Search

Introdução: A terapia com células CAR-T é uma das mais inovadoras e estudadas nos últimos tempos pela área da hematologia. Trata-se de uma imunoterapia em que os linfócitos T são modificados geneticamente, obtendo-se a presença do Receptor Quimérico de Antígeno (CAR), que reconhece as células tumorais promovendo sua destruição. O processo para terapia de células CAR-T contempla a coleta de linfócitos por aférese, manipulação genética dessas células em laboratório de terapia celular, quimioterapia linfodepletora (ciclofosfamida + fludarabina) e por fim, a infusão das células CAR-T. Após a infusão das células, é necessária intensa vigilância quanto ao aparecimento de reações adversas ao medicamento. Dentre essas reações, destacam-se: Síndrome de Liberação de Citocinas (SLC), caracterizada principalmente por febre, hipotensão arterial e hipóxia e a Síndrome de Neurotoxicidade Associada a Células Imunológicas Efetoras, que ocorre, principalmente, nas primeiras duas semanas após a infusão das células CAR-T. Em nosso hospital, foi iniciado o processo de coleta e infusão das células CAR-T em dezembro de 2022. Portanto, apresentaremos a experiência do nosso serviço com a implantação desta terapêutica. Métodos e resultados: Realizamos a coleta de células autólogas, de sete pacientes com diagnóstico de Linfoma não-Hodgkin difuso de grandes células B refratários/recidivados, com a idade média de 66 anos, no período de dezembro de 2022 a abril de 2023. Destes, em três foram administradas as células CAR-T (Tisagenlecleucel, Kymriah®, Novartis) e nenhum apresentou reação durante o processo da infusão. Foi realizada a administração de difenidramina 50 mg, 30 a 60 minutos antes da infusão em todos os pacientes. Quatro pacientes não receberam as células CAR-T, dentre estes, um evoluiu com progressão da doença, dois evoluíram para óbito (um antes do início da manufatura e o outro antes do término da manufatura) e um paciente ainda aguarda solicitação de manufatura das células CAR-T. A média do CD3+ por coleta foi de 9,2×109 (variando de 4×109 a 26×109). Não foram relatadas reações adversas no momento da coleta das células. O tempo mínimo entre a coleta e a infusão das células CAR-T foi de 73 dias (variando de 73 a 102 dias). Esse tempo foi influenciado, especialmente, pela autorização de operadoras de planos de saúde e pelo processo de manufatura das células. A reação adversa ao medicamento, após a infusão, foi registrada em dois pacientes. Um paciente evoluiu com Síndrome de Neurotoxicidade, com indicação de corticoterapia e o outro paciente foi diagnosticado com Síndrome de Liberação de Citocinas, evoluindo com boa resposta após o uso de tocilizumabe. Após 10 dias da infusão das células, dois pacientes receberam alta hospitalar em bom estado geral e seguem em acompanhamento, mantendo remissão da doença cinco meses e dois meses após a infusão. Um paciente evoluiu para óbito 53 dias após a infusão devido choque séptico. Conclusão: A terapia com células CAR-T é um processo complexo, e deve ser implementado na rede hospitalar por meio de uma equipe multiprofissional, para que minimize os riscos aos pacientes. Também podemos observar que o processo de liberação para terapia demanda tempo, podendo contribuir para que o paciente possa evoluir com a progressão da doença ou óbito antes do início de todo o processo.

Introdução: O teste de viabilidade celular de Células Progenitoras Hematopoiéticas (CPH) pré-congelamento é um procedimento obrigatório, garantindo que as células coletadas atendam às especificações necessárias para o Transplante de Células Tronco Hematopoiéticas (TCTH). Na maioria dos serviços a análise da viabilidade em unidades criopreservadas é realizado em unidades com tempo longo de estocagem, não sendo aplicada rotineiramente. A partir de agosto de 2021 introduzimos rotina de análise de viabilidade celular das unidades coletadas em nosso serviço e submetidas a criopreservação, previamente à infusão. Objetivo: Nosso objetivo foi avaliar a viabilidade celular de CPH criopreservada antes início do regime de condicionamento do paciente, garantindo que o processo de criopreservação e estocagem foi adequado e eficiente. Método: Todas as unidades foram criopreservadas em DMSO 10%, sob taxa controlada de resfriamento e armazenadas em fase líquida de nitrogênio. O teste de viabilidade foi realizado previamente ao condicionamento e/ou infusão em todos os pacientes submetidos a Transplante de Células Progenitoras Hematopoiéticas (TCTH) com CPH criopreservadas em nosso hospital, a partir de agosto de 2021. A técnica empregada, por citometria de fluxo, utilizou corante 7-Amino Actinomicina (7AAD), um corante nuclear, que analisa células que estão no fim da apoptose. Resultados: No período de agosto de 2021 a 30 de junho de 2023 analisamos a viabilidade de 62 produtos de CPH criopreservados, sendo 98,4% obtidos por aférese (61 unidades) e 1,6% de medula óssea (uma unidade); 70,9% eram unidades autólogas (44 unidades) e 29,1% (18 unidades) eram alogênicas. Consideramos adequada a viabilidade acima de 80%. A mediana de dias de criopreservação foi 54,1 dias (máximo de 526 dias e mínimo de 03 dias de criopreservação). Tivemos 74,2% (46 unidades) das unidades com viabilidade acima de 95%, 20,9% (13 unidades) com viabilidade entre 90% e 94,99% e somente três unidades (4,8%) com viabilidade entre 85% e 89,99%. Conclusão: Estabelecemos meta de viabilidade acima de 80% para os produtos criopreservados e observamos que os valores obtidos foram muito adequados, com 95,16% das unidades apresentando acima de 90% de células viáveis. Os resultados foram semelhantes aos observados nos produtos frescos, o que demostra a alta qualidade e eficiência do processamento, criopreservação e armazenamento do laboratório de terapia celular.

Introdução: Para garantir um alto padrão de qualidade em Transplante de Células Progenitoras Hematopoiéticas (TCTH) é necessária a padronização das rotinas técnicas e monitoramento dos processos realizados nos serviços de hemoterapia, desde a coleta de Células Progenitoras Hematopoiéticas (CPH) até o período pós-infusão. Os indicadores de qualidade são ferramentas essenciais, pois permitem a mensuração e avaliação constante dos processos. Objetivo/métodos: Apresentar quatro indicadores de qualidade do serviço, que contribuem para assegurar o monitoramento de várias etapas do processo de TCTH, sendo eles: conformidade no recebimento de CPH coletadas em outros serviços, resultados de cultura microbiológica das CPHs, reações adversas na infusão de CPH e enxertia neutrofílica após TCTH, através de análise retrospectiva dos dados coletados pelo banco de sangue. Resultados: De 01/01/2018 a 30/06/2023, avaliamos os três primeiros indicadores citados a seguir: analisamos a conformidade no recebimento de 54 coletas de CPH provenientes de outros serviços, destinadas a 50 receptores e, do total, 14 (25,9%) eram CPH-MO (medula óssea), 35 (64,8%) de CPH- aférese, 4 (7,4%) cordão umbilical e 1 (1,9%) linfocitaférese. Houve 100% de conformidade quanto à análise da temperatura de transporte, registros de identificação (doador e receptor), método de coleta, inspeção visual e integridade da bolsa. Analisamos os resultados das culturas microbiológica das CPH, em 293 produtos obtidos por aférese, tivemos duas culturas positivas (0,68%). Nas unidades de CPH-MO, em 50 coletas, tivemos 4 (8%) culturas positivas, sendo uma em 2018 e três em 2021. Os microorganismos isolados foram Staphylococcus saccharolyticus (1), Staphylococcus capitis (1) e Cutibacterium acnes (3). Quanto às reações adversas nas infusões de CPH, em 334 infusões, observamos 10,8% (36) de reações, sendo náuseas, vômitos ou hipertensão arterial, responsáveis por 50% (18) dos casos e revertidos com medicações sintomáticas. O quarto indicador, enxertia neutrofílica pós-TCTH, foi avaliado no período de 01/01/2021 a 30/06/2023, em 146 TCTHs realizados, sendo 49 autólogos e 97 alogênicos. Dos autólogos, a enxertia neutrofílica média foi de 11,63 dias e mediana de 11; dentre os alogênicos, a média foi de 18,47 e a mediana de 18. Discussão/conclusão: A avaliação do recebimento de CPHs coletadas externamente mostrou 100% de conformidade no transporte e rastreabilidade do componente. Já nas culturas positivas foram observados germes típicos de pele, relacionadas à assepsia e antissepsia pré-procedimento. Foram implementadas medidas de conscientização, bem como treinamentos da equipe, acerca da técnica de higienização de mãos e pele, o que fez com que desde 2022 os níveis de contaminação retornassem a zero. Não observamos quadros graves de reações adversas pós-infusão. A análise do tempo de enxertia mostrou que tanto as médias quanto as medianas obtidas estão dentro dos intervalos esperados. Como demonstrado, os indicadores de qualidade são ferramentas essenciais a fim de mensurar e padronizar as diversas etapas nos processo de TCTH, permitindo o fornecimento de produtos com alta qualidade, eficiência e segurança.

Introdução: O desenvolvimento de técnicas que permitiram a criopreservação de Células Progenitoras Hematopoiéticas (CPH) para uso futuro foi o fundamento básico para desenvolvimento do Transplante de Células Progenitoras Hematopoiéticas (TCTH). A eficiência da criopreservação e manutenção de células criopreservadas por longos períodos já estão bem estabelecidas, entretanto, há necessidade de otimização do armazenamento, com adoção de medidas para manter em estoque somente as unidades que realmente têm expectativa de utilização. Rotinas para manejo e descarte de CPH necessitam ser implementadas, embora um consenso do tempo ideal ou tempo máximo de manutenção do armazenamento ainda não esteja bem estabelecido. Objetivo/método: Apresentar nossa rotina para avaliação de manutenção de células criopreservadas, de forma a otimizar o armazenamento e estabelecer condutas para o descarte de CPH, já prevendo os possíveis motivos de descarte no momento da coleta de células. Avaliamos os motivos de descarte de CPH coletadas em nosso serviço, no período de janeiro de 2014 a 30 de junho de 2023, por meio da análise retrospectiva das autorizações para descarte. Resultados: No período de janeiro de 2014 a julho de 2023 foram realizados descarte de CPH criopreservadas de 71 pacientes. Em nossa análise, verificamos descarte de 64 pacientes (90,2%) devido ao óbito do receptor, tivemos três descartes (4,2%) por mudança de programação do paciente (suspensa a realização de TCTH), dois descartes (2,8%) por impossibilidade de contato com o paciente (armazenamento de CPH superior a 10 anos). Tivemos um descarte (1,4%) por número insuficiente de células e um descarte (1,4%) por cultura positiva para fungo. Não ocorreu descarte por ruptura de cadeia do frio ou unidades acidentadas ou baixa viabilidade detectada após o armazenamento. Conclusão: O óbito foi a principal causa de descarte em cerca de 90% dos pacientes, seguido por mudança na programação do paciente. Uma verificação anual do status do receptor é realizada, de forma a identificar aqueles pacientes que ainda podem se beneficiar do transplante. Definir critérios para descarte de unidades autólogas e alogênicas, quando os pacientes não mais necessitarem destas células, ou quando houver causas que impliquem em sua indisponibilidade, é parte importante do processo de terapia celular. Estas possibilidades devem ser abordadas no momento da coleta destas unidades, podendo já ser previstas no termo de consentimento de coleta por aférese e em contratos de armazenamento.

Introdução: A terapia com Células CAR-T é uma modalidade de tratamento com linfócitos T reprogramados, que passam a reconhecer antígenos de células neoplásicas, produzindo anticorpos contra estas células. Esta terapia está disponível no Brasil e aprovada pela ANVISA desde 23/02/2022 (https://www.gov.br/anvisa/pt-br/assuntos/noticias-anvisa/2022/anvisa-aprova-produto-de-terapia-avancada-para-tratamento-de-cancer). A habilitação das instituições nas etapas relacionadas à linfocitaférese, criopreservação, transporte e administração das células CAR-T é crucial para que a terapia seja bem sucedida. Objetivo/ métodos: Em nosso hospital, a etapa de criopreservação é realizada por serviço parceiro. Nosso objetivo principal foi checar a adequação dos processos relacionados com a linfocitaférese, como o transporte e a administração das células CAR-T, através de revisão e introdução de novos procedimentos padronizados, aquisição de equipamentos, atualização de contratos de prestação de serviços com parceiros envolvidos no processo e aprimoramento de documentos, como os dos registros de qualidade. As empresas responsáveis por manufaturar as células CAR-T realizaram auditorias de qualidade, identificando os procedimentos essenciais a serem estabelecidos na rotina e contribuindo com melhorias na qualidade e documentação, apresentando normas e especificações de seus produtos, ministrando treinamentos e validando o processo de coleta de linfócitos e administração de CAR-T. Resultados: Foram realizadas revisões de 20 rotinas técnicas relacionadas aos processos de coleta, registros internos, transporte e administração de terapia celular. Ao final das auditorias, implementamos 18 novas rotinas, dando maior ênfase a processos como: padronização internacional código ISBT 128, cadeia de custódia do produto, transporte do produto coleatdo, recebimento/e administração do CAR-T. Realizamos adequações e treinamentos objetivando as coletas de linfócitos para manufatura de Tisagenlecleucel (Kymriah®-Novartis) e Axicatageneciloleucel (Yescarta®-Kite), além de registrar nos respectivos sistemas informatizados de cada empresa; Novartis – treinamento no sistema CELL CHAIN , Kite–treinamento no sistema KITE KONNECT. Discussão/conclusão: : As etapas do processo para coleta de linfócitos e administração de células CAR-T demandaram a implementação de novos processos no ciclo do sangue como registro e liberação de produtos celulares, adequação nas rotinas de liberação de sorologias, coleta de linfócitos e treinamento de colaboradores. Estes processos agregam maior segurança e qualidade ao ciclo do sangue e possibilitam que o produto final atenda às demandas das indústrias farmacêuticas e dos pacientes. A implantação de processos para coleta de linfócitos para posterior manufatura de células CAR-T se mostrou factível e agregou etapas importantes na terapia celular, dentro do nosso serviço.

Introdução: O sistema de grupo sanguíneo LW teve sua identificação na década de 40, com os estudos do Sistema Rh, sendo inicialmente considerado o equivalente a este último em animais. Em 1963 foi confirmado como um sistema de grupo sanguíneo independente e recebeu este nome em homenagem a Landsteiner e Wiener, que foram os primeiros a identificarem anti-LW em coelhos e porcos, imunizados com sangue de macacos Rhesus. Os três antígenos deste sistema, LWa, LWb e LWab, são expressos em uma proteína da família de moléculas de adesão intercelular (ICAM-4). Apresentamos um caso de identificação de anticorpo contra antígenos do Sistema LW em paciente Rh positivo, cujo teste sugeria a presença de aloanticorpo anti-D em paciente RHD positivo. Relato de caso: Paciente masculino, 37 anos, diagnóstico de diabetes mellitus tipo 1 e pancreatite aguda alcoólica. Nos vários atendimentos anteriores, desde dezembro de 2019, apresentava pesquisa de anticorpos irregulares (PAI) negativas, tipagem sanguínea ORh positivo. Recebeu um total de 10 unidades de concentrado de hemácias, última transfusão em 20/02/2021. Em 20/02/2020, apresentou PAI positivo em gel LISS (reatividade fraca com todas as hemácias do painel), negativo em gel enzima, TAD (IgG+/4+) e autoanticorpo positivo em gel LISS com eluato negativo. Em 27/09/2021 apresentou PAI com reatividade fraca com todas as hemácias do painel em gel LISS, reatividade somente com hemácias D positivas em gel enzima. Suspeitado de anticorpo contra antígeno de alta frequência, como reatividade semelhante a anticorpo anti-D, pensamos em anti-LW, já que paciente era RhD positivo. Após tratamento das hemácias do painel com ditiotreitol (DTT) 0,2M, não houve reatividade com soro do paciente, fortalecendo a hipótese de um anticorpo contra antígeno do Sistema LW. Discussão: Os antígenos do sistema LW são expressos em maior intensidade em hemácias de indivíduos RH D positivos do que em indivíduos RhD negativos, o que pode levar a falsa identificação de anti-D nos testes pré-transfusionais. Aloanticorpos contra antígenos do sistema LW são raros. O mais comumente descrito é o autoanticorpo anti-LW, que pode ser encontrado em pacientes com doença hemolítica autoimune ou pacientes com perda ou expressão diminuída do antígeno, em situações tais como gestação e em algumas doenças, como por exemplo doença de Hodgkin, leucemias e sarcoma. Conclusão: Anticorpos anti-LW são anticorpos de pouco significado clínico, entretanto recomenda-se a transfusão de hemácias Rh negativas quando houver identificação deste anticorpo. Na ocasião os concentrados de hemácias transfundidos foram CDE e Kell negativos, sem intercorrências transfusionais.

Objetivos: A Spectra OPTIA é uma separadora celular que utiliza centrifugação de fluxo contínuo e tecnologia de detecção óptica e está disponível nos maiores serviços de aférese do mundo. Entretanto, no Brasil, estudos envolvendo este equipamento são escassos. O objetivo deste estudo é avaliar o coeficiente de eficácia (CE) da coleta de células progenitoras hematopoiéticas periféricas (CPHP) autólogas na separadora celular Terumo OPTIA no nosso serviço e identificar preditores de uma coleta bem-sucedida (número de células coletadas CD34+ ≥ 3×106/kg). Materiais e métodos: Foram analisadas e revisadas coletas de CPHP autólogas entre janeiro de 2018 e dezembro 2020. O CE foi calculado com a tabela: Eficiência Coleta Stem Cell por Terumo BCT. As características dos pacientes e das coletas foram descritas em frequências absolutas e relativas, valores medianos e intervalo interquartil (IQR). O teste de Mann-Whitney foi empregado para comparação do CE das coletas, segundo grupos. Análises de regressão logística univariadas e o teste de Wald foram empregadas para características associadas a coleta com número de células insatisfatória (CD34+

There is no established method to assess the PD-L1 expression in brain tumours. Therefore, we investigated the suitability of affibody molecule (Z PD-L1 ) radiolabelled with F-18 (Al 18 F) and Ga-68 to measure the expression of PD-L1 in xenograft mouse models of GBM. Mice bearing subcutaneous and orthotopic tumours were imaged 1 h post-radioconjugate administration. Ex vivo biodistribution studies and immunohistochemistry (IHC) staining were performed. Tumoural PD-L1 expression and CD4+/CD8+ tumour-infiltrating lymphocytes were evaluated in human GBM specimens. Z PD-L1 was radiolabelled with radiochemical yields of 32.2 ± 4.4% (F-18) and 73.3 ± 1.8% (Ga-68). The cell-associated radioactivity in vitro was consistent with PD-L1 expression levels assessed with flow cytometry. In vivo imaging demonstrated that 18 F-AlF-NOTA-Z PD-L1 can distinguish between PD-L1 high-expressing tumours (U87-MGvIII) and PD-L1-negative ones (H292 PD-L1Ko ). The radioconjugate was quickly cleared from the blood and normal tissues, allowing for high-contrast images of brain tumours as early as 1 h post-injection. 68 Ga-NOTA-Z PD-L1 showed heterogeneous and diffuse accumulation that corresponded to the extensively infiltrating GCGR-E55 tumours involving contiguous lobes of the brain. Lastly, 39% of analysed GBM patient samples showed PD-L1+ staining of tumour cells that was associated with elevated levels of CD4+ and CD8+ lymphocytes. Our results suggest that the investigated radioconjugates are very promising agents with the potential to facilitate the future design of treatment regimens for GBM patients.

Objectives: To explore asthma control in patients undergoing pharmacotherapy on studies in the last 20 years in Brazil. Asthma is a chronic airway inflammation disease with a high prevalence worldwide. Even with a variety of drug treatment improvements, attaining asthma control is challenging, since it should have a personalized approach. In Brazil, studies on the prevalence of asthma control are scarce and usually from a small sample size., Data Sources: A systematic review was performed to assess asthma control in Brazilian population. Terms related to "asthma", "asthma control" and "Brazil" were used in the search strategies in PubMed, BVSalud, Embase and Cochrane Library, including Brazilian Journal of Allergy and Immunology as data sources. A narrative synthesis was performed to report key outcome., Study Selections: In total, 23 studies were included. Most of them were conducted in the Southeastern and Northeast regions, in a short duration., Results: Pediatric and non-pediatric population were assessed, with a higher proportion of female. In pediatric population, those with poorly controlled asthma usually had severe or persistent disease. In elderly, an increased asthma severity was found, although proper treatment might be effective. Most studies (70%) also described exacerbations, hospitalizations (48%), quality of life (39%), and emergency visits (30%). Despite heterogeneity of outcomes and population, studies show an important prevalence of uncontrolled asthma even in patients being treated, with better disease control with treatment improvements., Conclusions: Studies in Brazil have shown that asthma control remains a challenge and there is still a need for improvement on disease management.

Expanded vermiculite was used as an adsorbent to remove ammonia nitrogen from landfill leachate. Bench and pilot-scale adsorption experiments were performed with leachate collected from a closed sanitary landfill located in Curitiba, southern Brazil. At the bench-scale, two different heights of vermiculite and three different flow rates were tested using a fixed-bed column. These tests produced an average uptake capacity of 33.4 mg g -1 for the ammonia nitrogen concentration of 2,560 mg L -1 . The Yan model was used to determine the breakthrough and the exhaustion times due to the best fit of the data to this model. At the pilot-scale, the flow rate was determined from the shortest length of the mass transfer zone obtained from bench-scale experiments. Tests were performed using one stainless-steel column filled with 26.2 kg of expanded vermiculite, which resulted in a bed height of 1.6 m. A leachate flow rate of approximately 350 L d -1 was applied to achieve the required contact time of 8.3 h. At this scale, an average uptake capacity of 18.1 mg g -1 was obtained for the ammonia nitrogen concentration of 1,193 mg L -1 . It is worth mentioning that the flow rate and the concentration of the adsorbate in the feeding solution are fundamental to improve the operational time of the fixed-bed column. The main goal of this research was the determination of operating conditions to scale-up the adsorption process of ammonia nitrogen onto expanded vermiculite. The contact time was a key parameter to reach this goal.

Hypoxia is a complex microenvironmental condition known to regulate choline kinase α (CHKA) activity and choline transport through transcription factor hypoxia-inducible factor-1α (HIF-1α) and, therefore, may confound the uptake of choline radiotracer [ 18 F]fluoromethyl-[1,2- 2 H 4 ]-choline ([ 18 F]-D4-FCH). The aim of this study was to investigate how hypoxia affects the choline radiotracer dynamics. Three underlying mechanisms by which hypoxia could potentially alter the uptake of the choline radiotracer, [ 18 F]-D4-FCH, were investigated: 18 F-D4-FCH import, CHKA phosphorylation activity, and the efflux of [ 18 F]-D4-FCH and its phosphorylated product [ 18 F]-D4-FCHP. The effects of hypoxia on [ 18 F]-D4-FCH uptake were studied in CHKA-overexpressing cell lines of prostate cancer, PC-3, and breast cancer MDA-MB-231 cells. The mechanisms of radiotracer efflux were assessed by the cell uptake and immunofluorescence in vitro and examined in vivo ( n = 24). The mathematical modelling methodology was further developed to verify the efflux hypothesis using [ 18 F]-D4-FCH dynamic PET scans from non-small cell lung cancer (NSCLC) patients ( n = 17). We report a novel finding involving the export of phosphorylated [ 18 F]-D4-FCH and [ 18 F]-D4-FCHP via HIF-1α-responsive efflux transporters, including ABCB4, when the HIF-1α level is augmented. This is supported by a graphical analysis of human data with a compartmental model (M2T6k + k 5 ) that accounts for the efflux. Hypoxia/HIF-1α increases the efflux of phosphorylated radiolabelled choline species, thus supporting the consideration of efflux in the modelling of radiotracer dynamics.

Brazil has a higher rate of dysphagia in stroke patients compared to developed countries, but does not have a fully validated method for early identification of dysphagia in this population. The aim of this study is to translate the TOR-BSST © into Brazilian Portuguese and assess the newly translated version for reliability and validity with Brazilian adult patients with stroke. The translation of the TOR-BSST © followed a multi-step process, according to the International Quality of Life Assessment project. For validation, we included patients with age ≥ 18 years and stroke diagnosis confirmed by neuroimaging and tolerance for videofluoroscopic swallowing assessment. The BR-PT final TOR-BSST © was administered by two trained screeners within two hours of videofluoroscopy. All assessors were independent and blinded. Estimates for reliability used the intraclass correlation coefficient (ICC) and for accuracy both sensitivity (SN) and negative predictive (NP) values were used, along with 95% confidence intervals (CI). Sixty patients were enrolled and tested for a mean (SD) of 14.4 (6.9) days from last seen normal. Of all the patients, 41 (68.3%) failed the BR-PT final TOR-BSST © and 21 (35%) were scored to have dysphagia on videofluoroscopy, of which 11 (52.4%) had mild dysphagia. The overall reliability between screeners was satisfactory (ICC = 0.59; 95% CI 0.32 to 0.76). The SN and NP values for the BR-PT final TOR-BSST © were 85.7% (95% CI 0.62-0.96) and 84.2% (95% CI 0.72-0.95), respectively. The TOR-BSST © was successfully translated to Brazilian Portuguese with the BR-PT final TOR-BSST © proven to have high sensitivity and negative predictive values when compared to gold standard videofluoroscopy., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Hepatitis A virus (HAV) infection has been considered one of the leading causes of acute hepatitis. The aim of the present study was to estimate the prevalence of HAV among children and adolescents in a population-based study in the capitals of the States of the North, Southeast and South of Brazil and identify predictive factors for the infection. A multi-stage sampling was used to select subjects aged between 5-9 and 10-19 years. Individual and household levels aside from the level of variables in the areas were collected. The outcome was the total IgG antibodies to HAV levels detected using a commercial Enzyme Immuno Assay (EIA). The associations between HAV and the independent variables were assessed using the odds ratio. A multilevel analysis was performed by GLLAMM using the Stata software. The prevalence of HAV infection in the 5-9 and 10-19 age groups was 28.7% and 67.5%, respectively for the North, 20.6% and 37.7%, for the Southeast and 18.9% and 34.5% for the South Region. The prevalence of HAV increased according to age in all sites. Variables related to education at the individual level (North and South), family and area level (South and Southeast) and family income level (Southeast and South) were independently associated with HAV infection. This emphasizes the need for individualized strategies to prevent the infection.

The timeline of the COVID-19 pandemic began on December 31, 2019, in China, with SARS-CoV-2 identified as the etiological agent. This article aims to describe the COVID-19 epidemic's spatial and temporal dynamics in the first hundred days in the State of Pernambuco, Brazil. We present the evolution in cases and deaths according to epidemiological weeks. We analyzed the series of accumulated daily confirmed COVID-19 cases, with projections for the subsequent 15 days, using the JoinPoint app. This software allows identifying turning points, testing their statistical significance. We also analyze the trend in the spread of COVID-19 to the interior of the state, considering the percent distribution of cases in the state capital, Recife, municipalities in Greater Metropolitan Recife, and the state's interior, by sets of three weeks, constructing thematic maps. The first hundred days of the COVID-19 epidemic resulted in 52,213 cases and 4,235 deaths from March 12, or epidemiological week 11, until June 20, 2020 (epidemiological week 25). The peak in the epidemic curve occurred in epidemiological week 21 (May 23), followed by deceleration in the number of cases. We initially detected the spread of cases from the city center to the periphery of the state capital and Metropolitan Area, followed by rapid spread to the state's interior. There was a decrease in the mean daily growth starting in April, but with an average threshold of more than 6,000 weekly cases of COVID-19. At the end of the period, the state's case series indicates the persistence of SARS-CoV-2 circulation and community transmission. Finally, paraphrasing Gabriel Garcia Marques in One Hundred Years of Solitude, we ask whether we are facing "a pause in the storm or a sign of redoubled rain".

Background: Neuroschistosomiasis is defined as an infection of the nervous system caused by Schistosoma mansoni . Neuroschistosomiasis is an important differential diagnostic consideration in pediatric patients presenting with myelopathy. Surgical excision combined with antiparasitic drugs typically provides a satisfactory outcome and often results in neurological recovery., Case Description: A 4-year-old child presented with acute and progressive myelopathy. A thoracolumbar magnetic resonance image revealed a T12-L2 conus medullaris mass that was isointense on T1 and hyperintense on T2 (with an extensive syringomyelia at the thoracic spinal cord) and showed enhanced heterogeneity with gadolinium. The lesion was excised through T12-L2 laminotomy. Intraoperatively, the tumor appeared reddish and infiltrative. The frozen section suggested a granulomatous process, while the final pathology confirmed conus medullaris schistosomiasis., Conclusion: Schistosomal myeloradiculopathy should be considered among the different diagnosis in children presenting with lower thoracic region, conus medullaris, and/or cauda equina infiltrative spinal masses., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

This study aimed to assess the impact of programs for prenatal, childbirth, and neonatal care (Mother Owl and Stork Network) on avoidable neonatal mortality in Pernambuco State, Brazil, using the adequacy approach. We analyzed the trend in avoidable neonatal mortality and the impact of these programs on avoidable neonatal mortality in four health regions in the state from 2000 to 2016. The Mortality Information System (SIM) and the Information System on Live Births (SINASC) and official documents were used as the data sources. Deaths were classified according to the Brazilian List of Avoidable Causes of Deaths Via Interventions by the Unified National Health System. Linear regression and joinpoint methods were used to analyze tendencies and identifying turning points in the neonatal mortality curves. There was a sharp drop in avoidable neonatal mortality in the state, especially in early neonatal mortality. Except for the I-Recife region, where there was a downturn in the mortality curves after implementation of the Stork Network, there was no association between the turning points in the curves and the periods with the programs' implementation in the regions. Other factors appear to have led to the improvement of these indicators, such as the expansion of the high-risk network. Strengthening this network can thus help reduce avoidable neonatal deaths, especially early deaths.

Background: Fabry disease is a rare X-linked inherited disorder caused by deficiency of α-Galactosidase A. Hundreds of mutations and non-coding haplotypes in the GLA gene have been described; however, many are variants of unknown significance, prompting doubts about the diagnosis and treatment. The α-Galactosidase A enzymatic activity in dried blood spot (DBS) samples are widely used for screening purposes; however, even when values below the normal are found, new tests are required to confirm the diagnosis. Here we describe an analysis of GLA variants and their correlation with DBS α-Galactosidase A enzymatic activity in a large Brazilian population with Fabry disease symptoms., Results: We analyzed GLA variants by DNA sequencing of 803 male patients with suspected Fabry disease or belonging to high-risk populations; in 179 individuals, 58 different exonic variants were detected. From these, 50 are variants described as pathogenic and eight described as variants of unknown significance. The other individuals presented complex non-coding haplotypes or had no variants. Interestingly, the enzymatic activity in DBS was different among pathogenic variants and the other genotypes, including variants of unknown significance; the first presented mean of 12% of residual activity, while the others presented levels above 70% of the activity found in healthy controls., Conclusion: The activity of α-Galactosidase A in DBS was markedly reduced in males with known pathogenic variants when compared with subjects presenting variants of unknown significance, non-coding haplotypes, or without variants, indicating a possible non-pathogenic potential of these latter genotypes. These findings bring a better understanding about the biochemical results of α-Galactosidase A in DBS samples, as well as the possible non-pathogenic potential of non-coding haplotypes and variants of unknown significance in GLA gene. These results certainly will help clinicians to decide about the treatment of patients carrying variants in the gene causing this rare but life-threatening disease.

Objective: To report the stabilization of urinary glycosaminoglicans (GAG) excretion and clinical improvements in patients with mucopolysaccharidosis type I (MPS I) under an alternative dose regimen of laronidase of 1.2 mg/kg every other week., Methods: We participated in a dose-optimization trial for laronidase in MPS-I patients using four alternative regimens: 0.58 mg/kg every week, 1.2 mg/kg every two weeks, 1.2 mg/kg every week and 1.8 mg/kg every other week (EOW). After the trial ended, the patients resumed the recommended dose and regimen of 0.58 mg/kg every week. Under this regimen, some patients presented difficulties in venous access and were unable to commute weekly to the treatment center. Therefore, we used an alternative regimen that consisted of 1.2 mg/kg EOW in eight patients. A retrospective study of medical records of MPS-I patients who underwent both enzyme replacement therapy (ERT) regimens, of 0.58 mg/kg every week and 1.2 mg/kg EOW, was done., Results: Patients remained clinically stable under the alternative regimen, did not present elevation of urinary GAG nor any adverse event.Conclusions: The switch of dose regimen to 1.2 mg/kg EOW of laronidase was safe, and did not cause any clinical worsening in patients who had been previously under standard dose ERT.

Background: Since renal failure is one of the main causes of death in patients with Fabry disease (FD), renal follow-up is an important part of clinical monitoring in these patients. Despite its known limitations, serum creatinine is still the most widely used biomarker. While new renal biomarkers are described, their effectiveness has not yet been fully evaluated in relation to FD., Objectives: This study aimed to compare renal biomarkers commonly and rarely used in the evaluation of FD patients., Method: The usual biomarkers for renal monitoring (microalbuminuria, proteinuria, and creatinine) and some more rarely used (cystatin C, beta 2-microglobulin [β2M], neutrophil gelatinase-associated lipocalin/lipocalin-2) were quantified in the blood and/or urine samples of 40 FD patients, 39 controls without chronic kidney disease (CKD) paired by age and sex and 38 controls with CKD undergoing hemodialysis., Results: Significant statistical differences (p < 0.05) were observed for cystatin C and lipocalin-2 in plasma levels, for β2M and serum creatinine levels and by estimated glomerular filtration rate when compared FD patients and control group with CKD and for proteinuria and microalbuminuria in urine samples and for lipocalin-2 in plasma levels when compared FD patients and control group without CKD. Urine creatinine (UCreat), pH, and urine specific gravity did not present a significant statistical difference between groups., Conclusion: Considering serum creatinine as gold standard, all renal parameters evaluated, including receiver operating characteristic curve, indicated β2M as the best biomarker, followed by cystatin C, proteinuria and microalbuminuria, while the results for lipocalin-2 and UCreat do not indicate good predictors of renal impairment. It suggests that at least 2 altered biomarkers should be considered to characterize a renal alteration, thereby establishing a better therapeutic course for FD patients. If possible, along with serum creatinine, measurement of β2M or cystatin C for renal evaluation of Fabry's patients should be considered., (© 2019 S. Karger AG, Basel.)

Antimicrobial peptides (AMPs) are mostly endogenous, cationic, amphipathic polypeptides, produced by many natural sources. Recently, many biological functions beyond antimicrobial activity have been attributed to AMPs, and some of these have attracted the attention of the cosmetics industry. AMPs have revealed antioxidant, self-renewal and pro-collagen effects, which are desirable in anti-aging cosmetics. Additionally, AMPs may also be customized to act on specific cellular targets. Here, we review the recent literature that highlights the many possibilities presented by AMPs, focusing on the relevance and impact that this potentially novel class of active cosmetic ingredients might have in the near future, creating new market outlooks for the cosmetic industry with these molecules as a viable alternative to conventional cosmetics., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This study evaluated the physicochemical characterization of Curcuma longa L. leaves with respect to proximate composition, mineral content, the presence of antinutritional factors, content of bioactive compounds and antioxidant capacity, and color measurements of leaves in natura and leaves subjected to microwave drying, oven drying, and freeze-drying methods. The proximate composition showed appreciable levels of protein (39.5 g.100 g -1 ), carbohydrates (44.74 g.100 g -1 ), total fiber (34.47 g.100 g -1 ), soluble fiber (22.65 g.100 g -1 ), insoluble fiber (11.81 g.100 g -1 ), ash (13.81 g.100 g -1 ), and low lipid contents (2.47 g.100 g -1 ). No cyanogenic compounds were detected in both samples. Freeze-drying stood out as the method that led to the greatest reductions of the bioactive compounds (33.12-73.86%, dry basis) and antioxidant capacity when compared to the leaves in natura. Microwave drying was the preservation method that produced dry leaves with higher content of bioactive compounds and antioxidant capacity. Therefore, microwave drying produced dehydrated Curcuma longa L. leaves with the highest bioactive compounds and antioxidant activity., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Tuberculosis (TB) is one of the world's major public health problems. Epidemiological surveillance has proved to be an important tool to assist in the control and prevention of communicable diseases such as TB and AIDS. This study aimed to estimate the rate and factors associated with the underreporting of TB among cases of coinfection with human immunodeficiency virus (HIV)/AIDS in the state of Pernambuco, based on data from the TB and Aids Notifiable Diseases Information System (Sinan TB and Sinan AIDS)., Methods: A cross-sectional study was carried out based on the records of the TB and AIDS Notification System to identify cases of TB underreporting in the study period. In order to identify underreporting, a probabilistic linkage was undertaken using RecLink III software., Results: The rate of TB underreporting was 29%, and the factors associated were: presenting a clinical form of TB as cavitary or unspecified pulmonary TB or having both kinds of TB at the same time; being treated outside the municipality of Recife; and being treated at health services not specialized for HIV/AIDS., Discussion: The proportion of underreporting found in our study was lower than that observed in other Brazilian studies that took into account underreporting from mortality data., Conclusion: The variables associated with underreporting of TB were mostly related to the healthcare system rather than to individual characteristics, which points to the need for training of health professionals in order to notify the information systems correctly.

In August 2015, pediatric neurologists at public hospitals in Recife, Pernambuco State, Brazil, observed an increase in the number of disproportional microcephaly cases associated with other congenital anomalies. The fact caused social commotion and mobilization of the academic community and led the Brazilian Ministry of Health to declare a national public health emergency, followed by the declaration of a Public Health Emergency of International Concern by the World Health Organization. The hypothesis for the phenomenon was congenital Zika virus (ZIKV) infection, based on spatial-temporal correlation and the clinical-epidemiological characteristics of the two epidemics. Further evidence accumulated, and within the scope of epidemiologial reasoning fulfilled criteria that gave support to the hypothesis. The plausibility of the hypothesis is based on the neurotropism of ZIKV, demonstrated in animals, affecting neural progenitors in the developing brain, and in humans, due to neurological complications in adults following infection. Isolation of viral RNA and antigens in the amniotic fluid of infected mothers and in brains of newborns and fetuses with microcephaly further demonstrated the consistency of the hypothesis. The criterion of temporality was met by identifying adverse pregnancy outcomes in a cohort of mothers with a history of rash and positive ZIKV serology. Finally, the first case-control study demonstrated a strong association between microcephaly and congenital ZIKV infection. The knowledge built with the epidemiological paradigm was supported by the scientific community, thereby establishing the consensus for a causal relationship between ZIKV and the microcephaly epidemic.

Background: Starting in August 2015, there was an increase in the number of cases of neonatal microcephaly in Northeast Brazil. These findings were identified as being an epidemic of microcephaly related to Zika virus (ZIKV) infection. The present study aims to analyse the spatial distribution of microcephaly cases in Recife (2015-2016), which is in Northeast Brazil, and its association with the living conditions in this city., Methods: This was an ecological study that used data from reported cases of microcephaly from the State Health Department of Pernambuco (August 2015 to July 2016). The basic spatial unit of analysis was the 94 districts of Recife. The case definition of microcephaly was: neonates with a head circumference of less than the cut-off point of -2 standard deviations below the mean value from the established Fenton growth curve. As an indicator of the living conditions of the 94 districts, the percentage of heads of households with an income of less than twice the minimum wage was calculated. The districts were classified into four homogeneous strata using the K-means clustering algorithm. We plotted the locations of each microcephaly case over a layer of living conditions., Results: During the study period, 347 microcephaly cases were reported, of which 142 (40.9%) fulfilled the definition of a microcephaly case. Stratification of the 94 districts resulted in the identification of four strata. The highest stratum in relation to the living conditions presented the lowest prevalence rate of microcephaly, and the overall difference between this rate and the rates of the other strata was statistically significant. The results of the Kruskal-Wallis test demonstrated that there was a strong association between a higher prevalence of microcephaly and poor living conditions. After the first 6 months of the study period, there were no microcephaly cases recorded within the population living in the richest socio-economic strata., Conclusion: This study showed that those residing in areas with precarious living conditions had a higher prevalence of microcephaly compared with populations with better living conditions.

Background: Treatment of maternal iron-deficiency anaemia can reduce risks of prematurity and low birth weight; hence a reliable diagnosis of maternal iron needs is critical. However, erythrocyte indices and serum ferritin have shown a weak correlation with iron status during pregnancy. This study verified the accuracy of those tests to predict the responsiveness to a therapeutic test with oral iron as reference standard for iron deficiency in pregnant women., Methods: A prospective diagnostic study phase 3 was conducted in a single prenatal care center in Northeast Brazil. Between August 2011 and October 2012 a consecutive sampling included 187 women in their 2(nd)-3(rd) trimesters of low-risk pregnancy and having anaemia (haemoglobin <11.0 g/dL). Until December 2012, 139 women completed a trial with daily pills of ferrous sulfate (40 mg of iron), during 23 to 125 days. Haemoglobin (Hb), other erythrocyte indices and ferritin (index-tests) were assessed pre-treatment by automated analyzers. Hb was performed also post-treatment to assess the therapeutic response by its post-pretreatment differences. We estimated sensitivity (Se), specificity (Sp), predictive values (PV), likelihood ratios (LR), diagnostic Odds Ratio (OR), area under Receiver Operating Characteristic curve (AUC), accuracy ratio and agreement coefficient of the index-tests against an increase of at least 0.55 Hb Z-score (reference standard test). We calculated the Z-scores according to the reference population from Centers for Disease Control and Prevention., Results: Hb had a mean increase of 0.24 Z-score after 30 iron pills (p 0.013). All index-tests demonstrated PV- above 70 %, PV+ around 40 %, LR around 1.0, and AUC of 0.5 to 0.6. Hb and haematocrit had Se of 50 % (95 % CI 40 to 70); and Sp of 59 % (95 % CI 43 to 74) and 47 % (95 % CI 38 to 57), respectively. Ferritin, Mean Corpuscular Volume, Mean Corpuscular Haemoglobin, Mean Corpuscular Haemoglobin Concentration and Red blood cell Distribution Width had Se below 40 % with Sp above 70 %., Conclusions: Erythrocyte indices and ferritin could not predict the iron needs of anemic pregnant women. Increases of Hb Z-scores after a short treatment with oral iron may be a reliable therapeutic test., Trial Registration: World Health Organization International Clinical Trials Registry Platform U1111-1123-2605; Brazilian Registry of Clinical Trials RBR-237wbg , registered 28 July 2011.

Dengue infection has not been routinely investigated among pregnant women and parturients with acute febrile syndrome in endemic settings. Here, we report two cases of dengue fever detected at the time of delivery in parturients enrolled in a cohort prospective study conducted in a hospital in Recife, Brazil. The parturients reported fever onset within seven days prior to delivery, and dengue infection was confirmed upon detection of viral ribonucleic acid (RNA) by using the reverse transcriptase-polymerase chain reaction. Dengue infection should be considered as a diagnostic possibility in cases of fever during pregnancy and labor, especially in endemic areas.

The increase in the number of reported cases of microcephaly in Pernambuco State, and Northeast Brazil, characterized an epidemic that led the Brazilian Ministry of Health to declare a national public health emergency. The Brazilian Ministry of Health initially defined suspected cases as newborns with gestational age (GA) ≥ 37 weeks and head circumference (HC) ≤ 33cm, but in December 2015 this cutoff was lowered to 32cm. The current study aimed to estimate the accuracy, sensitivity, and specificity of different cutoff points for HC, using ROC curves, with the Fenton and Intergrowth (2014) curves as the gold standard. The study described cases reported in Pernambuco from August 8 to November 28, 2015, according to sex and GA categories. The Fenton and Intergrowth methods provide HC growth curves according to GA and sex, and microcephaly is defined as a newborn with HC below the 3rd percentile in these distributions. Of the 684 reported cases, 599 were term or post-term neonates. For these, the analyses with ROC curves show that according to the Fenton criterion the cutoff point with the largest area under the ROC curve, with sensitivity greater than specificity, is 32cm for both sexes. Using the Intergrowth method and following the same criteria, the cutoff points are 32cm and 31.5cm for males and females, respectively. The cutoff point identified by the Fenton method (32cm) coincided with the Brazilian Ministry of Health recommendation. Adopting Intergrowth as the standard, the choice would be 32cm for males and 31.5cm for females. The study identified the need to conduct critical and on-going analyses to evaluate cutoff points, including other characteristics for microcephaly case definition.

A population-based hepatitis survey was carried out to estimate the prevalence of hepatitis B virus (HBV) infection and its predictive factors for the state capitals from the north, south, and southeast regions of Brazil. A multistage cluster sampling was used to select, successively, census tracts, blocks, households, and residents in the age group 10-69 years in each state capital. The prevalence of hepatitis B surface antigen (HBsAg) was lower than 1% in the north, southeast, and south regions. Socioeconomic condition was associated with HBV infection in north and south regions. Variables related to the blood route transmission were associated with HBV infection only in the south whereas those related to sexual behavior were associated with HBV infection in the north and south regions. Drug use was associated in all regions, but the type of drug differed. The findings presented herein highlight the diversity of the potential transmission routes for hepatitis B transmission in Brazil. In one hand, it reinforces the importance of national control strategies of large impact already in course (immunization of infants, adolescents, and adults up to 49 years of age and blood supply screening). On the other hand, it shows that there is still room for further control measures targeted to different groups within each region., (© The American Society of Tropical Medicine and Hygiene.)

The present study analysed the concordance among four different molecular diagnostic methods for tuberculosis (TB) in pulmonary and blood samples from immunocompromised patients. A total of 165 blood and 194 sputum samples were collected from 181 human immunodeficiency virus (HIV)-infected patients with upper respiratory complaints, regardless of suspicious for TB. The samples were submitted for smear microscopy, culture and molecular tests: a laboratory-developed conventional polymerase chain reaction (PCR) and real-time quantitative PCR (qPCR) and the Gen-Probe and Detect-TB Ampligenix kits. The samples were handled blindly by all the technicians involved, from sample processing to results analysis. For sputum, the sensitivity and specificity were 100% and 96.7% for qPCR, 81.8% and 94.5% for Gen-Probe and 100% and 66.3% for Detect-TB, respectively. qPCR presented the best concordance with sputum culture [kappa (k) = 0.864)], followed by Gen-Probe (k = 0.682). For blood samples, qPCR showed 100% sensitivity and 92.3% specificity, with a substantial correlation with sputum culture (k = 0.754) and with the qPCR results obtained from sputum of the corresponding patient (k = 0.630). Conventional PCR demonstrated the worst results for sputa and blood, with a sensitivity of 100% vs. 88.9% and a specificity of 46.3% vs. 32%, respectively. Commercial or laboratory-developed molecular assays can overcome the difficulties in the diagnosis of TB in paucibacillary patients using conventional methods available in most laboratories.

Objective: To analyze the accuracy of hemoglobin (Hb) concentrations as a diagnostic indicator of iron deficiency in pregnant women and to measure the efficacy of oral iron therapy using Hb z-scores rather than Hb absolute values., Methods: The sensitivity and specificity of Hb < 11.0 g/dL, and its receiver operating characteristic (ROC) curve, in the diagnosis of iron deficiency (serum ferritin (SF) < 12.0 ng/mL) were determined in 318 women in their second trimester of pregnancy who had been screened for a clinical trial conducted in 2001 in Northeast Brazil. A secondary analysis of iron therapy efficacy was carried out using data from the trial's three different treatments (60 mg of oral iron once per week (n = 46), twice per week (n = 50), and once per day (n = 44)). The mean differences between post- and pre-treatment Hb absolute values (g/dL) and z-scores (standard deviation (SD)) were calculated for the three treatment groups for study participants with and without iron deficiency., Results: Hb sensitivity, specificity, and area under the ROC curve were 60.7%, 44.3%, and 0.54 respectively. Women without iron deficiency showed improvements in Hb absolute values (as in the clinical trial's overall results) but did not have improved Hb z-scores (with scores of - 0.6 SD (95% confidence interval (CI): - 0.99, - 0.28); - 0.2 SD (95% CI: - 0.47, 0.08); and - 0.1 SD (95% CI: - 0.33, 0.18) for weekly, twice-per-week, and daily iron treatment schemes respectively). In contrast, iron-deficient women treated with the intermittent schemes had reductions in both Hb absolute values and Hb z-scores, respectively: weekly = - 0.42 g/dL (95% CI: - 0.72, - 0.12) and - 1.4 SD (95% CI: - 1.74, - 0.99); twice per week = - 0.14 g/dL (95% CI: - 0.46, 0.17) and - 1.1 SD (95% CI: - 1.44, - 0.75)., Conclusions: These analyses revealed that Hb concentrations were not an accurate indicator of either iron needs or iron-therapy response in pregnant women.

Background: The challenge of diagnosing smear-negative pulmonary TB (tuberculosis) in people living with HIV justifies the use of instruments other than the smear test for diagnosing the disease. Considering the clinical-radiological similarities of TB amongst HIV-infected adults and children, the proposal of this study was to assess the accuracy of a scoring system used to diagnose smear-negative pulmonary TB in children and adolescents, in HIV-infected adults suspected of having smear-negative pulmonary TB., Methods: A Phase III validation study aiming to assess the diagnostic accuracy of a scoring system for diagnosing smear-negative pulmonary TB in HIV-infected adults. The study assessed sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values of the scoring system. Three versions of the scoring system were tested., Results: From a cohort of 2,382 (HIV-infected adults), 1276 were investigated and 128 were diagnosed with pulmonary TB. Variables associated with the diagnosis of TB were: coughing, weight loss, fever, malnutrition, chest X-ray, and positive tuberculin test. The best diagnostic performance occurred with the scoring system with new scores, with sensitivity = 81.2% (95%-CI 74.5% -88%), specificity = 78% (75.6% -80.4%), PPV = 29.2% (24.5% -33.9%) and NPV = 97.4% (96.4% -98.4%), LR+ = 3.7 (3.4-4.0) and LR- = 0.24 (0.2-0.4)., Conclusion: The proposed scoring system (with new scores) presented a good capacity for discriminating patients who did not have pulmonary TB, in the studied population. Further studies are necessary in order to validate it, thus permitting the assessment of its use in diagnosing smear-negative pulmonary TB in HIV-infected adults.

Background: Pregnancy anemia remains as a public health problem, since the official reports in the 70's. To guide the treatment of iron-deficiency anemia in pregnancy, the haemoglobin concentration is the most used test in spite of its low accuracy, and serum ferritin is the most reliable test, although its cutoff point remains an issue., Methods/design: The aim of this protocol is to verify the accuracy of erythrocyte indices and serum ferritin (studied tests) for the diagnosis of functional iron-deficiency in pregnancy using the iron-therapy responsiveness as the gold-standard. This is an ongoing phase III accuracy study initiated in August 2011 and to be concluded in April 2013. The subjects are anemic pregnant women (haemoglobin concentration < 11.0 g/dL) attended at a low-risk prenatal care center in the Northeast of Brazil. The sample size (n 278) was calculated to estimate sensitivity of 90% and 80% of specificity with relative error of 10% and power of 95%. This study has a prospective design with a before-after intervention of 80 mg of daily oral iron during 90 days and will be analyzed as a delayed-type cross-sectional study. Women at the second trimester of pregnancy are being evaluated with clinical and laboratorial examinations at the enrollment and monthly. The 'responsiveness to therapeutic test with oral iron' (gold-standard) was defined to an increase of at least 0.55 Z-score in haemoglobin after 4 weeks of treatment and a total dose of 1200 mg of iron. At the study conclusion, sensitivities, specificities, predictive values, likelihood ratios and areas under the ROC (Receiver Operating Characteristic) curves of serum ferritin and erythrocyte indices (red blood cell count, haematocrit, haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red blood cell distribution width, reticulocyte count) will be tested. The compliance and adverse effects are considered confounding variables, since they are the main obstacles for the iron-therapy responsiveness., Discussion: This study protocol shows a new approach on iron-deficiency anemia in pregnancy from a functional point of view that could bring some insights about the diagnostic misclassifications arising from the dynamic physiologic changes during the gestational cycle., Trial Registration: WHO International Clinical Trials Registry Platform U1111-1123-2605.

Conus venoms are rich sources of biologically active peptides that act specifically on ionic channels and metabotropic receptors present at the neuromuscular junction, efficiently paralyzing the prey. Each species of Conus may have 50 to 200 uncharacterized bioactive peptides with pharmacological interest. Conus regius is a vermivorous species that inhabits Northeastern Brazilian tropical waters. In this work, we characterized one peptide with activity on neuronal acetylcholine receptor (nAChR). Crude venom was purified by reverse-phase HPLC and selected fractions were screened and sequenced by mass spectrometry, MALDI-ToF, and ESI-Q-ToF, respectively. A new peptide was identified, bearing two disulfide bridges. The novel 2,701 Da peptide belongs to the cysteine framework I, corresponding to the cysteine pattern CC-C-C. The biological activity of the purified peptide was tested by intracranial injection in mice, and it was observed that high concentrations induced hyperactivity in the animals, whereas lower doses caused breathing difficulty. The activity of this peptide was assayed in patch-clamp experiments, on nAChR-rich cells, in whole-cell configuration. The peptide blocked slow rise-time neuronal receptors, probably α 3 β 4 and/or α 3 β 4 α 5 subtype. According to the nomenclature, the new peptide was designated as α -RgIB.

Objectives: To estimate the probability of survival and to evaluate risk factors for death in a cohort of persons living with human immunodeficiency virus (PLHIV) who had started tuberculosis (TB) treatment., Methods: A prospective cohort study was conducted between June 2007 and December 2009 with HIV-infected patients who had started anti-tuberculosis treatment in the State of Pernambuco, Brazil. Survival data were analysed using the Kaplan-Meier estimator, the log-rank test and the Cox model. Hazard ratios and their respective 95%CIs were estimated., Results: Of a cohort of 2310 HIV-positive individuals, 333 patients who had commenced treatment for TB were analysed. The mortality rate was 5.25 per 10,000 person-years (95%CI 4.15-6.63). The probability of survival at 30 months was 74%. Risk factors for death in the study population were being female, age ≥30 years, having anaemia, not using highly active antiretroviral therapy (HAART) during treatment for TB and disseminated TB. Protective factors for death were a CD4 lymphocyte count >200 cells/mm(3) and treatment for TB having started in an out-patient clinic., Conclusions: The use of HAART can prevent deaths among HIV-TB patients, corroborating the efficacy of starting HAART early in individuals with TB.

A population-based survey to provide information on the prevalence of hepatitis viral infection and the pattern of risk factors was carried out in the urban population of all Brazilian state capitals and the Federal District, between 2005 and 2009. This paper describes the design and methodology of the study which involved a population aged 5 to 19 for hepatitis A and 10 to 69 for hepatitis B and C. Interviews and blood samples were obtained through household visits. The sample was selected using stratified multi-stage cluster sampling and was drawn with equal probability from each domain of study (region and age-group). Nationwide, 19,280 households and ~31,000 residents were selected. The study is large enough to detect prevalence of viral infection around 0.1% and risk factor assessments within each region. The methodology seems to be a viable way of differentiating between distinct epidemiological patterns of hepatitis A, B and C. These data will be of value for the evaluation of vaccination policies and for the design of control program strategies.

Crucial determinants of the potential effects of mercury in aquatic ecosystems are the speciation, partitioning, and cycling of its various species. These processes are affected by site-specific factors, such as water chemistry, sediment transport, and hydrodynamics. This study presents two different approaches to the development of one-dimensional/dynamic-deterministic models for the evaluation and prediction of mercury contamination in a lowland tidal river, the River Yare (Norfolk, UK). The models described here were developed to encompass the entire river system and address the mass balance of mercury in a multicompartment system, including tidal reversal and saline limit. The models were focused on river systems, with the River Yare being used as a case study because previous modelling studies have been centred on lakes and wetlands whilst there is a paucity of information for rivers. Initial comparisons with actual measured water parameters (salinity and suspended solids) indicate that both models exhibit good agreement with the actual values.

This study presents results of the application of two-one-dimensional/dynamic-deterministic models developed to evaluate and predict mercury contamination of a lowland river, the River Yare, Norfolk, UK. As a general indication of model performance, MODEL 1 produced a prediction of the overall mass balance of mercury in the River Yare that was 6% lower than an estimate, based on measurements, and 10% lower than the prediction provided by MODEL 2. The mercury surficial sediment concentrations calculated by MODEL 1 varied from 0.46 mg kg(-1) in 1995 (Reach 3) to 3.55 mg kg(-1) in 1986 (Reaches 6 and 7), whereas the minimum mercury concentration calculated by MODEL 2 was 0.42 mg kg(-1) in 1995 (Reach 3) and the maximum was 8.45 mg kg(-1) in 1986 (Reach 5). Average mercury concentrations experimentally measured in surficial sediments ranged from 0.47 mg kg(-1) in 1995 (Reach 3) to 8.10 mg kg(-1) in 1986 (Reach 6). MODEL 2 gave an excellent prediction of mercury in fish flesh compared with the results obtained from the actual analysis of fish flesh. Both models demonstrated good ability to simulate actual values determined for all compartments, water, surficial sediments, bottom sediments, and fish.

This multicentric population-based study in Brazil is the first national effort to estimate the prevalence of hepatitis B (HBV) and risk factors in the capital cities of the Northeast, Central-West, and Federal Districts (2004-2005). Random multistage cluster sampling was used to select persons 13-69 years of age. Markers for HBV were tested by enzyme-linked immunosorbent assay. The HBV genotypes were determined by sequencing hepatitis B surface antigen (HBsAg). Multivariate analyses and simple catalytic model were performed. Overall, 7,881 persons were included; < 70% were not vaccinated. Positivity for HBsAg was less than 1% among non-vaccinated persons and genotypes A, D, and F co-circulated. The incidence of infection increased with age with similar force of infection in all regions. Males and persons having initiated sexual activity were associated with HBV infection in the two settings; healthcare jobs and prior hospitalization were risk factors in the Federal District. Our survey classified these regions as areas with HBV endemicity and highlighted the risk factors differences among the settings.

Background: Cerebral palsy (CP) with dystonia-choreoathetosis is a common cause of disability in children and in adults, and responds poorly to medical treatment. Bilateral pallidal deep brain stimulation (BP-DBS) of the globus pallidus internus (GPi) is an effective treatment for primary dystonia, but the effect of this reversible surgical procedure on dystonia-choreoathetosis CP, which is a subtype of secondary dystonia, is unknown. Our aim was to test the effectiveness of BP-DBS in adults with dystonia-choreoathetosis CP., Methods: We did a multicentre prospective pilot study of BP-DBS in 13 adults with dystonia-choreoathetosis CP who had no cognitive impairment, little spasticity, and only slight abnormalities of the basal ganglia on MRI. The primary endpoint was change in the severity of dystonia-choreoathetosis after 1 year of neurostimulation, as assessed with the Burke-Fahn-Marsden dystonia rating scale. The accuracy of surgical targeting to the GPi was assessed masked to the results of neurostimulation. Analysis was by intention to treat., Findings: The mean Burke-Fahn-Marsden dystonia rating scale movement score improved from 44.2 (SD 21.1) before surgery to 34.7 (21.9) at 1 year post-operatively (p=0.009; mean improvement 24.4 [21.1]%, 95% CI 11.6-37.1). Functional disability, pain, and mental health-related quality of life were significantly improved. There was no worsening of cognition or mood. Adverse events were related to stimulation (arrest of the stimulator in one patient, and an adjustment to the current intensity in four patients). The optimum therapeutic target was the posterolateroventral region of the GPi. Little improvement was seen when the neurostimulation diffused to adjacent structures (mainly to the globus pallidus externus [GPe])., Interpretation: Bilateral pallidal neurostimulation could be an effective treatment option for patients with dystonia-choreoathetosis CP. However, given the heterogeneity of motor outcomes and the small sample size, results should be interpreted with caution. The optimum placement of the leads seemed to be a crucial, but not exclusive, factor that could affect a good outcome., Funding: National PHRC; Cerebral Palsy Foundation: Fondation Motrice/APETREIMC; French INSERM Dystonia National Network; Medtronic.

Objective: Hereditary nonsyndromic deafness is an autosomal recessive condition in about 80% of cases, and point mutations in the GJB2 gene (connexin 26) and two deletions in the GJB6 gene (connexin 30), del(GJB6-D13S1830) and del(GJB6-D13S1854), are reported to account for 50% of recessive deafness. Aiming at establishing the frequencies of GJB2 mutations and GJB6 deletions in the Brazilian population, we screened 300 unrelated individuals with hearing impairment, who were not affected by known deafness related syndromes., Methods: We firstly screened the most frequently reported mutations, c.35delG and c.167delT in the GJB2 gene, and del(GJB6-D13S1830) and del(GJB6-D13S1854) in the GJB6 gene, through specific techniques. The detected c.35delG and c.167delT mutations were validated by sequencing. Other mutations in the GJB2 gene were screened by single-strand conformation polymorphism and the coding region was sequenced when abnormal patterns were found., Results: Pathogenic mutations in GJB2 and GJB6 genes were detected in 41 individuals (13.7%), and 80.5% (33/41) presented these mutations in homozygosis or compound heterozygosis, thus explaining their hearing defect. The c.35delG in the GJB2 gene was the most frequent mutation (37/300; 12.4%), detected in 23% familial and 6.2% the sporadic cases. The second most frequent mutation (1%; 3/300) was the del(GJB6-D13S1830), always found associated with the c.35delG mutation. Nineteen different sequence variations were found in the GJB2 gene. In addition to the c.35delG mutation, nine known pathogenic alterations were detected c.167delT, p.Trp24X, p.Val37Ile, c.176&#95;191del16, c.235delC, p.Leu90Pro, p.Arg127His, c.509insA, and p.Arg184Pro. Five substitutions had been previously considered benign polymorphisms: c.-15C>T, p.Val27Ile, p.Met34Thr, p.Ala40Ala, and p.Gly160Ser. Two previously reported mutations of unknown pathogenicity were found (p.Lys168Arg, and c.684C>A), and two novel substitutions, p.Leu81Val (c.G241C) and p.Met195Val (c.A583G), both in heterozygosis without an accompanying mutation in the other allele. None of these latter four variants of undefined status was present in a sample of 100 hearing controls., Conclusions: The present study demonstrates that mutations in the GJB2 gene and del(GJB6 D13S1830) are important causes of hearing impairment in Brazil, thus justifying their screening in a routine basis. The diversity of variants in our sample reflects the ethnic heterogeneity of the Brazilian population.

Background: The objectives were to estimate the prevalence of hepatitis A among children and adolescents from the Northeast and Midwest regions and the Federal District of Brazil and to identify individual-, household- and area-levels factors associated with hepatitis A infection., Methods: This population-based survey was conducted in 2004-2005 and covered individuals aged between 5 and 19 years. A stratified multistage cluster sampling technique with probability proportional to size was used to select 1937 individuals aged between 5 and 19 years living in the Federal capital and in the State capitals of 12 states in the study regions. The sample was stratified according to age (5-9 and 10- to 19-years-old) and capital within each region. Individual- and household-level data were collected by interview at the home of the individual. Variables related to the area were retrieved from census tract data. The outcome was total antibodies to hepatitis A virus detected using commercial EIA. The age distribution of the susceptible population was estimated using a simple catalytic model. The associations between HAV infection and independent variables were assessed using the odds ratio and corrected for the random design effect and sampling weight. Multilevel analysis was performed by GLLAMM using Stata 9.2., Results: The prevalence of hepatitis A infection in the 5-9 and 10-19 age-group was 41.5 and 57.4%, respectively for the Northeast, 32.3 and 56.0%, respectively for the Midwest and 33.8 and 65.1% for the Federal District. A trend for the prevalence of HAV infection to increase according to age was detected in all sites. By the age of 5, 31.5% of the children had already been infected with HAV in the Northeast region compared with 20.0% in the other sites. By the age of 19 years, seropositivity was approximately 70% in all areas. The curves of susceptible populations differed from one area to another. Multilevel modeling showed that variables relating to different levels of education were associated with HAV infection in all sites., Conclusion: The study sites were classified as areas with intermediate endemicity area for hepatitis A infection. Differences in age trends of infection were detected among settings. This multilevel model allowed for quantification of contextual predictors of hepatitis A infection in urban areas.

Objective: To estimate the additional number of affected individuals based on the prevalence of sickle-cell syndromes among relatives of index cases., Methods: Cross-sectional study of relatives of a random sample of index cases identified through a neonatal screening program in Northeastern Brazil, between 2001 and 2005. The extended family trial model included 463 relatives of 21 index cases. Relatives were classified as nuclear family (NF: father, mother, and siblings); first degree extended family (N1: grandparents, uncles and aunts, and first cousins); second degree extended family (N2: children of first cousins); extended family (NA: NF+N1+N2); and extended nuclear family (NA1: NF+N1). The presence of HBB*S and other abnormal hemoglobins was confirmed by high-performance liquid chromatography. The association between the presence of HBB*S and other variables was calculated using prevalence ratios and their respective 95% confidence intervals, and differences between means were calculated using Student's t test with a 5% significance level., Results: Of relatives, 81% had no knowledge of sickle-cell anemia and HBB*S was present in 114 family members. A total of 53.3% of the studied population was considered as of reproductive age, and 80% of HBB*S carriers had already had children. Frequency was higher among NF (69%), but was also high in N1 (22.8%). NA1 screening resulted in the detection of 69 carriers additional (a 172% increase)., Conclusions: These results indicate that family screening for the identification of sickle-cell carriers should be extended to first degree relatives.

Objective: To study the systolic and diastolic function of asymptomatic patients with severe obesity using a Doppler echocardiography., Methods: Thirty candidates for bariatric surgery, with an average BMI of 49.2 +/- 8.8 kg/m2 and no previous history of heart disease were evaluated through transthoracic echocardiography., Results: Enlarged left chambers were observed in 42.9% of the sample, diastolic dysfunction in 54.6% and left ventricular hypertrophy in 82.1%, of which 50% of the cases presented the geometric pattern of eccentric hypertrophy. Indexation of left ventricular mass to height resulted in a significantly higher number of diagnoses for hypertrophy than indexation to body surface area (p = 0.0053), demonstrating that this index is more appropriate to determine ventricular hypertrophy in obese people. Correlations between left ventricular hypertrophy with obesity duration and pressure levels were positive as well as correlations between body mass index and diastolic dysfunction indicators., Conclusion: This study demonstrated that echocardiograms performed on asymptomatic severely obese patients can detect alterations in the cardiac structure that are common in cases of obesity cardiomyopathy and can be associated with the development of heart failure, arrhythmias and sudden death, enabling the identification of patients with greater cardiovascular risk [corrected]

Mitochondrial mutations are responsible for at least 1% of the cases of hereditary deafness, but the contribution of each mutation has not yet been defined in African-derived or native American genetic backgrounds. A total of 203 unselected hearing-impaired patients were screened for the presence of the mitochondrial mutation A1555G in the 12S rRNA gene and mutations in the tRNASer(UCN) gene in order to assess their frequency in the ethnically admixed Brazilian population. We found four individuals with A1555G mutation (2%), which is a frequency similar to those reported for European-derived populations in unselected samples. On the other hand, complete sequencing of the tRNASer(UCN) did not reveal reported pathogenic substitutions, namely A7445G, 7472insC, T7510C, or T7511C. Instead, other rare substitutions were found such as T1291C, A7569G, and G7444A. To evaluate the significance of these findings, 110 "European-Brazilians" and 190 "African-Brazilians" unrelated hearing controls were screened. The T1291C, A7569G and G7444A substitutions were each found in about 1% (2/190) of individuals of African ancestry, suggesting that they are probably polymorphic. Our results indicate that screening for the A1555G mutation is recommended among all Brazilian deaf patients, while testing for mutations in the tRNASer(UCN) gene should be considered only when other frequent deafness-causing mutations have been excluded or in the presence of a maternal transmission pattern.

We present general formulae for several common situations in the genetic counseling of heterogeneous disorders. The occurrence or not of parental consanguinity is taken into account, since it distorts significantly the prior probabilities favoring the different mechanisms. Nonsyndromic deafness is used as a numerical application, since it can be produced by any type of monogenic inheritance and can be mixed with variable proportions of environmental cases. Recurrence risks are calculated including or not including environmental factors in the origin of the defect. In underdeveloped countries the proportion of environmentally determined cases of deafness is significantly higher than in first-world countries. Therefore, when environmental causes cannot be excluded, recurrence risks are always higher in developed than in developing countries. On average, when parental consanguinity is present there is a significant increase in recurrence risks for deafness, whether environmental factors are included or not., (Copyright 2000 Wiley-Liss, Inc.)

In response to increasing scientific evidence of the environmental toxicity of mercury and its organic compounds, this study reviews the state of knowledge about the mercury cycle in aquatic systems. It describes the aquatic chemistry of mercury and discusses the importance of biological and physicochemical parameters such as pH, temperature, dissolved organic carbon, oxygen concentration, mercury and methylmercury concentration and availability, as well as sulfate, manganese, and iron concentration in surfaced waters. There is still a paucity of information on environmental dependency of factors that regulate the formation, destruction, and trophic transfer of methylmercury. This lack has led to numerous studies to define the factors that can influence its bioconcentration and bioaccumulation. This review presents some alternative models for mercury cycling, speciation, and partitioning based on the trend toward "site-specific water quality standards," in which chemical speciation is considered on a site-by-site basis.