Características clinicoepidemiológicas y endoscópicas en portadores del virus C de la hepatitis con tratamiento de hemodiálisis / Clinical epidemiological and endoscopic characteristics in carriers of the viral hepatitis C with hemodialysis treatment i: en

Introducción: Los pacientes con insuficiencia renal crónica en tratamiento de hemodiálisis constituyen un importante grupo de riesgo para adquirir la infección por el virus C de la hepatitis. Objetivo: Caracterizar a portadores del virus C de la hepatitis en tratamiento de hemodiálisis según variables clinicoepidemiológicas y endoscópicas. Métodos: Se realizó una investigación observacional, descriptiva, retrospectiva y longitudinal de 63 pacientes con insuficiencia renal crónica, en tratamiento de hemodiálisis, portadores del virus C de la hepatitis, quienes fueron atendidos en la consulta de Gastroenterología del Hospital General Docente Dr. Juan Bruno Zayas de Santiago de Cuba, desde enero de 2015 hasta septiembre de 2019. Resultados: En la investigación primaron el sexo masculino, el grupo etario de 31-60 años, además de la hipertensión arterial y la diabetes mellitus como antecedentes personales. Los factores de riesgo de mayor incidencia fueron las inyecciones y las transfusiones frecuentes. Conclusiones: Existió una correlación significativa entre el tiempo en hemodiálisis y el tiempo de diagnóstico del virus C de la hepatitis; sin embargo, la replicación viral se mantuvo baja.

Introduction: The patients with chronic renal failure in hemodialysis treatment constitute an important risk group to acquire the infection for the viral hepatitis C. Objective: To characterize carriers of the viral hepatitis C in hemodialysis treatment according to clinical epidemiological and endoscopic variables. Methods: An observational, descriptive, retrospective and longitudinal investigation of 63 patients with chronic renal failure, in hemodialysis treatment, carriers of the viral hepatitis C was carried out, who were assisted in the Gastroenterology Service of Dr. Juan Bruno Zayas Teaching General Hospital in Santiago de Cuba from January, 2015 to September, 2019. Results: In the investigation there was a prevalence of the male sex, the 31-60 age group, besides hypertension and the diabetes mellitus as personal history. The risk factors of more incidence were injections and frequent transfusions. Conclusions: There was a significant correlation between the time in hemodialysis and the time of diagnosis of the viral hepatitis C; however, the viral replication stayed low.

Caracterización de la evolución clínica del trasplante renal en pacientes con virus de la hepatitis C positivo / Characterization of the clinical course of kidney transplantation in patients with positive hepatitis C virus

Introducción: La infección por el virus de la hepatitis C es un evento común en los receptores de trasplante renal que la arrastran desde su estancia en los tratamientos de hemodiálisis previos al implante. La positividad al virus C se ha asociado a una evolución desfavorable después del trasplante, dado por una mayor frecuencia de complicaciones clínicas, metabólicas e inmunológicas que repercuten de forma negativa tanto en la supervivencia del injerto como del paciente. Objetivos: Caracterizar la evolución clínica de los pacientes trasplantados de riñón con virus de la hepatitis C positivo y determinar la evolución de este grupo de enfermo de acuerdo a variables demográficas, clínicas y de supervivencia. Método: Estudio analítico, transversal, retrospectivo en pacientes trasplantados renales del Hospital Clínico Quirúrgico Hermanos Ameijeiras, desde el año 2005 al 2017. Se excluyeron los menores de 15 años, los retrasplantes, los trasplantes dobles y los combinados o cuando no se pudo obtener la información. Se comparan las variables escogidas entre enfermos que llegan al trasplante con serología positiva al virus C, (HVC positivos), con los HVC negativos. Resultados: Del total de 156 enfermos, 65 por ciento (102) fueron HVC positivos, no se encontraron diferencias entre grupo en cuanto a edad y sexo de receptores y donantes, así como tampoco en el tratamiento inmunosupresor utilizado. El donante vivo se empleó menos en los HVC positivos donde se encontraron más enfermos con poliquistosis renal. La necrosis tubular aguda (NTA) y el rechazo fueron más frecuentes en los HVC positivos, siendo la primera estadísticamente significativa, p=0,0421, también resultaron significativamente más frecuente en el grupo HVC positivo, la proteinuria, p=0,041, la elevación de enzimas hepáticas, p=0,047 y la diabetes postrasplante, p=0,047. La supervivencia del injerto y los pacientes fue menor en los HVC positivos. Conclusiones: En este estudio la hepatitis por virus C impacta negativamente en la evolución del injerto y propicia la aparición de algunas complicaciones clínicas, lo que sin dudas pudiera influir en una menor expectativa de vida tanto para el injerto como para el enfermo(AU)

Introduction: Hepatitis C virus infection is a common event in kidney transplant recipients that has dragged it along since their stay in hemodialysis treatments prior to implantation. Positivity to virus C has been associated with an unfavorable evolution after transplantation, due to higher frequency of clinical, metabolic and immunological complications that negatively affect both graft and patient survival. Objectives: To describe the clinical evolution of kidney transplant patients with positive hepatitis C virus and to determine the evolution of this group of patients according to demographic, clinical and survival variables. Method: An analytical, cross-sectional, retrospective study in kidney transplant patients at Hermanos Ameijeiras Hospital was carried out from 2005 to 2017. This study excluded children under 15 years of age, re-transplants, double and combined transplants or when it was not possible to gather the information. The variables chosen among patients who arrive at transplantation with positive serology for virus C (positive HCV) were compared with negative HCV. Results: One hundred and fifty six patients were the total, 65 percent (102) were HVC positive, no differences were found between groups in terms of age and sex of recipients and donors, nor in the immunosuppressive treatment used. The living donor was less used in positive HVC where more patients with polycystic kidney disease were found. Acute tubular necrosis (ATN) and rejection were more frequent in positive HVC, the former being statistically significant, p = 0.0421, proteinuria, p = 0.041, elevation was also significantly more frequent in the positive HVC group of liver enzymes, p = 0.047 and post-transplant diabetes, p = 0.047. Graft and patient survival was lower in positive HCV. Conclusions: In this study, hepatitis C virus has negative impact on the evolution of the graft and favors the appearance of some clinical complications, which undoubtedly could influence a shorter life expectancy for both the graft and the patient(AU)

El síndrome de fatiga crónica en el curso de la hepatitis C. Presentación de un caso / Chronic fatigue syndrome in the course of Hepatitis C

RESUMEN Se supone que aproximadamente 80 millones de personas a nivel mundial están infectadas con el virus de la hepatitis C. Un aproximado del 60 % de dichos pacientes aqueja síndrome de fatiga crónica. Se presentó un paciente portador de hepatitis crónica de tipo C, con manifestaciones clínicas de síndrome de fatiga crónica por más de dos años. Se han reportado estudios internacionales que han demostrado la relación existente entre el desarrollo de la respuesta inmune y el daño que ocasiona en el tejido cerebral la infección por virus de hepatitis C. Este trabajo tiene como objetivo la presentación del primer caso que se tiene referencia (AU).

ABSTRACT It is believed that almost 80 million persons are infected with the Hepatitis C virus around the world, and 60 % of them suffer the chronic fatigue syndrome. For that reason we present the case of a patient who is a carrier of the chronic fatigue syndrome for more than two years. Reports of international research have showed the relation between the immune answer and the damage caused by the infection of the hepatitis C virus in the brain tissues. The aim of this work is presenting the first case reported in Cuba (AU).

Incidencia del virus C de la hepatitis en pacientes en hemodiálisis / Incidence of hepatitis C virus in hemodyalisis patients

Se realizó un estudio descriptivo y transversal de 107 pacientes con insuficiencia renal crónica terminal, tratados periódicamente con hemodiálisis en el Servicio de Hemodiálisis del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" de Santiago de Cuba, de enero a junio del 2012, quienes habían recibido al menos 3 transfusiones sanguíneas y además presentaban el virus de la hepatitis C -- confirmado por el método inmunoenzimático de ELISA --, a fin de caracterizarles y determinar en ellos la morbilidad de dicho virus. En la investigación se obtuvo una preponderancia del sexo masculino (53,0 %), el grupo etario de 45-54 años (30,0 %) y la nefropatía hipertensiva como causa de insuficiencia renal crónica (50,5 %); además, se realizaron menos de 3 transfusiones en 48 pacientes (51,0 %). El virus de la hepatitis C mantenía una alta morbilidad en los pacientes con insuficiencia renal crónica terminal que recibieron tratamiento hemodialítico en este Servicio de Hemodiálisis.

A descriptive and cross-sectional study was carried out in 107 patients with end-stage chronic renal failure, treated with periodic hemodyalisis at the Hemodyalisis Service of "Dr. Juan Bruno Zayas Alfonso" General Teaching Hospital of Santiago de Cuba, from January to June 2012, who received at least three blood transfusions and also had the hepatitis C virus -- confirmed by ELISA immunoassay method--, in order to characterize them and to determine the virus morbidity in them. There was a predominance of males (53.0%), the age group of 45-54 years (30.0%) and hipertensive nephropathy as a cause of chronic renal failure (50.5%) in the study; also, less than three transfusions were made in 48 patients (51.0%). The hepatitis C virus remained a high morbidity in patients with end-stage chronic renal failure who received hemodyalisis in this Hemodyalisis Service.

Epidemiología y factores de riesgo / Epidemiology and risk factors

La distribución geográfica del carcinoma hepatocelular (CHC) depende de la incidencia y prevalencia de sus agentes etiológicos en los diferentes lugares. Esto ha llevado a la realización de un mapa que muchas veces puede coincidir con las características de dichas entidades causales; las más importantes son la hepatitis B, la hepatitis C e incluso el alcohol en algunas regiones del mundo. Las estadísticas informadas en cuanto a raza, edad y sexo también dependen mucho de estas causas, y por eso en algunos casos los datos pueden ser similares, pero bien vale la pena recordarlos.

The geographical distribution of hepatocellular carcinoma (HCC) depends on the incidence and prevalence of related etiological agents in different places. This has led to the creation of a map upon which the characteristics of these causal entities can often be matched. The most important are hepatitis B, hepatitis C and even alcohol in some regions. The statistics are also reported in terms of race, age and sex and are heavily relied upon in these cases as well. In some cases the data may be similar which is well worth remembering.

Analysis of influence of HLA-B broad specific Bw4 motif on HCV specific T cell response / 中华微生物学和免疫学杂志

Objective To study the influence of Bw4 broad specific motif on hepatitis C virus (HCV) specific T cell response.Methods The 86 patients with HCV infection were enrolled in this study,who had history of non-standard paid blood donation.The sequence specific primer SSP-PCR and specific primer Amplification Refractory Mutation system was used to analyze HLA type.The T cell response,using PBMCs stimulated by HCV nonstructural protein NS3,NS4 and NS5 was tested by ELISPOT assay.Results There were 29 (33.7％) cases with homozygosity Bw4/4,38 cases (44.2％) with heterozygosity Bw4/6 and 19(22.1％) cases with homozygosity Bw6/6 in 86 patients with HCV infection.HCV viral loads in Bw4/4group,Bw4/6 group and Bw6/6 group were (3.98±0.32) Log (copy/ml),(5.22± 0.29) Log (copy/ml),(5.04±0.38) Log(copy/ml),respectively and there was a significant difference in HCV load among three groups(P=0.0153).The 24 cases with HCV infection were test HCV specific T cell response divided homozygosity Bw4/4 group and non-homozygosity Bw4/4 group.The HCV specific T cell response frequency in homozygosity Bw4/4 group and non-homozygosity Bw4/4 group was 50％ (5/10) and 14.28％ (2/14,respectively.The HCV specific T cell response magnitude in homozygosity Bw4/4 group and non-homozygosity Bw4/4 group was 70 SFU/106 PBMC (0-2020 SFU/106 PBMC)and 0 SFU/106 PBMC (0-200 SFU/106 PBMC).The response magnitude and frequency in homozygosity Bw4/4 group was significantly higher than that of non-homozygosity Bw4/4 group,P value was 0.0450 and 0.069,respectively.In homozygosity Bw4/4 group NS5 induced T cell response was dominant.The NS5 specific T cell response frequency in Bw4/4 group and non-Bw4/4 group was 50％ and 7.14％,respectively,and the difference was nearly significant(P=0.050).Conclusion The HCV-infected blood donors with homozygosity for HLA-Bw4 alleles is associated with a significant lower HCV virus load and stronger HCV specific T cell response,compared with non-homozygosity Bw4/4 group.

Tolerancia del tratamiento con interferón estándar y ribavirina en pacientes cirróticos por virus de la hepatitis C / Tolerance to treatment with standard interferon and ribavirin in patients presenting with cirrhosis from hepatitis C

En el tratamiento de la cirrosis hepática compensada de etiología vírica la respuesta viral sostenida con el interferón y ribavirina es menor y se acompaña de mayor frecuencia e intensidad de efectos adversos en relación con pacientes no cirróticos. No obstante, dadas las pocas opciones terapéuticas para este grupo de pacientes y la necesidad de retrasar la aparición de las complicaciones, nos motivamos a la realización de este trabajo. Se presentan los resultados de un grupo de 36 pacientes con diagnóstico de cirrosis hepática por el virus de la hepatitis C (VHC) en estadio de Child A incluidos en un ensayo clínico multicéntrico, liderado por el Instituto de Gastroenterología, a los que se les administró un esquema terapéutico de interferón alfa-2b más ribavirina por 48 sem, se evaluó su tolerancia a través de los eventos adversos tantos clínicos como hematológicos. Los resultados demuestran que esta alternativa de tratamiento es segura y bien tolerada

In treatment of compensating hepatic cirrhosis of viral etiology the maintained viral response with Interferon and Ribavirin is minor and it is accompanied of a greater frequency of adverse effects in relation to non-cirrhotic patients. However, due to the scarce therapeutical options for this group of patients and the need to retard the appearance of complications, was the reason of present paper. Authors present the results from a group of 36 patients diagnosed with hepatic cirrhosis from HCV in A Child's stage included in multicenter clinical trials, sponsored by the Institute of Gastroenterology; patients received a therapeutical scheme of Interferon alfa-2b plus Ribavirin during 48 weeks assessing their tolerance by clinical and hematologic adverse events. Results demonstrate that this treatment alternative is safe and well-tolerated

Analysis of GB virus C infection among HIV-HCV coinfected patients / Análise da infecção pelo vírus GB-C em pacientes com coinfecção VIH-VHC

The aim of this study was to evaluate the effect of GB virus C on laboratory markers and histological parameters among HIV-seropositive patients coinfected with HCV. Lower degrees of hepatic lesions were observed in the triple-infected patients, in comparison with HIV-HCV coinfected patients who were negative for GBV-C RNA.

O objetivo do estudo foi avaliar o efeito da infecção pelo vírus GB-C em marcadores laboratoriais e parâmetros histológicos em pacientes HIV soropositivos coinfectados com VHC. Menor grau de lesão hepática foi observado nos pacientes com tripla infecção em comparação aos pacientes coinfectados com VIH-VHC negativos para GBV-C RNA.

Viral Hepatitis C in a leading Brazilian hospital: epidemiological factors and genotyping

The hepatitis C virus (HCV) is classified into six different genotypes and their distribution is different throughout the world. Epidemiologic studies are important to determine several characteristics of the virus, as well as the disease. This study analysed the prevalence of HCV and its genotypes among patients from a leading hospital in Ceará, which is located in Northeast Brazil. A total of 119 anti-HCV-seropositive patients, each having previously completed a questionnaire about risk behaviours related to HCV infection were tested for HCV infection using a qualitative HCV polymerase chain reaction (PCR) assay and genotyping by restriction fragment length polymorphism (RFLP). The detection was based on amplifying of the non-coding 5' region. Of the 119 patients, 95 showed positive results in the qualitative HCV test. History of surgery was the most reported risk factor, followed by the use of drugs, having tattoos, undergoing haemodialysis and occupational exposure. Genotype 1 was the most prevalent (46.9 percent), followed by genotype 3 (34.4 percent) and 2 (8.3 percent). The genotype distribution was similar for all of the various risk behaviours.

O vírus da hepatite C (VHC) é classificado em seis genótipos diferentes e sua distribuição é diferente em todo o mundo. Os estudos epidemiológicos são importantes para determinar várias características sobre o vírus, bem como da doença. Este estudo analisou a prevalência do VHC e seus genótipos em pacientes atendidos em hospital de referência no Ceará, o qual é localizado no nordeste do Brasil. Um total de 119 pacientes, os quais eram soropositivos anti-VHC, preencheram questionários sobre fatores de risco relacionados à infecção pelo VHC e foram testados quanto à infecção ao VHC usando o teste da reação da polimerase em cadeia (PCR) qualitativo para VHC e genotipagem por "restriction fragment length polymorphism" (RFLP). A detecção foi baseada na amplificação da região não codificante 5'. Dos 119 pacientes, 95 mostraram resultados positivos no teste qualitativo para VHC. A história prévia de cirurgia foi o fator de risco mais relatado, seguido pelo uso de drogas, ter tatuagem, ter sido submetido à hemodiálise e risco ocupacional. O genótipo 1 foi o mais prevalente (46,9 por cento), seguido pelo genótipo 3 (34,4 por cento) e 2 (8,3 por cento). A distribuição dos genótipos foi similar entre os vários fatores de risco analisados.

Características da reação tipo 1 e associação com vírus B e C da hepatite na hanseníase / Type 1 reaction in leprosy: characteristics and association with hepatitis B and C viruses

O episódio reacional tipo 1 ou reação reversa é ocorrência inflamatória aguda que atinge a pele e nervos periféricos, encontrada em até 30 por cento dos pacientes com hanseníase, sendo causa comum de incapacidade física. Fatores de risco associados incluem uso de poliquimioterapia e infecções virais. Neste estudo, foram avaliados 620 pacientes com hanseníase. Reação reversa foi diagnosticada em 121 (19,5 por cento) casos, sendo mais freqüente nos indivíduos borderlines (48 por cento). Início da poliquimioterapia foi considerado fator de risco para reação reversa, com 52 por cento dos casos apresentando o primeiro episódio neste momento. Neurite foi documentada em 73 por cento dos casos. A presença de vírus B ou C da hepatite foi documentada em 9 por cento de 55 pacientes com reação reversa e em nenhum dos 57 pacientes sem reação (p = 0, 026; teste exato de Fisher), sugerindo possível papel destes agentes como fatores de risco para desenvolvimento de reação reversa na hanseníase.

Type 1 reaction or reversal reaction is an acute inflammatory episode in the skin and peripheral nerves that is found in up to 30 percent of leprosy patients and commonly causes physical disabilities. Multidrug chemotherapy and viral infections are associated risk factors. In this study, 620 leprosy patients were evaluated. Reversal reactions were diagnosed in 121 cases (19.5 percent) and were most frequently found in borderline patients (48 percent). Starting on multidrug chemotherapy was considered to be a risk factor for reversal reaction: 52 percent of the cases presented their first episode at this time. Neuritis was found in 73 percent of the cases. The presence of hepatitis B or C virus was documented in 9 percent of the 55 patients with reversal reaction, while it was not detected in any of the 57 patients without reaction (p = 0.026, Fisher’s exact test). This suggests that these agents may have a role as risk factors for developing reversal reactions.

Determinación de la fibrosis y cirrosis hepática a través de un simple índice no invasivo en pacientes con hepatitis crónica por virus c

Objetivo: utilizar el índice APRI para la determinación de fibrosis significativa y cirrosis hepática en pacientes con hepatitis crónica por virus C. Pacientes y métodos: se realizó un estudio retrospectivo con 54 pacientes con hepatitis crónica por virus C, el diagnóstico fue establecido por ARN del virus C y parámetros bioquímicos y biopsia hepática. Resultados: de los 54 pacientes el 57% perteneció al sexo femenino, el promedio de edad fue de 41,7 años para el total de la muestra. La fibrosis leve (F1) predominó en un 28% siendo más frecuente en el sexo femenino. El índice APRI, reveló en nuestra muestra una sensibilidad de 52% y una especificidad de 17%, con un valor predictivo positivo de 54% y un valor predictivo negativo de 15% para la fibrosis significativa, y una sensibilidad de 29% con una especificidad de 17%, un valor predictivo positivo de 33% y un valor predictivo negativo de 14% para la cirrosis. Conclusión: el índice APRI fue más sensible para detectar la fibrosis pero con una baja especificidad, mientras que para la cirrosis es poco sensible y específico.

Objetive: to use APRI index for predicting significant hepatic fibrosis and cirrosis in patients with chronic hepatitis C infection.Patients and methods: a retrospective study was done with 54 patients who chronic hepatitis infection, the diagnosis was established by the presence of hepatitis C virus RNA, biochemical and liver biopsy parameters. Results: of 54 patients, 57% were female, the mean age was 41,7 years old. Mild fibrosis (F1) was more frequent with 28% in women. APRI index in our study had a sensitivity of 52% and specificity of 17%, positive predictive value of 54% and negative predictive value of 15% for significative fibrosis and a sensitivity of 29%, specificity of 17%, positive predictive value of 33% and negative predictive value of 14% for cirrosis. Conclusion: APRI index was more sensitivity for predicting fibrosis but with a low specificity whereas for cirrosis was less.

Chronic liver disease prevention strategies and liver transplantation / Estratégias de prevenção da doença hepática crônica e transplante de fígado

Chronic liver disease is a considerable burden on society, being one of the three main causes of death in certain regions of Africa and Asia. Liver transplant is the only treatment option for cirrhosis, which is the end stage of many chronic liver diseases. This article reviews the preventable causes of cirrhosis and the preventive strategies which could be implemented in order to avoid the catastrophic consequences of cirrhosis. With small variations around the world, 70 to 80 percent of the end stage liver diseases are caused by excessive alcohol consumption and by viral hepatitis, both of which are potentially preventable. Excessive alcohol consumption has important public health consequences because of its involvement not only with cirrhosis, but also with motor vehicle accidents, unemployment, domestic violence etc. Among the viral causes, Hepatitis Virus B and C have the greatest impact on public health. Effective vaccine is available for Hepatitis Virus B and must be put in use. While a vaccine for Hepatitis Virus C is awaited, effective preventive strategies should be undertaken to avoid the preventable cases of end stage liver disease.

As doenças hepáticas crônicas estão entre as três principais causas de morte na Africa e Asia.O transplante de fígado é o único tratamento curativo para esta doença hepática de caráter terminal.O presente artigo tem como objetivo apresentar as causas passíveis de prevenção de cirrose e as estratégias que podem ser utilizadas no sentido de preveni-las. Com pequenas variações ao redor do mundo, 70 a 80 por cento das doenças hepáticas terminais são causadas por consumo excessivo de álcool e por hepatites virais que são doenças passíveis de prevenção.O consumo excessivo de álcool é importante problema de saúde pública, pois envolve violência doméstica, acidentes de trânsito, além da possível evolução para cirrose e suas conseqüências. Entre as causas virais as hepatites pelo vírus B e C têm o maior impacto na saúde pública. Para a hepatite B já há vacinas disponíveis. Enquanto a vacina para a hepatite C é ainda aguardada, estratégias efetivas de prevenção devem ser efetuadas com o objetivo precípuo de se evitar, por conseqüência, casos de hepatopatias crônicas desta natureza.

Hepatocarcinoma: patología maligna de mal pronóstico / Hepatocarcinoma: malignant pathology with poor prognosis

El hepatocarcinoma es el tumor primario hepático más frecuente, cuyo pronóstico está ligado a la detección temprana. Su asociación con el daño hepatocelular producido por la infección crónica del virus de hepatitis B y C, obligan a establecer seguimientos estrictos en estos pacientes. Hasta el momento, el tratamiento quirúrgico mediante la resección completa del tumor ha demostrado ser la mejor alternativa con intención curativa para el hepatocarcinoma, sin embargo esta posibilidad está limitada a unos pocos pacientes, debido a la detección tardía de estos tumores, que en su inicio son indolentes y asintomáticos. De igual manera la coexistencia de enfermedad hepática crónica, contraindica en muchos casos la posibilidad de resección por el alto riesgo de falla hepática. En esta revisión se muestra la incidencia de este tumor en nuestro medio, mostrando su distribución, formas de presentación y características clínicas, con el fin de estimular su detección temprana y tratamiento.

The hepatocarcinoma is the most frequent primary hepatic tumor which prognostic is related to the early detection. The association between chronic hepatocellular damage by human hepatitis virus B and C, forces to establish strict follow up in these patients. Until now, the surgical treatment by means of the complete resection of the tumor has demonstrated to be the best alternative with healing intention for the hepatocarcinoma, however this possibility is limited to some few patients, due to the late detection of these tumors that are non-symptomatic in their beginning. In a same way the coexistence of chronic hepatic illness, contraindicates in many cases the resection possibility for the high risk of liver failure. In this revision, the incidence of this tumor is shown in our hospital, as well as its distribution, presentation forms and clinical characteristics, with the purpose of stimulating its early detection and treatment.