neurotoxoplasmosis according to these diagnostic criteria (group 1), 37 patients with AIDS and neurological involvement of other etiology (group 2), and 16 anti-HIV-negative individuals with neurological manifestations (group 3). Serum and cerebrospinal fluid were examined for the presence of anti-T. gondii IgG, by indirect immunofluorescence. In 72 of them, the total amounts of these antibodies were determined in order to assess local production of anti-T. gondii antibodies in the central nervous system and to correlate their titers with infection activity in patients with AIDS and neurotoxoplasmosis. IgG titers > or = 1/64 in cerebrospinal fluid reached 100% specificity for the diagnosis of neurotoxoplasmosis in AIDS. Evidence of local synthesis of these antibodies was detected in 42.8% of patients of group 1, in 29.1% of patients of group 2 and in no patient of group 3. The test showed 70.8% specificity and therefore was not useful in our study for the differential diagnosis of neurotoxoplasmosis in patients with AIDS.

[Soroepidemiological survey of hepatitis B virus among HIV/AIDS patients in Belém, Pará--Brasil]. / Estudo soroepidemiológico da infecção pelo vírus da hepatite B entre portadores do vírus da imunodeficiência humana/SIDA na Cidade de Belém, Pará--Brasil.

The objective of this investigation was to study the prevalence of hepatitis B virus infection in a sample of 406 adult patients with human immunodeficiency virus infection who attended at the public health care in the city of Belém, Pará, Brazil, as well as analyzing possible risk factors for hepatitis B virus infection. The overall prevalence of hepatitis B virus infection was 51% (CI: 46.1 - 55.8), with 7.9% (CI: 5.3 - 10.5) for HBsAg, 45.1% (CI: 40.3 - 49.9) for anti-HBc and 32.3% (CI: 27.5 - 36.8) for anti-HBs. After adjustment using logistic regression, hepatitis B serological markers were associated with the following variables: age, marital status and sexual preference. The frequency of hepatitis B markers was 28.7% in heterosexuals and 68.8% in homo/bisexuals (CI: 3.50 - 9.08; OR: 5.63; p=0.000). In married people the frequency was 31% and 58.7% in single people (CI: 1.29 - 3.63); OR: 2.16; p=0.003). Multivariate analysis showed no association between hepatitis B virus infection and illicit injectable drug use.

[Hepatitis C: prevalence and risk factors among patients with HIV/AIDS in Belém Pará, in Brazilian Amazon]. / Hepatite C: prevalência e fatores de risco entre portadores do VIH/SIDA em Belém, Pará, na Amazônia brasileira.

The objective of this investigation was to study the prevalence of hepatitis C virus infection and to identify possible risk factors for its transmission, in 406 adult patients with HIV/AIDS who attended at public health services, in Belém city, Pará, Brazil. The anti-HCV was performed by third generation immunoenzymatic technique, and the HCV RNA by polymerase chain reaction. The overall prevalence of hepatitis C virus was 16% (CI: 12.4 - 19.6). Multivariate analysis showed association between virus C infection and age, with significant risk in the group about fifty years old or more (OR=9.75), blood transfusion (OR=4.74) and use of injecting drugs (OR=149.28). The hepatitis C virus infection was detected in 83.7% of intravenous drug users and 22.1% of transfused patients. These data indicate the efficient transmission of the virus through the percutaneous exposition and reaffirm the high risk to hepatitis C among injectable illicit drug user.

[HIV and hepatitis B virus co-infection: prevalence and risk factors]. / Co-infecção HIV e vírus da hepatite B: prevalência e fatores de risco.

The objective of this study was to assess the prevalence of hepatitis B virus and possible risk factors for this disease in 401 patients infected with the human immunodeficiency virus, followed at the University Hospital of the Ribeirão Preto Medical School, São Paulo State University. Each participant was submitted to a specific questionnaire and had a blood sample tested for the serologic markers HBsAg, total anti-HBcAg, anti-HBsAg and anti-HCV, using ELISA technique. The overall prevalence of hepatitis B markers was 40.9%, with 8.5% for HBsAg, 39.7% for total anti-HBcAg and 5.5% for anti-HBsAg. The variables that showed association with HBV were: age, higher education level, history of jaundice, time spent in prison, having a homosexual partner and positive markers for anti-HCV. Co-infection HBV/HCV was present in 20.4% of the participants.

[Detection of anti-Toxoplasma gondii IgG, IgM and IgA immunoglobulins in the serum, cerebrospinal fluid and saliva of patients with acquired immunodeficiency syndrome and neurotoxoplasmosis]. / Detecção de imunoglobulinas IgG, IgM e IgA anti-Toxoplasma gondii no soro, líquor e saliva de pacientes com síndrome da imunodeficiência adquirida e neurotoxoplasmose.

We studied 55 patients with acquired immunodeficiency syndrome (AIDS) and neurotoxoplasmosis (group 1), 37 patients with AIDS and neurological involvement due to another etiology (group 2) and 18 anti-HIV-negative individuals with neurological manifestations, by searching for anti-T. gondii IgG, IgA and IgM immunoglobulins in serum, cerebrospinal fluid (CSF)and saliva, using ELISA. The negative predictive value of the test for IgG in serum was 100% and in CSF, 92.4%. There was no difference among the three groups studied regarding IgA in serum. For IgA, in CSF the test reached 72.7% specificity (p<0.05). In saliva, only the detection of IgG was found to be correlated with a diagnosis of neurotoxoplasmosis. We emphasize that the absence of anti-T. gondii IgG antibodies in serum and CSF strongly indicates the absence of a diagnosis of neurotoxoplasmosis and that specific IgA immunoglobulins in CSF and IgG in saliva may represent two auxiliary markers for the differential diagnosis of toxoplasmic encephalitis in AIDS.

Enzyme linked immunosorbent assay (ELISA) for the detection of IgG, IgM, IgE and IgA against Cysticercus cellulosae in cerebrospinal fluid of patients with neurocysticercosis.

The objective of this study was to analyze different immunoglobulins classes (IgG, IgM, IgE and IgA) against Cysticercus cellulosae in the cerebrospinal fluid (CSF), through enzyme linked immunosorbent assay (ELISA), correlating them to clinical and tomographic profiles in patients with neurocysticercosis (NCC). Eighty-five specimens of CSF were obtained from 43 cases with NCC (26 with the active form and 17 with the inactive form) and from 42 patients with other neurological diseases. The inactive form of NCC presented a profile in CSF similar to the group without NCC. The active form of NCC presented elevation of specific immunoglobulins (IgG, IgM, IgE, and IgA) in decreasing order, with the highest values being detected among the cases with intraventricular cysts, or with inflammation signs in CSF or in those with multiple clinical manifestations. The highest sensitivity and specificity were obtained with ELISA-IgG (88.5% and 93.2%, respectively). This study confirmed the importance of ELISA in the immunologic diagnosis of NCC.

[Assessment of educational objectives in two different curricular structures--Faculty of Medicine of Ribeiráo Preto, University of São Paulo, Brazil]. / Análise do desempenho dos formandos em relação a objetivos educacionais da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, em duas estruturas curriculares distintas.

OBJECTIVE: The objective of the study was to assess the impact of the curricular change on the achievement of the educational objectives of the institution, analyzing the performance of graduating students, from the Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil. METHODS: Techniques of recognized validity and reliability (MCQ, OSCE, PMP) were used for the evaluation of skills and competence in the cognitive, psychomotor and clinical domains. Three of the 3 final years classes educated according to the previous curricular structure (n=222) and three classes educated according to the new curricular structure (n=261) were evaluated during the study period. RESULTS: The performance of graduating students in these different tests permitted us to estimate the extent of achievement of 17 of the 36 intermediate educational objectives of the institution in the two curricular structures. Comparison of the two curricula demonstrated the absence of significant differences in the extent of achievement of ten of the 17 objectives. For six of the seven remaining objectives a significant increase (p<0.05) in the extent of achievement was observed with the new curricular structure. CONCLUSIONS. The results indicate that the new curricular structure was associated with a better performance of the students in cognitive skills related to general practice and in basic clinical and psychomotor skills.

Clinical, demographic and epidemiological characteristics of patients with hepatitis B followed at a university hospital in southeastern Brazil: predominance of HBeAg negative cases.

INTRODUCTION: Hepatitis B is common in Brazil, although there are regional differences regarding the degree of endemicity, the most frequent forms of transmission and the presence of different evolutive stages of chronic disease. The present study aimed to determine the clinical, demographic and epidemiological characteristics of patients chronically infected with hepatitis B virus (HBV) residing in the Ribeirão Preto region, southeastern Brazil. METHODS: A total of 529 medical records of individuals with HBV monoinfection were reviewed. RESULTS: More than 60% of the subjects were males, with a mean age of 38 years-old. The HBeAg-negative serological pattern was verified in 84.4% of the patients, among whom the risk of vertical/intrafamily transmission was 43.2% (p = 0.02). The consumption of alcohol in amounts exceeding 20 g a day was observed in 21.3% of the subjects and was more frequent among men (33%) (p < 0.001). Among patients with cirrhosis, 54.1% were alcohol abusers (p = 0.04), all of them males. The presence of cirrhosis was more frequent in the HBeAg-positive group (24.4%) than in the HBeAg-negative group (10.2%) (p < 0.001). CONCLUSIONS: High proportions of HBV-infected subjects with an HBeAg-negative pattern were observed, with a higher risk of vertical/intrafamily transmission. Alcohol abuse was associated with male subjects and with cirrhosis of the liver in this group. A tendency toward an increase in the number of HBeAg-negative cases was observed over time.

[Influence of acute-phase inflammatory response on serum levels of retinol and retinol binding protein in HIV/AIDS patients]. / Influência da resposta inflamatória de fase aguda nos níveis séricos de retinol e da proteína de ligação do retinol em pacientes com AIDS.

INTRODUCTION: Hyporetinolemia is an independent prognostic factor in AIDS patients. Inflammatory activity causes a reduction in the serum levels of this nutrient in the general population. However, there are no studies assessing the impact of inflammatory activity on the serum retinol level in AIDS patients. METHODS: A cross-sectional assessment was conducted on 41 patients hospitalized due to AIDS complications. Inflammatory markers (C-reactive protein and tumor necrosis factor-alpha) and serum retinol and retinol binding protein concentrations were quantified. RESULTS: Despite the low (14.6%) prevalence of hyporetinolemia, a significant negative correlation was observed between the inflammatory markers and the serum retinol and retinol binding protein levels in AIDS patients. CONCLUSIONS: Acute-phase inflammatory activity is associated with low serum retinol levels in individuals with AIDS.

Long-term follow-up of patients with chronic hepatitis C with sustained virologic response to interferon.

BACKGROUND AND AIM: The durability of the sustained virologic response (SVR) in patients with chronic hepatitis C after treatment and the ideal follow-up time for these patients remains undefined. The objective of the study was to evaluate the durability of the virologic response in patients with chronic hepatitis C followed up for at least 12 months after SVR at HCFMRP-USP. METHODS: The study was conducted on 174 patients with chronic hepatitis C treated with different antiviral regimens who had achieved SVR. Qualitative serum HCV-RNA was determined by the commercial kit (COBAS AMPLICOR HCV, v2.0). RESULTS: There was predominance of male (73%) with a mean age of 45.6 ± 10 years. Liver cirrhosis was present in 16.1% of the study subjects. Mean follow-up time after SVR was 47 months (12-156 months). Twenty-two patients received monotherapy with interferon; 94 received interferon plus ribavirin, and 58 received pegylated interferon plus ribavirin. A total of 134 patients (77.0%) received one treatment course, 29 (16.7%) received two courses, and 11 (6.3%) received three courses. The distribution of HCV genotypes was: genotype 1 (40.2%), genotype 3 (40.8%) and genotype 2 (10.3%). Genotype was undetermined in 8.7% of cases. None of the 174 patients had recurrence of HCV infection. Two cirrhotic patients developed hepatocellular carcinoma (HCC) during follow-up. CONCLUSIONS: Among patients with SVR there was no recurrence of HCV infection or evidence of liver disease progression in any patient followed up for a mean of 47 months after SVR, except for patients with advanced hepatic disease before treatment, who may develop HCC despite SVR. Therefore, one can assume that SVR is associated with long term good prognosis.