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RESUMO Introdução: o câncer da mama é o câncer de maior incidência no sexo feminino no Brasil, representando 29,7% de todos os cânceres. Mais de dois terços das mulheres com câncer da mama apresentam expressão para receptores hormonais, estando, nestes casos, indicada a terapia hormonal com tamoxifeno, que pode representar fator de risco para o desenvolvimento do câncer do endométrio (risco relativo quatro vezes maior). Objetivo: este trabalho teve como objetivo avaliar a associação entre o uso de tamoxifeno e o desenvolvimento de distúrbios endometriais bem como eventuais outros fatores associados. Pacientes e método: Estudo de coorte retrospectivo de 364 pacientes com câncer da mama, das quais 286 utilizaram tamoxifeno e 78 não utilizaram esta hormonioterapia. Resultados: pacientes que usaram tamoxifeno tiveram um seguimento médio de 51,42 meses, semelhante àquelas sem terapia hormonal (p=0,081). Um total de 21 (7,3%) mulheres que usaram tamofixeno e nenhuma mulher sem terapia hormonal apresentaram alterações endometriais durante o seguimento (p=0,01). Nas 270 mulheres que tinham informação sobre obesidade, esta se associou significantemente com o desenvolvimento de alterações endometriais (p=0,008). A associação entre tamofixeno e alterações endometriais permaneceu significante (p=0,039) após ajustar para interação com obesidade. Conclusão: o uso de tamoxifeno no tratamento do câncer da mama esteve associado ao maior risco para desenvolvimento de alterações endometriais especialmente quando associado à obesidade.

To assess whether a warning system based on mobile SMS messages increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based treatment regimens and their impressions and satisfaction with respect to incoming messages.A randomized controlled trial was conducted from May 2009 to April 2010 with HIV-infected Brazilian women. All participants (n=21) had a monthly multidisciplinary attendance; each participant was followed over a 4-month period, when adherence measures were obtained. Participants in the intervention group (n=8) received SMS messages 30 min before their last scheduled time for a dose of medicine during the day. The messages were sent every Saturday and Sunday and on alternate days during the working week. Participants in the control group (n=13) did not receive messages.Self-reported adherence, pill counting, microelectronic monitors (MEMS) and an interview about the impressions and satisfaction with respect to incoming messages.The HIV Alert System (HIVAS) was developed over 7 months during 2008 and 2009. After the study period, self-reported adherence indicated that 11 participants (84.62%) remained compliant in the control group (adherence exceeding 95%), whereas all 8 participants in the intervention group (100.00%) remained compliant. In contrast, the counting pills method indicated that the number of compliant participants was 5 (38.46%) for the control group and 4 (50.00%) for the intervention group. Microelectronic monitoring indicated that 6 participants in the control group (46.15%) were adherent during the entire 4-month period compared to 6 participants in the intervention group (75.00%). According to the feedback of the 8 participants who completed the research in the intervention group, along with the feedback of 3 patients who received SMS for less than 4 months, that is, did not complete the study, 9 (81.81%) believed that the SMS messages aided them in treatment adherence, and 10 (90.90%) responded that they would like to continue receiving SMS messages.SMS messaging can help Brazilian women living with HIV/AIDS to adhere to antiretroviral therapy for a period of at least 4 months. In general, the results are encouraging because the SMS messages stimulated more participants in the intervention group to be adherent to their treatment, and the patients were satisfied with the messages received, which were seen as reminders, incentives and signs of affection by the health clinic for a marginalized population.

PURPOSE: We sought to assess the effect of naproxen versus placebo on prevention of atrial fibrillation after coronary artery bypass graft (CABG) surgery.METHODS: in this randomized, double-blind, placebo-controlled, single-center trial of 161 consecutive patients undergoing CABG surgery, patients received naproxen 275 mg every 12 hours or placebo at the same dosage and interval over 120 hours immediately after CABG surgery. the primary outcome was the occurrence of atrial fibrillation in the first 5 postoperative days.RESULTS: the incidence of postoperative atrial fibrillation was 15.2% (12/79) in the placebo versus 7.3% (6/82) in the naproxen group (P = .11). the duration of atrial fibrillation episodes was significantly lower in the naproxen (0.35 hours) versus placebo group (3.74 hours; P = .04). There was no difference in the overall days of hospitalization between placebo (17.23 +/- 7.39) and naproxen (18.33 +/- 9.59) groups (P = .44). Intensive care unit length of stay was 4.0 +/- 4.57 days in the placebo and 3.23 +/- 1.25 days in the naproxen group (P = .16). the trial was stopped by the data monitoring committee before reaching the initial target number of 200 patients because of an increase in renal failure in the naproxen group (7.3% vs 1.3%; P = .06).CONCLUSIONS: Postoperative use of naproxen did not reduce the incidence of atrial fibrillation but decreased its duration, in a limited sample of patients after CABG surgery. There was a significant increase in acute renal failure in patients receiving naproxen 275 mg twice daily. Our study does not support the routine use of naproxen after CABG surgery for the prevention of atrial fibrillation. (C) 2011 Elsevier Inc. All rights reserved. . the American Journal of Medicine (2011) 124, 1036-1042 Duke Univ, Duke Clin Res Inst, Med Ctr, Durham, NC 27705 USA Universidade Federal de São Paulo, Div Invas Clin Electrophysiol, Dept Cardiol, São Paulo, Brazil Pontificia Univ Catolica Rio Grande do Sul, Div Cardiol, Porto Alegre, RS, Brazil Brazilian Clin Res Inst, São Paulo, Brazil Universidade Federal de São Paulo, Div Invas Clin Electrophysiol, Dept Cardiol, São Paulo, Brazil Web of Science

Because of the worse results from retransplantation in relation to the initial liver transplantation, there is a need to refine the indication for retransplantation, such that fair distribution of this benefit is obtained.This was a study of 139 patients who underwent liver retransplantation. Thirty variables were studied: 18 relating to the recipient and 12 to the donor. All the independent variables were initially compared with the length of survival using univariate analyses. Variables presenting significance were compared with the dependent variable of length of survival, to determine which factors were related to longer survival among patients, when evaluated together.A multivariate model for determining long-term survival among patients with retransplants was built up using the following variables: recipient's age, creatinine, urgency of retransplantation and early failure of the first graft. Through this multivariate model it was possible to determine a score that was categorized according to tertile distributions (below the 33rd percentile, score24; 33rd to 66th percentile, 24or = scoreor = 32; above the 66th percentile, score32). One-year, 3-year, and 5-year patient survival rates following retransplantation were respectively 85%, 82%, and 77% for scores24; 69%, 66%, and 61% for scores between 24 and 32; and 21%, 19%, and 16% for scores32 (P0.0001).The variables of recipient's age, creatinine, urgency of retransplantation, and early failure of the initial transplantation were factors that were independently related to the long-term survival of patients with liver retransplants.

Background: Transcranial Doppler (TCD) is the key test in determining the need for prophylactic blood transfusion to prevent stroke in children with sickle cell disease (SCD). The role of TCD in assessing stroke risk in adults with SCD as well as the pattern of TCD velocities in these patients are still undetermined. Methods: The authors compared TCD velocities in SCD adults (n = 56) with those of healthy controls (n = 56). Results: Velocities in SCD adults were lower than those found in children and higher than in controls and negatively correlated to hematocrit in both groups. Conclusion: The pattern of TCD velocities in adults with SCD is different from that described in children. Age-specific TCD criteria may assist the detection of stroke risk in these patients.

PURPOSE: the morbidity in HIV-positive patients due to puerperal fever was studied and correlated to the method and duration of labor, the duration of premature rupture of the membranes, CD4+ cell count and the viral load (VL) at peridelivery. METHODS: a total of 207 HIV-positive women with prenatal examinations and deliveries between May 1997 and December 2001 were enrolled. Of these, 32 had natural childbirth and 175 had a cesarean section. Of the total of enrolled patients, 62.8% were submitted to elective cesarean section. The average age of the group was 27.4 years, and 25.6% were nulliparous and 26% were primiparous. At the moment of the delivery the average gestational age was 37.8 weeks. At the end of pregnancy the average of the CD4+ cell count was approximately 481 cells/mm3 and the viral load 49,100 copies/mL. RESULTS: puerperal morbidity occurred in 34 patients, with 33 after cesarean section and one after natural childbirth. The most usual intercurrent post-cesarean infection was that of the surgical wound (13% of the infection cases). Analyzed factors, such as delivery duration, duration of rupture of the membranes, number of CD4+ cells or the viral load at peridelivery, did not interfere in puerperal morbidity. CONCLUSIONS: puerperal morbidity was 16.8% and occurred more frequently after cesarean sections (18.9%) than after vaginal deliveries (3.1%). The other factors did not present a significant effect on puerperal morbidity.

OBJETIVO: Avaliar a qualidade de vida (QV) de gestantes infectadas pelo HIV, utilizando o questionário HIV/AIDS - Targeted Quality of Life(HAT-QoL).MÉTODOS: Estudo descritivo que incluiu 60 gestantes atendidas no Núcleo Multidisciplinar de Patologias Infecciosas na Gestação (NUPAIG) - UNIFESP/EPM e na rede de referência da Secretaria Municipal de São Paulo. Foi realizado no período de fevereiro de 2011 a outubro de 2012. Foram coletadas variáveis sociodemográficas e clínicas de 60 gestantes infectadas pelo HIV, que responderam o questionário HAT-QoL, o qual incluiu 34 questões sobre qualidade de vida.RESULTADOS:A média de idade foi 30 anos e o tempo médio de infecção pelo HIV foi de 5,7 anos. Somente 8,3% das pacientes tinham contagem de células CD4 ≤200 células mm³ e 45% apresentavam carga viral indetectável. Os escores médios dos domínios variaram entre 47,5 e 83,7. Os domínios com escores mais baixos foram preocupações financeiras e preocupações com o sigilo. Os domínios com escores mais altos e menor impacto na qualidade de vida foram preocupações com a medicação e confiança no profissional.CONCLUSÃO: Neste estudo inicial, com 60 grávidas, concluímos que o HAT-QOL poderá contribuir para a avaliação da qualidade de vida na população de gestantes infectadas pelo HIV no Brasil. PURPOSE: It was to assess the quality of life (QOL) of HIV-infected pregnant women using the HIV/AIDS - Targeted Quality of Life (HAT-QoL) questionnaire.METHODS:A descriptive study of 60 pregnant women attended at the Multidisciplinary Nucleus of Infectious Diseases During Pregnancy (NUPAIG) - UNIFESP/EPM and in the referral network of the Municipal Office of São Paulo, conducted from February 2011 to October 2012. Sociodemographic and clinical variables were collected from 60 HIV-infected pregnant women who answered the HAT-QoL questionnaire, which included 34 questions about quality of life.RESULTS:The average age was 30 years and the average period of HIV infection was 5.7 years. Only 8.3% of patients had a CD4 cell score of ≤200 cells/mm³ and 45% showed undetectable viral load. The average domain scores ranged from 47.5 to 83.7. The domains with the lowest scores were financial concerns and concerns about secrecy. The domains with the highest scores and lower impact on quality of life were concerns about medication and confidence in the professional.CONCLUSION: In this initial study with 60 pregnant women, we concluded that the HAT-QOL can contribute to the assessment of quality of life in the population of HIV-infected pregnant women in Brazil.

OBJECTIVE: Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy. METHOD: We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015. RESULTS: Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p = 0.001). The placebo group showed modest improvement (p = 0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p = 0.95), whereas the oxybutynin group revealed a significant decrease (p = 0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p = 0.001). CONCLUSION: Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy.

It was to assess the quality of life (QOL) of HIV-infected pregnant women using the HIV/AIDS - Targeted Quality of Life (HAT-QoL) questionnaire.A descriptive study of 60 pregnant women attended at the Multidisciplinary Nucleus of Infectious Diseases During Pregnancy (NUPAIG) - UNIFESP/EPM and in the referral network of the Municipal Office of São Paulo, conducted from February 2011 to October 2012. Sociodemographic and clinical variables were collected from 60 HIV-infected pregnant women who answered the HAT-QoL questionnaire, which included 34 questions about quality of life.The average age was 30 years and the average period of HIV infection was 5.7 years. Only 8.3% of patients had a CD4 cell score of ≤200 cells/mm³ and 45% showed undetectable viral load. The average domain scores ranged from 47.5 to 83.7. The domains with the lowest scores were financial concerns and concerns about secrecy. The domains with the highest scores and lower impact on quality of life were concerns about medication and confidence in the professional.In this initial study with 60 pregnant women, we concluded that the HAT-QOL can contribute to the assessment of quality of life in the population of HIV-infected pregnant women in Brazil.

TRATAMENTO ANTI-RETROVIRAL contemporâneo (TARV), baseado em esquemas contendo pelo menos tres drogas, mostrou-se altamente eficaz na reducao da morbi-mortalidade associada a infeccao pelo virus da imunodeficiencia humana (HIV). Entretanto, o TARV pode induzir complicacoes metabolicas graves, tais como resistencia a insulina (RI), sindrome metabolica (SM), lipodistrofia (LDF) e doencas cardiovasculares (DCV). Os efeitos metabolicos do TARV no incremento do risco de aterosclerose precoce e acelerada, em pacientes infectados por HIV, sao bem reconhecidos. Essas condicoes clinicas inter-relacionadas tem prevalencia significativamente maior entre pacientes infectados por HIV em uso de TARV. Alteracoes do metabolismo da glicose em graus variados tem sido associadas ao TARV. Glicemias entre 140‐199 mg/dL, medidas apos duas horas da ingesta oral de 75 g de glicose (TOTG), ou glicemias de jejum entre 100‐125 mg/dL sugerem a presenca de RI. Quica o metodo mais pratico seja, no entanto, atraves do Homeostasis Model Assessment — HOMA-IR, calculado como [insulina de jejum (mU/mL) x glicemia de jejum (mmol/L)]/22,5. Em bons laboratorios, esse metodo tem excelente correlacao com o clamp hiperinsulinemico euglicemico, considerado o padrao-ouro da determinacao de IR. Nao ha consenso acerca do valor de HOMA acima do qual se diagnostica resistencia a insulina, variando de 2,5 a 3,5. Curiosamente, apesar de a populacao a partir da qual se calcula o HOMA “normal” dever ter tolerância normal a glicose e IMC < 25 kg/m2, alguns laboratorios corrigem os valores de HOMA para o IMC do paciente. Tal pratica subestima grosseiramente a prevalencia de RI.

Before the AIDS pandemia, the Mycobacterium avium complex (MAC) was responsible in most cases for the pneumopathies that attack patients with basic chronic pulmonary diseases such as emphysema and chronic bronchitis36. In 1981, with the advent of the acquired immunodeficiency syndrome (AIDS), MAC started to represent one of the most frequent bacterial diseases among AIDS patients, with the disseminated form of the disease being the major clinical manifestation of the infection8. Between January 1989 and February 1991, the Section of Mycobacteria of the Adolfo Lutz Institute, São Paulo, isolated MAC from 103 patients by culturing different sterile and no-sterile processed specimens collected from 2304 patients seen at the AIDS Reference and Training Center and/or Emilio Ribas Infectology Institute. Disseminated disease was diagnosed in 29 of those patients on the basis of MAC isolation from blood and/or bone marrow aspirate. The other 74 patients were divided into categories highly (5), moderately (26) and little suggestive of disease (43) according to the criteria of DAVIDSON (1989)10. The various criteria for MAC isolation from sterile and non-sterile specimens are discussed. Anterior a pandemia de AIDS, o Complexo Mycobacterium avium (MAC) era responsável pela maioria das vezes, por pneumopatias acometendo pacientes com doença pulmonar crônica de base como enfisema e bronquite crônica36. Em 1981, com o advento da síndrome de imunodeficiência adquirida (SIDA), o MAC passou a representar uma das doenças bacterianas mais frequentes em pacientes com esta síndrome, sendo a doença disseminada a principal forma de manifestação clínica da infecção8. Entre Janeiro de 1989 e Fevereiro de 1991, no Setor de Micobactérias do Instituto Adolfo Lutz em São Paulo, o MAC foi isolado de 103 pacientes a partir do cultivo de diferentes espécimes estéreis e não estéreis processados, coletados de 2.304 pacientes atendidos no Centro de Referência e Treinamento AIDS e/ou Instituto de Infectologia Emilio Ribas. A doença disseminada foi diagnosticada em 29 destes, com base no isolamento do MAC a partir do sangue e/ou aspirado de medula óssea. Os outros 74 pacientes foram agrupados nas categorias altamente (5), moderadamente (26) e pouco sugestiva de doença (43) de acordo com os postulados de DAVIDSON (1989)10. Os diferentes critérios para valorizar o seu isolamento de espécimes estéreis e não estéreis são discutidos.

In the present study, we investigated the influence of HIV-1 subtype in the response to the dendritic cell (DC) therapeutic vaccine for HIV. HIV-1 viral load and TCD8+/TCD4+ cell counts for up to 48 weeks after vaccination. Out of 19 immunized subjects, 13 were infected by subtype B, 5 by subtype F, and 1 by subtype D. Overall, 42.1% (8/19) achieved a viral load decline of ≥ 1 log10sustained up to 48 weeks after immunization. Such magnitude of viral load drop was seen in 80% (4/5) of subtype F infected patients, and in 23.0% (3/13) of the subtype B infected ones (p=0.08). Moreover, mean viral load decline was 1.32 log10, for subtype F infected individuals compared to 0.5 log10among subtype B infected patients (p=0.01). The variation in TCD4+ cell count was not related to HIV-1 subtype. Larger studies are necessary to confirm the efficacy of this immunotherapy and the differential response according to the background genetic diversity of HIV-1.

In early 1985, the Parakana-Apiterewa, a small, primitive Indian tribe, was contacted in the southern Amazon Basin. The tribe was thought to have been totally isolated from civilization until recent development of their land. Blood specimens were collected in 1985, shortly after the discovery of the tribe, and analyzed for the presence of rhinovirusneutralizing antibody to nine different immunotypes. Six to forty-seven percent of the serum samples tested contained antibody to at least one immunotype of rhinovirus. The prevalence of rhinovirus antibody in the Parakana-Apiterewa Indians was similar to that reported in United States populations, suggesting that there had been considerable direct or indirect contact in the past between tribe members and persons in the outside world.

Background: Transcranial Doppler (TCD) is used to select children with sickle cell disease (SCD) for primary stroke prevention using regular blood transfusion. Whether it can also identify high stroke risk in adults with SCD is not known. Methods: The authors examined 112 adult patients from two convenience population samples with SCD and 53 healthy control subjects to compare velocities in adults to those reported in children with SCD and to evaluate the influence of age and hematocrit on TCD. Results: Adults with SCD had a higher mean time-averaged maximum mean velocity (110.9 ± 25.7 cm/s) compared with healthy controls (71.1 ± 12.0 cm/s), and the difference is approximately proportional to their anemia. No cases with velocities ≥200 cm/s (the threshold used in children for prophylactic treatment) were found in this sample. Conclusions: Transcranial Doppler velocities in adults with sickle cell disease (SCD) are lower than those in children with SCD. Velocity criteria used in children cannot be used to stratify risk of stroke in adults.

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To study the reasons for referral to electrodiagnostic evaluation, 490 patients referred for electrodiagnostic evaluation to two laboratories (UNIFESP and UNEF) answered the following question: "What was the reason that brought you to look for a physician and that led him to ask this examination?" Paresthesia and/or pain were answered as the main reason by 175 of them (26% UNIFESP and 40% UNEF). The electromyographical examinations were normal in 30.8% and 35.3% and involvement of the median nerve at the wrist was detected in 5 9% and 51.5% of them. Nocturnal symptoms and paresthesia were commonly noted in both groups of patients; they, however, were not able to separate the patients with and without median nerve compression at the wrist. The question asked seems to be a useful selection instrument, to select two similar symptomatic samples of patients from two laboratories serving with very different target populations.

The objective of the present study was to translate, to do cultural equivalence and validation of the Levine et al. (1993) or Boston Carpal Tunnel Questionnaire (BCTQ) to Portuguese. The BCTQ application to patients, selected by the question "What was the reason that brought you to look for a physician and that led him to ask this examination?" showed very good reproducibility. The validity was measured through the comparison of the severity symptoms scores (SSS) and the functional status scores (FSS) with the results of grip forces, Minnesota, two point discrimination, Semmes-Weinstein filaments perception and sensory conduction at the median nerve. The internal consistency was evaluated through Chronbach's alpha coefficient comparing the SSS and the FSS. The measuring properties were evaluated through paired t-test between pre and pos-surgical scores. Reproducibility, internal consistency, validation and measuring properties of the translated BCTQ were similar to those found by Levine et al. with the original version.

The objective of the present study was to translate, to do cultural equivalence and validation of the Levine et al. (1993) or Boston Carpal Tunnel Questionnaire (BCTQ) to Portuguese. The BCTQ application to patients, selected by the question "What was the reason that brought you to look for a physician and that led him to ask this examination?" showed very good reproducibility. The validity was measured through the comparison of the severity symptoms scores (SSS) and the functional status scores (FSS) with the results of grip forces, Minnesota, two point discrimination, Semmes-Weinstein filaments perception and sensory conduction at the median nerve. The internal consistency was evaluated through Chronbach's alpha coefficient comparing the SSS and the FSS. The measuring properties were evaluated through paired t-test between pre and pos-surgical scores. Reproducibility, internal consistency, validation and measuring properties of the translated BCTQ were similar to those found by Levine et al. with the original version.

Com o objetivo de conhecermos os motivos de encaminhamento para estudo eletrofisiológico, perguntamos a 490 pacientes, encaminhados a dois laboratórios de neurofisiologia (UNIFESP e UNEF): "Qual o motivo que a(o) levou a procurar o médico e que fez com que ele solicitasse este exame"? Parestesia e/ou dor nas mãos e/ou punhos foram espontaneamente referidas como motivo principal por 175 deles (26% UNIFESP e 40% UNEF). O exame eletroneuromiográfico foi normal em, respectivamente, 30,8% e 35,3% e revelou compressão do nervo mediano no carpo em 59% e 51,5% destes pacientes. Sintomas noturnos e parestesia foram comuns nos dois grupos de pacientes, mas não foram capazes de discriminar aqueles com e sem compressão do nervo mediano no carpo. O sintoma dor predominou nos pacientes com exame normal. A pergunta formulada pareceu ser bom instrumento de seleção. Conseguiu selecionar duas amostras de pacientes sintomáticos semelhantes, em laboratórios com população alvo muito diferente. To study the reasons for referral to electrodiagnostic evaluation, 490 patients referred for electrodiagnostic evaluation to two laboratories (UNIFESP and UNEF) answered the following question: "What was the reason that brought you to look for a physician and that led him to ask this examination?" Paresthesia and/or pain were answered as the main reason by 175 of them (26% UNIFESP and 40% UNEF). The electromyographical examinations were normal in 30.8% and 35.3% and involvement of the median nerve at the wrist was detected in 5 9% and 51.5% of them. Nocturnal symptoms and paresthesia were commonly noted in both groups of patients; they, however, were not able to separate the patients with and without median nerve compression at the wrist. The question asked seems to be a useful selection instrument, to select two similar symptomatic samples of patients from two laboratories serving with very different target populations.

Brazil was the first country to provide unrestricted, cost-free access to antiretroviral (ARV) medicine for AIDS treatment. However, there is little data about the benefits of such a policy for these patients. We evaluated the duration of benefit obtained with the introduction of ARVs, defined as the durability of the first ARV regiment. We reviewed the medical charts of patients attended from 1996-2000, at the outpatient clinics of the Federal University of São Paulo, Brazil. A total of 120 drug-naive HIV-1 infected patients were eligible to participate in the study. About half of the individuals (53%) presented with disease symptoms; 59% of them had CD(4) count below 200 cells/mm(3). Mean estimated duration of the benefit of therapy was 14.1 months. The most used regimen in this cohort was Zidovudine/3TC/Indinavir (26%), followed by Zidovudine/DDI (17%), and Zidovudine/3TC/Nelfinavir (13%). The most frequent cause of interruption of therapy was gastrointestinal intolerance. Use of treatment regimens with three drugs was more effective than with two drugs, but only for patients with CD(4)200 cells/mm(3) or CV100,000 copies RNA/mL. However, the use of triple therapy was associated with a significantly higher probability of reaching maximum viral suppression, during a longer period (p0.05). The patients enrolled in the study benefitted from therapy for a limited time, after the introduction of double or triple antiretroviral therapy. The incidence of adverse events was significantly associated with loss of the benefits provided by the initial therapeutic regimen.

INTRODUÇÃO: A transmissão transfusional da tripanossomíase americana tem-se reduzido no Brasil, com a progressiva ampliação do controle de qualidade do sangue. Nesse sentido, realizou-se pesquisa para avaliar a atual soro-prevalência da infecção por Trypanosoma cruzi em candidatos a doador de sangue em Londrina, Paraná (Brasil), e comparar essa taxa com a encontrada em candidatos a doador estudados em 1958 e 1975, na mesma cidade. MÉTODO: Estudo transversal para determinação da soroprevalência. O imuno-diagnóstico de infecção por Trypanosoma cruzi foi realizado através das técnicas imunoenzimática (ELISA) e imunofluorescência indireta. RESULTADOS E CONCLUSÃO: A taxa de soroprevalência encontrada foi de 1,3%. Foi detectada tendência de queda temporal da taxa de positividade dos testes sorológicos para o diagnóstico de infecção por Trypanosoma cruzi nos bancos de sangue do município estudado nos anos de 1958, 1975 e 1995. INTRODUCTION: Transmission of American trypanossomiasis by transfusion has been reduced by expansion of control measures of blood quality in Brazil. A research project was, therefore, undertaken to evaluate soropositivity for Trypanosoma cruzi infection on blood donors and to compare this rate with those found in 1958 and 1975 in blood banks. METHOD: A transversal study was carried out on blood donors in Londrina, Paraná, Brazil. ELISA and Immunofluorescence were the serological test techniques used in the diagnosis of Trypanosoma cruzi infection. RESULTS AND CONCLUSION: A serumprevalence rate of 1.3% was found with a tendency for positive serum findings for Trypanosoma cruzi infection on blood donors to decrease over Aime (1958, 1975, and 1995).

Seropositivity for Chagas disease was evaluated in 834 children aged between 7 and 14 from the Municipal Teaching System in the district of Londrina, State of Parana. A seroprevalence rate of 0.1% was found through the use of an indirect immunofluorescent test and an enzyme-linked immunosorbent assay. This low rate of seroprevalence provides evidence that the vectorial transmission of Chagas disease has been eliminated in Londrina. The main reason for the elimination of vectorial transmission of Trypanosoma cruzi infection, as evaluated by serological tests, may be a remarkable change in the economic structure of the northern region of Parana in the 1960's. At that time coffee production was almost completely replaced by soy beans, wheat and grazing in the rural areas. This change deeply affected the rural ecology and caused an exodus of the population from rural to urban areas as well as a decrease in the total number of the population of that region. The measures introduced for controlling the disease through the Program of Chagas Disease Control established by the Fundacao Nacional de Saude of the Brazilian Ministry of Health, certainly, had a positive impact on the reduction of American trypanosomiasis prevalence in the area under study. However, it does not seem that this was the most relevant factor responsible for the elimination of vectorial transmission of Chagas disease in Londrina.

A profilaxia antimicrobiana é uma das medidas de controle da infecção da ferida cirúrgica. Mesmo com os princípios básicos hoje bem estabelecidos, cerca de 40% das indicações habituais de profilaxia são inadequadas e um dos erros mais comuns está relacionado à duração, em geral superior a 48 horas. Ajustes na profilaxia, além de favorecer sua eficácia na prevenção da infecção cirúrgica, provavelmente contribuiriam para reduzir a pressão seletiva sobre a emergência de bactérias resistentes e custos hospitalares. A simples instituição de uma rotina de antibiótico-profilaxia não garante a adesão dos cirurgiões para adequação do uso de antimicrobianos. No presente estudo, uma intervenção foi realizada na Disciplina de Gastroenterologia Cirúrgica da Universidade Federal de São Paulo - Escola Paulista de Medicina, com a implantação de uma rotina de profilaxia, com a supervisão direta de um infectologista. Os objetivos deste estudo foram avaliar a adequação do uso do antibiótico profilático e seu efeito sobre a infecção cirúrgica pós-operatória. Foi considerada adequada a profilaxia com duração menor ou igual a 24 horas. Dos 318 procedimentos cirúrgicos realizados nos períodos pré e pós-intervenção, em 67,9% foi usado um antibiótico profilático. A intervenção reduziu o uso inadequado de antibiótico de 46,3% para 20,4% (χ² = 15,59; p < 0,05). Infecção do sítio cirúrgico ocorreu em 35,8% dos procedimentos, não se observando modificação deste índice com a adequação da antibiótico-profilaxia. A participação do infectologista é importante na difícil tarefa de racionalizar o uso dos antimicrobianos em nível hospitalar. Antibiotic prophylaxis is an important measure for the control of surgical site infection. Its principles are well establish in the literature. However, at least 40% of the indications for prophylaxis are inadequate. One of the most common errors is related to the duration of the prophylaxis, which is frequently greater than 48 hours. Adjustments made in prophylaxis would not only decrease surgical site infection rates, but also contribute to the reduction of the selection of resistant bacteria in hospitals and reduce costs. The establishment of prophylaxis routine does not guarante the correct use of antibiotics by surgeons. This study was conducted in the Disciplina de Gastroenterologia Cirúrgica of the Universidade Federal de São Paulo - Escola Paulista de Medicina. The aim of the study were to evaluate the adequate use of the prophylactic antibiotic and its effect on the surgical site infection rate. Antibiotic utilization for 24 hours or less was considered adequate. Of the 318 surgical procedures performed before and after the implementation of the study; 67.9% were followed by the use of prophylactic antibiotic. There was a reduction of inadequate use of antibiotic from 46.3% to 20.4% (χ2 15.59; p < 0.005). Infection of the surgical site occurred in 35.8% of the procedures. No significant change in this percentage was observed with the correct use of prophylactic antibiotic.

Avaliação de TNF-alfa em pacientes com calazar tem despertado grande interesse devido ao seu papel no sistema imunológico e à sua atividade caquetizante. O objetivo deste estudo foi examinar a associação entre os níveis plasmáticos de TNF-alfa, medidos através de sua imunorreatividade (ELISA) e bioatividade (ensaio citotóxico sobre as células L-929), e as manifestações clínicas da leishmaniose visceral. Amostras de 19 pacientes foram obtidas para determinação do TNF-alfa antes, durante e após a terapia antimonial, utilizando o ensaio de citotoxicidade (todos os pacientes) e o ELISA (14 pacientes). Resultados discrepantes entre os ensaios de citotoxicidade e o ELISA foram observados. Níveis circulantes de TNF-alfa, medidos pelo ELISA, foram mais altos nos pacientes que nos controles e declinaram significantemente com a melhora clínica e laboratorial. Níveis plasmáticos antes do tratamento (média = 124,7 pg/ml; DP = 93,3) foram mais elevados que ao final da terapêutica (13,9 pg/ml; DP = 25,1; p = 0,001). Por outro lado, níveis plasmáticos de TNF-alfa, avaliados pela citotoxicidade, não seguiram um curso previsível durante a evolução. Esta discrepância pode ser devida à presença de fatores no plasma que podem influenciar a liberação e atividade do TNF-alfa. Ainda, a lise observada pode não ser totalmente atribuída ao TNF-alfa. Evaluation of TNF-alpha in patients with Kala-azar has drawn increasing interest due to its regulatory role on the immune system, in addition to its cachetizing activity. The objective of this study was to examine the association between plasma levels of TNF-alpha, measured by immunore-activity (ELISA) and bioactivity (cytotoxicity assay with L-929 cells), and clinical manifestations of visceral leishmaniasis. Plasma samples from 19 patients with Kala-azar were obtained before, during and at the end of antimonial therapy. TNF-alpha determinations was done by using the cytotoxicity assay (all patients) and the enzyme-linked immunoassay (ELISA - 14 patients). A discrepancy between results obtained by ELISA and cytotoxicity assay was observed. Levels of circulating TNF-alpha, assessed by ELISA, were higher in patients than in healthy controls, and declined significantly with improvement in clinical and laboratory parameters. Plasma levels before treatment were 124.7 ± 93.3 pg/ml (mean ± SD) and were higher than at the end of therapy 13.9 ± 25.1 pg/ml (mean ± SD) (p = 0.001). In contrast, plasma levels of TNF-alpha evaluated by cytotoxicity assay did not follow a predicted course during follow-up. Lysis, in this case, might be not totally attributed to TNF-alpha. The discrepancy might be attributed to the presence of factor(s) known to influence the release and activity of TNF-alpha. Escola Paulista de Medicina Division of Infectious Diseases Universidade Federal do Rio Grande do Norte Division of Infectious Diseases UNIFESP, EPM, Division of Infectious Diseases SciELO

O complexo Mycobacterium avium (CMA) é frequentemente isolado de pacientes com complicações tardias de Síndrome de Imunodeficiência Adquirida (AIDS), especialmente na América do Norte e Europa. Entretanto, existem poucos relatos do isolamento deste complexo a partir do sistema nervoso central (SNC) nestes países. Acredita-se que infecções pelo CMA sejam raras entre pacientes portadores de AIDS em países da África e América Latina. Neste trabalho relatamos o isolamento do CMA do líquor de 11 pacientes portadores de AIDS dentre 1723 (0.63%) atendidos no Centro de Referência e Treinamento -AIDS, de São Paulo, e discutimos a significância deste achado. Mycobacterium avium complex (MAC) is frequently isolated from patients with late complications of Acquired Immunodeficiency Syndrome (AIDS), especially in North America and Europe. However, its isolation from the central nervous system (CNS) has been seldom reported in these countries. MAC infections in AIDS patients in African and Latin American countries are believed to be uncommon. We report the isolation of MAC from cerebrospinal fluid (CSF) of 11 AIDS patients out of 1723 (0.63%) seen at "Centro de Referência e Treinamento - AIDS", São Paulo and discuss the significance of its isolation.

A matched-pair case-control study was done on 4 groups of renal transplant patients who acquired nosocomial infections: 1) urinary tract infection, 2) postoperative wound infection, 3) urinary tract plus postoperative wound infection and 4) the entire group of patients. For urinary tract infection patients a prolonged period of hemodialysis before hospitalization was considered a risk factor. Renal transplantation with an HLA-1 (identical) donor graft was a characteristic related to the control group. High levels of plasma creatinine and prolonged vesical catheterization were risk factors for acquiring postoperative wound infection. The latter was also considered to be a risk factor for both infections, as well as the inadequate use of antibiotic prophylaxis and the number of antibiotics used. For the entire group of patients surgical wall hematoma was a risk factor. In this group the independent risk factors analyzed by multivariate logistic regression were renal transplantation with a cadaver donor graft, prolonged vesical catheterization and prolonged use of antibiotics. Careful management of the cadaver donor allograft, decreasing the changes of contamination, decreasing the interval of urinary catheter maintenance and use of antibiotics in the postoperative period are measures that can contribute to lessen the incidence of these nosocomial infections in renal transplant recipients.

Comparou-se a eficácia da baciloscopia in natura e pós concentração (Coloração Ziehl Neelsen) e cultura tradicional e automatizada MA de amostras de escarro ou saliva/muco para a detecção do Complexo M. tuberculosis (MTB) em Centro de Referencia Ambulatorial para Tuberculose na Cidade de São Paulo. A identificação do grupo MTB baseou-se no crescimento em meio com Ácido para nitrobenzóico, e visualização do fator corda. Do total de 374 amostras, 228 eram de pacientes sob diagnóstico inicial e 146 em tratamento. 83 amostras eram saliva/muco. Destas, sete foram positivas à baciloscopia, 03 (3,6%) no material concentrado e uma (1,2%) in natura (p=0.5 McNemar Test). Cinco amostras (6%) positivas na cultura pelo método tradicional e 07 (8,4%) p=0.5 pelo MA. As amostras de escarro eram 74 foram positivas na baciloscopia, sendo 34 (11,7%) in natura e 45 (15,5%) no material concentrado, p=0.001. No método tradicional 56 (19,2%) e 67 (23%) pelo MA p=0.001. Independente da característica da amostra a baciloscopia pós concentração e a cultura pelo MA foram mais sensíveis. Effectiveness of bacilloscopy were compared in natura and pos-concentrated (Ziehl Neelsen staining), and tradicional and automated culture-AM of sputum or saliva/mucus samples for detection of M. tuberculosis complex (MTB) in Ambulatory Reference Center in the city of São Paulo. Identification of MTB group was based on growth in medium with para nitrobenzoic acid, and cord factor visualization. From the total 374 samples, 228 were from patients under initial diagnostic and 146 in treatment. 83 samples were saliva/mucus. Seven of these were bacilloscopy positive, 03 (3.6%) in concentrated material and one (1.2%) in natura (p=.500ª McNemar Test). Five samples (6%) positive for culture by traditional method and 07 (8.4%) p=0.5 for AM. For sputum 74 were bacilloscopy positive, being 34 (11.7%) in in natura and 45 in concentrated material, p=0.001. In traditional method, 56 (19.2%) and 67 (23%) for AM, p=0.001. Independently of sample characteristics, pos-concentrated bacilloscopy and culture by AM were more effectiveness.