Cost-Effectiveness Analysis of Rituximab for Chronic Lymphocytic Leukemia Using a Semi-Markovian Model Approach in R.

OBJECTIVES: This study aims to compare the strategies fludarabine, cyclophosphamide, and rituximab and fludarabine and cyclophosphamide for the treatment of chronic lymphocytic leukemia in Brazil. METHODS: A three-states clock-reset semi-Markovian model was constructed in R. The time horizon of the analysis was 15 years and monthly cycles were used. Transition probabilities were derived from the survival curves of the CLL-8 study. Other probabilities were also derived from the medical literature. Costs included in the model referred to the application of injectable drugs, prescription cost, cost of treating adverse events, and costs of supportive care. The model was evaluated by microsimulation. To determine the study result, multiple cost-effectiveness threshold values were used. RESULTS: In the main analysis, an incremental cost-effectiveness ratio of 19 029.38 PPP-US dollars (USD)/quality-adjusted life-year (QALY) (41 141.52 Brazilian real/QALY) was observed. In 1.8% of the iterations, fludarabine and cyclophosphamide was considered dominant over fludarabine, cyclophosphamide, and rituximab. It can be shown that at 1 gross domestic product (GDP) per capita/QALY, 36.1% of the iterations would consider the technology cost-effective. At 2 GDP per capita/QALY, this number rises to 82.1%. At 50 000 USD/QALY, 92.8% of the iterations would suggest the technology to be cost-effective. In terms of some threshold accepted or proposed around the world, the technology would be considered cost-effective at 50 000 USD/QALY, 3 GDP per capita/QALY, and 2 GDP per capita/QALY. It would not be cost-effective at 1 GDP per capita/QALY or the opportunity costs threshold. CONCLUSION: It can be considered that rituximab is cost-effective for the treatment of chronic lymphocytic leukemia in Brazil.

The economic burden of malaria: a systematic review.

BACKGROUND: Quantifying disease costs is critical for policymakers to set priorities, allocate resources, select control and prevention strategies, and evaluate the cost-effectiveness of interventions. Although malaria carries a very large disease burden, the availability of comprehensive and comparable estimates of malaria costs across endemic countries is scarce. METHODS: A literature review to summarize methodologies utilized to estimate malaria treatment costs was conducted to identify gaps in knowledge. RESULTS: Only 45 publications met the inclusion criteria. They utilize different methods, include distinct cost components, have varied geographical coverage (a country vs a city), include different periods in the analysis, and focus on specific parasite types or population groups (e.g., pregnant women). CONCLUSIONS: Cost estimates currently available are not comparable, hindering broad statements on the costs of malaria, and constraining advocacy efforts towards investment in malaria control and elimination, particularly with the finance and development sectors of the government.

Padronização de multiplex PCR para detecção de dermatófitos em pelos e crostas de cães e gatos / Standardization of a PCR multiplex for the detection of dermatophytes in dogs and cats fur and crusts

Objetivou-se padronizar uma reação do tipo multiplex PCR (mPCR) para detectar Microsporum canis, Microsporum gypseum e o complexo Trichophyton mentagrophytes em amostras de pelos e/ou crostas de cães e gatos. 250 amostras de pelos e/ou crostas de cães e gatos foram analisadas por meio de exame direto e cultura, o DNA das mesmas foi extraído para mPCR. Primers foram desenhados e como controle positivo da reação utilizou-se o DNA extraído de colônias de M. canis (URM 6273), M. gypseum (URM 6921) e T. mentagrophytes (URM 6211), provenientes da Coleção de Culturas (Micoteca URM), Departamento de Micologia, Centro de Ciências Biológicas da Universidade Federal de Pernambuco (CCB/UFPE). Como controles negativos de reação, utilizou-se água destilada esterilizada e DNA extraído de Alternaria sp. para verificar a especificidade dos primers. Do total de amostras analisadas, 15 (6%) foram identificadas, em cultura, como dermatófitos, e destas, 10 foram M. canis, três M. gypseum e dois T. mentagrophytes (complexo). Destas 15 amostras positivas, 11 (73,3%) foram detectadas por meio da mPCR. Além destas, seis outras, negativas em cultura, foram identificadas como M. gypseum. Verificou-se uma boa concordância entre os resultados da cultura e mPCR (Kappa: 0,66). O protocolo padronizado neste estudo pode ser utilizado como um método de triagem, por apresentar uma sensibilidade maior que a da cultura, usado paralelamente aos exames de rotina, permitindo um diagnóstico em menor tempo.(AU)

The aim of this study was to standardize a multiplex PCR (mPCR) reaction to detect Microsporum canis, Microsporum gypseum and the Trichophyton mentagrophytes complex in dog and cat fur and/or crusts. 250 fur and/or crusts samples from dogs and cats were analyzed by direct examination and culture, DNA from them was extracted for mPCR. Primers were designed and the DNA extracted from colonies of M. canis (URM 6273), M. gypseum (URM 6921) and T. mentagrophytes (URM 6211) from the Collection of Cultures - URM Micoteca - Department of Mycology, Biological Sciences Center of the Federal University of Pernambuco (CCB / UFPE). As negative controls, sterile distilled water and DNA extracted from Alternaria sp., were used to verify the specificity of the primers. Of the total samples analyzed, 15 (6%) were identified in culture as dermatophytes, and of these, 10 were M. canis, three M. gypseum and two T. mentagrophytes (complex). Of these 15 positive samples, 11 (73.3%) were detected by mPCR. Besides these, six others, negative in culture, were identified as M. gypseum. There was good agreement between culture results and mPCR (Kappa: 0.66). The protocol standardized in this study can be used as a screening method, because it has a sensitivity greater than that of the culture, used in parallel to the routine exams, allowing a diagnosis in a shorter time.(AU)

Searching whole genome sequences for biochemical identification features of emerging and reemerging pathogenic Corynebacterium species.

Biochemical tests are traditionally used for bacterial identification at the species level in clinical microbiology laboratories. While biochemical profiles are generally efficient for the identification of the most important corynebacterial pathogen Corynebacterium diphtheriae, their ability to differentiate between biovars of this bacterium is still controversial. Besides, the unambiguous identification of emerging human pathogenic species of the genus Corynebacterium may be hampered by highly variable biochemical profiles commonly reported for these species, including Corynebacterium striatum, Corynebacterium amycolatum, Corynebacterium minutissimum, and Corynebacterium xerosis. In order to identify the genomic basis contributing for the biochemical variabilities observed in phenotypic identification methods of these bacteria, we combined a comprehensive literature review with a bioinformatics approach based on reconstruction of six specific biochemical reactions/pathways in 33 recently released whole genome sequences. We used data retrieved from curated databases (MetaCyc, PathoSystems Resource Integration Center (PATRIC), The SEED, TransportDB, UniProtKB) associated with homology searches by BLAST and profile Hidden Markov Models (HMMs) to detect enzymes participating in the various pathways and performed ab initio protein structure modeling and molecular docking to confirm specific results. We found a differential distribution among the various strains of genes that code for some important enzymes, such as beta-phosphoglucomutase and fructokinase, and also for individual components of carbohydrate transport systems, including the fructose-specific phosphoenolpyruvate-dependent sugar phosphotransferase (PTS) and the ribose-specific ATP-binging cassette (ABC) transporter. Horizontal gene transfer plays a role in the biochemical variability of the isolates, as some genes needed for sucrose fermentation were seen to be present in genomic islands. Noteworthy, using profile HMMs, we identified an enzyme with putative alpha-1,6-glycosidase activity only in some specific strains of C. diphtheriae and this may aid to understanding of the differential abilities to utilize glycogen and starch between the biovars.

Consumer Willingness to Pay for Dengue Vaccine (CYD-TDV, Dengvaxia®) in Brazil; Implications for Future Pricing Considerations.

Introduction and Objective: Dengue virus is a serious global health problem with an estimated 3.97 billion people at risk for infection worldwide. In December 2015, the first vaccine (CYD-TDV) for dengue prevention was approved in Brazil, developed by Sanofi Pasteur. However, given that the vaccine will potentially be paid via the public health system, information is need regarding consumers' willingness to pay for the dengue vaccine in the country as well as discussions related to the possible inclusion of this vaccine into the public health system. This was the objective of this research. Methods: We conducted a cross-sectional study with residents of Greater Belo Horizonte, Minas Gerais, about their willingness to pay for the CYD-TDV vaccine. Results: 507 individuals were interviewed. These were mostly female (62.4%) had completed high school (62.17%), were working (74.4%), had private health insurance (64.5%) and did not have dengue (67.4%). The maximum median value of consumers' willingness to pay for CYD-TDV vaccine is US$33.61 (120.00BRL) for the complete schedule and US$11.20 (40.00BRL) per dose. At the price determined by the Brazil's regulatory chamber of pharmaceutical products market for the commercialization of Dengvaxia® for three doses, only 17% of the population expressed willingness to pay for this vaccine. Conclusion: Brazil is currently one of the largest markets for dengue vaccine and the price established is a key issue. We believe the manufacturer should asses the possibility of lower prices to reach a larger audience among the Brazilian population.

De novo assembly and characterization of the Trichuris trichiura adult worm transcriptome using Ion Torrent sequencing.

Infection with helminthic parasites, including the soil-transmitted helminth Trichuris trichiura (human whipworm), has been shown to modulate host immune responses and, consequently, to have an impact on the development and manifestation of chronic human inflammatory diseases. De novo derivation of helminth proteomes from sequencing of transcriptomes will provide valuable data to aid identification of parasite proteins that could be evaluated as potential immunotherapeutic molecules in near future. Herein, we characterized the transcriptome of the adult stage of the human whipworm T. trichiura, using next-generation sequencing technology and a de novo assembly strategy. Nearly 17.6 million high-quality clean reads were assembled into 6414 contiguous sequences, with an N50 of 1606bp. In total, 5673 protein-encoding sequences were confidentially identified in the T. trichiura adult worm transcriptome; of these, 1013 sequences represent potential newly discovered proteins for the species, most of which presenting orthologs already annotated in the related species T. suis. A number of transcripts representing probable novel non-coding transcripts for the species T. trichiura were also identified. Among the most abundant transcripts, we found sequences that code for proteins involved in lipid transport, such as vitellogenins, and several chitin-binding proteins. Through a cross-species expression analysis of gene orthologs shared by T. trichiura and the closely related parasites T. suis and T. muris it was possible to find twenty-six protein-encoding genes that are consistently highly expressed in the adult stages of the three helminth species. Additionally, twenty transcripts could be identified that code for proteins previously detected by mass spectrometry analysis of protein fractions of the whipworm somatic extract that present immunomodulatory activities. Five of these transcripts were amongst the most highly expressed protein-encoding sequences in the T. trichiura adult worm. Besides, orthologs of proteins demonstrated to have potent immunomodulatory properties in related parasitic helminths were also predicted from the T. trichiura de novo assembled transcriptome.

Recovery of Mollicutes from the reproductive tract of dairy cattle in the state of Pernambuco, Brazil / Recuperação de Mollicutes do trato reprodutivo de bovinos leiteiros no Estado de Pernambuco

The aim of the present study was to report the occurrence of members of the Mollicutesclass in the reproductive system of dairy cattle in Brazil. Five farms containing dairy cattle were visited in January of 2012. In total, 100 cows of different ages, breeds and stages of lactation were examined in the present study. The cows were part of intensive or semi-intensive management systems and were submitted to mechanical milking or hand milking. The samples were collected after washing the vulvar region with water and soap, and then drying it with paper towels and disinfecting the area with alcohol (70°GL). Vaginal mucous was collected using a sterile alginate cotton swab, which was rubbed on the vagina, as well as the lateral and internal walls. Vulvovaginal mucous samples were cultured in both liquid and solid modified Hayflick´s medium, for mycoplasmas, and UB medium, for ureaplasmas. The PCR assays for Mollicutesand Ureaplasmaspp. were performed according to the standard protocols described in the current literature. During isolation, the frequency of Mycoplasmaspp. was of 13.0% (13/100) and for Ureaplasmaspp. was of 6.0% (6/100). In the PCR assays the frequency of Mollicuteswas of 26.0% (26/100) and for Ureaplasmaspp. was of 13.0% (13/100) in the dairy cattle studied. This is the first report of these agents in reproductive system of bovine of the Pernambuco state. Further studies are necessary to determine the pathogenic potential and species of these field isolates.

O presente estudo relata a ocorrência de membros da Classe Mollicutesno sistema reprodutivo de bovinos leiteiros no Brasil. Foram visitadas em janeiros de 2012 cinco fazendas de bovinos leiteiros. Um total de 100 vacas de diferentes idades, raças e estágios de lactação foram examinadas. Os animais foram mantidos em sistema de manejo intensivo e/ou semi-intensivo, sendo submetidos aos sistemas de ordenha manual ou mecânica. As amostras de muco foram colhidas após a lavagem da região vulvar com água e sabão, com posterior desinfecção com álcool (70°GL). O muco vaginal foi colhido com suabe alginado estéril que foi friccionado nas paredes internas da vagina. Em seguida, as amostras foram cultivadas em meio Hayflick´s modificado, para micoplasmas, e em meio UB, para ureaplasmas, ambos caldo e placa. Os ensaios da PCR para Mollicutese Ureaplasmaspp. foram realizados de acordo com protocolo padrão descrito na literatura. No isolamento, a frequência de Mycoplasmaspp. foi de 13% (13/100) e para Ureaplasmaspp. foi de 6% (6/100). Nas reações da PCR a frequência para Mollicutesfoi de 26% (26/100) e para Ureaplasmas spp. foi de 13% (13/100) nos rebanhos bovinos leiteiros estudados. Este é o primeiro relato destes agentes no trato reprodutivo de bovinos no Estado de Pernambuco. Estudos adicionais são necessários para determinar as espécies e o potencial patogênico destes isolados de campo.

Occurrence of Toxoplasma gondii DNA in sheep naturally infected and slaughtered in abattoirs in Pernambuco, Brazil / Ocorrência de DNA de Toxoplasma gondii em ovelhas naturalmente infectadas e abatidas em matadouros de Pernambuco

The aim of the present study was to assess the occurrence of antibodies to Toxoplasma gondii and to detect genomic DNA of the parasite in the reproductive organs, fetuses and fetal membranes of sheep in slaughterhouses in the state of Pernambuco, Brazil. The Indirect Immunofluorescence technique (IFA) was used for screening. The Polymerase Chain Reaction (PCR) was used to detect DNA of T. gondii in the animals that were positive in the serology. In the serology, 13/50 samples were positive and genomic DNA of T. gondii was detected in one uterus, tube, ovary, placenta and fetus (heart, brain and umbilical cord) sample from a sheep that was positive in the serology. The present study provides evidence of the occurrence of T. gondii DNA in the organs of the reproductive system, placenta and fetus of a naturally infected sheep.

Objetivou-se estudar a ocorrência de anticorpos contra Toxoplasma gondii e detectar o DNA genômico do parasito em órgãos reprodutivos, fetos e anexos fetais de ovelhas em matadouros no estado de Pernambuco, Brasil. Foram coletadas amostras de soro sanguíneo, útero, trompas e ovários, além de fetos e placentas. Para a triagem utilizou-se a técnica de Imunofluorescência Indireta (RIFI) e para a detecção do DNA de T. gondii empregou-se a Reação em Cadeia da Polimerase (PCR) nos animais positivos na sorologia e em todos os fetos e anexos fetais. Na sorologia, 13/50 amostras foram positivas e o DNA genômico de T. gondii foi detectado em uma amostra de útero, trompa, ovário, placenta e feto (coração, cérebro e cordão umbilical) de uma ovelha positiva na sorologia. A identidade molecular dos produtos amplificados foi confirmada por sequenciamento. Neste estudo comprova-se a ocorrência do DNA de T. gondii em órgãos do sistema reprodutivo, placenta e feto de ovelha naturalmente infectada.

Bioassay for selection of biocontroller bacteria against bean common blight (Xanthomonas axonopodis pv. phaseoli)

Emphasis has been given on selection of micro-organism for biological control. However, in order to evaluate the biological control potential of a great number of micro-organisms in a small period of time it is necessary to develop an efficient bioassay. Seven hundred and sixty bacterial isolates from different habitats, were selected for compatibility with Rhizobium leguminosarum bv. phaseoli (SEMIA 4077 e SEMIA 4080). Among them 596 isolates were ineffective against both rhizobia. Bean seeds immersed in suspension of each one of these isolates were agitated for 5 hours at 10°C and sowed in non-sterilized soil. The plants were kept in greenhouse. After the development of cotyledonary and primary leaves, these were removed and bioassayed for Xanthomonas axonopodis pv. phaseoli (XAP) control. In the cotyledonary leaves, it was observed that the isolate DFs093 offered 100 percent control, DFs041 and DFs1297 offered 90 percent and DFs490, DFs769, DFs831, DFs842 and DFs843 offered 80 percent control. In the primary leaves, the DFs482 isolated offered 100 percent and the DFs080, DFs348, DFs513, DFs622, DFs769, DFs842 and DFs912 offered 80 percent of XAP control.

Tem-se dado muita ênfase ao controle biológico mediante seleção de microorganismos. Porém, para se avaliar o potencial de biocontroladores de forma massal e em pequeno intervalo de tempo é necessário desenvolver um bioensaio eficiente. Bactérias de diferentes sítios, num total de 760 isolados, foram selecionadas para compatibilidade com Rhizobium leguminosarum bv. phaseoli estirpes SEMIA 4077 e SEMIA 4080, onde 596 isolados foram inefetivos contra ambos rizóbios. Sementes de feijão foram imersas em suspensão de cada um destes isolados sendo agitadas por 5 horas a 10°C, plantadas em solo não esterelizado, sendo as plantas mantidas em casa de vegetação. Após o desenvolvimento das folhas cotiledonares e folhas primárias, estas foram retiradas e avaliadas por bioensaio para o controle de Xanthomonas axonopodis pv. phaseoli (XAP). Nas folhas cotiledonares, observou-se que o isolado DFs093, proporcionou 100 por cento de controle, DFs041 e DFs1297 propiciaram, 90 por cento e DFs490, DFs769, DFs831, DFs842 e DFs843 proporcionaram 80 por cento de controle. Nas folhas primárias, o isolado, DFs482 propiciou 100 por cento e os isolados DFs080, DFs348, DFs513, DFs622, DFs769, DFs842 e DFs912 proporcionaram 80 por cento de controle para XAP.

Molecular characteristics of Machado-Joseph disease mutation in 25 newly described Brazilian families

A doença de Machado-Joseph (MJD) é uma forma de ataxia espinocerebelar (AEC) de herança autossômica dominante, que foi descrita inicialmente em pacientes norte-americanos provenientes das ilhas portuguesas dos Açores. Clinicamente essa doença é caracterizada por uma ataxia cerebelar progressiva, de início tardio e com algumas características associadas tais como: oftalmoplegia, sinais piramidais e extrapiramidais e amiotrofias. A mutaçäo responsável é uma expansäo de trinucleotídeos CAG localizada na regiäo codificadora do gene MJD1. Como parte de um estudo colaborativo sobre AEC no Brasil, nós identificamos 25 famílias, näo aparentadas, segregando a mutaçäo MJD. Nesse artigo nós relatamos as características moleculares do trinucleotídeo CAG presente no gene MJD1 em 62 indivíduos dessas famílias com MJD e em 63 indivíduos que näo apresentam a mutaçäo MJD (126 cromossomos normais) e que foram considerados como controles. Nós observamos uma grande diferença entre os tamanhos dos alelos CAG normais e expandidos. Os alelos normais variaram entre 12 e 33 CAGs (média de 23 CAGs), enquanto que os alelos expandidos tiveram de 66 a 78 CAGs (média de 71.5 CAGs). Näo encontramos nenhuma diferença entre o tamanho dos alelos expandidos em pacientes masculinos e femininos ou entre alelos transmitidos via paterna ou materna. Uma correlaçäo negativa significante foi observada entre a idade de início da doença e o tamanho do segmento de CAG expandido (r=-0,6, P=0,00006); no entanto o tamanho do segmento de CAG expandido foi responsável por somente 40 por cento da variabilidade na idade de início da doença (r2=0.4). Nós observamos também instabilidade do segmento expandido de CAG durante a transmissäo de pais para filhos. Expansöes e contraçöes foram observadas; contudo, houve uma tendência geral para expansäo, com um aumento médio de +2,4 CAGs. Essa tendência para expansäo, pareceu ser maior nas transmissöes paternas (aumento médio de +3,5 CAGs) que nas maternas (aumento médio de +1,3 CAGs). Antecipaçäo foi observada em todas as transmissöes nas quais as idades de início para pais e filhos eram conhecidas, porém, nem todas as antecipaçöes foram acompanhadas de aumento no tamanho do segmento de CAG expandido. Em conclusäo, os nossos resultados mostram que o diagnóstico molecular da mutaçäo responsável pela MJD pode ser estabelecido em todos os indivíduos que apresentam a doença, bem como excluído naqueles portadores de outras formas de AEC.

Frequency of the different mutations causing spinocerebellar ataxia (SCA1, SCA2, MJD/SCA3 and DRPLA) in a large group of Brazilian patients

Spinocerebellar ataxia type 1 (SCA1), spinocerebellar ataxia type 2 (SCA2) and Machado-Joseph disease or spinocerebellar ataxia type 3 (MJD/SCA3) are three distinctive forms of autosomal dominant spinocerebellar ataxia (SCA) caused by expansions of an unstable CAG repeat localized in the coding region of the causative genes. Another related disease, dentatorubropallidoluysian atrophy (DRPLA) is also caused by an unstable triplet repeat and can present as SCA in late onset patients. We investigated the frequency of the SCA1, SCA2, MJD/SCA3 and DRPLA mutations in 328 Brazilian patients with SCA, belonging to 90 unrelated families with various patterns of inheritance and originating in different geographic regions of Brazil. We found mutations in 35 families (39 percent), 32 of them with a clear autosomal dominant inheritance. The frequency of the SCA1 mutation was 3 percent of all patients; and 6 percent in the dominantly inherited SCAs. We identified the SCA2 mutation in 6 percent of all families and in 9 percent of the families with autosomal dominant inheritance. The MJD/SCA3 mutation was detected in 30 percent of all patients; and in the 44 percent of the dominantly inherited cases. We found no DRPLA mutation. In addition, we observed variability in the frequency of the different mutations according to geographic origin of the patients, which is probably related to the distinct colonization of different parts of Brazil. These results suggest that SCA may be occasionally caused by the SCA1 and SCA2 mutations in the Brazilian population, and that the MJD/SCA3 mutation is the most common cause of dominantly inherited SCA in Brazil.