Reproductive health syndemics impact retention in care among women living with HIV in Rio de Janeiro, Brazil

ABSTRACT Syndemic psychosocial and reproductive factors affecting women's retention in HIV care remain understudied. We analyzed correlates of non-retention in a cohort of women with HIV in Brazil from 2000-2015. Participants self-reported exposure to physical/sexual violence, illicit drug use, adolescent pregnancy, or induced abortion. Lifetime history of these psychosocial stressors were used to create a syndemic score based on the presence or absence of these conditions. All dichotomous variables were summed (range 0 to 4), with greater scores indicating more syndemic factors experienced. Logistic regression models identified predictors of non-retention, defined as < 2 HIV viral load or CD4 results within the first year of enrollment. Of 915 women, non-retention was observed for 18%. Prevalence of syndemic factors was adolescent pregnancy (53.2%), physical/sexual violence (38.3%), induced abortion (27.3%), and illicit drug use (17.2%); 41.2% experienced > 2 syndemic conditions. Syndemic scores of 2 and 3 were associated with non-retention, as well as low education, years with HIV and seroprevalent syphilis. Psychosocial and reproductive syndemics can limit women's retention in HIV care. Syphilis infection predicted non-retention and could be explored as a syndemic factor in future studies.

Effects of glutamine alone or in combination with zinc and vitamin A on growth, intestinal barrier function, stress and satiety-related hormones in Brazilian shantytown children

OBJECTIVE: To determine the impact of supplemental zinc, vitamin A, and glutamine alone or in combination on growth, intestinal barrier function, stress and satiety-related hormones among Brazilian shantytown children with low median height-for-age z-scores. METHODS: A randomized, double-blind, placebo-controlled trial was conducted in children aged two months to nine years from the urban shanty compound community of Fortaleza, Brazil. Demographic and anthropometric information was assessed. The random treatment groups available for testing (a total of 120 children) were as follows: (1) glutamine alone, n = 38; (2) glutamine plus vitamin A plus zinc, n = 37; and a placebo (zinc plus vitamin A vehicle) plus glycine (isonitrogenous to glutamine) control treatment, n = 38. Leptin, adiponectin, insulin-like growth factor (IGF-1), and plasma levels of cortisol were measured with immune-enzymatic assays; urinary lactulose/mannitol and serum amino acids were measured with high-performance liquid chromatography. ClinicalTrials.gov: NCT00133406. RESULTS: Glutamine treatment significantly improved weight-for-height z-scores compared to the placebo-glycine control treatment. Either glutamine alone or all nutrients combined prevented disruption of the intestinal barrier function, as measured by the percentage of lactulose urinary excretion and the lactulose:mannitol absorption ratio. Plasma leptin was negatively correlated with plasma glutamine (p = 0.002) and arginine (p = 0.001) levels at baseline. After glutamine treatment, leptin was correlated with weight-for-age (WAZ) and weight-for-height z-scores (WHZ) (p≤0.002) at a 4-month follow-up. In addition, glutamine and all combined nutrients (glutamine, vitamin A, and zinc) improved the intestinal barrier function in these children. CONCLUSION: Taken together, these findings reveal the benefits of glutamine alone or in combination ...

Factors associated with thrombocytopenia in severe leptospirosis (Weil's disease)

OBJECTIVE: This study was conducted to investigate factors associated with thrombocytopenia in a large cohort of patients with leptospirosis in an endemic area. METHODS: This retrospective study included 374 consecutive patients with leptospirosis who were admitted to tertiary hospitals in Fortaleza, Brazil. All patients had a diagnosis of severe leptospirosis (Weil's disease). Acute kidney injury was defined according to the RIFLE criteria. Thrombocytopenia was defined as a platelet count <100,000/mm3. RESULTS: A total of 374 patients were included, with a mean age of 36.1±15.5 years, and 83.4% were male. Thrombocytopenia was present at the time of hospital admission in 200 cases (53.5%), and it developed during the hospital stay in 150 cases (40.3%). The patients with thrombocytopenia had higher frequencies of dehydration (53% vs. 35.3%, p = 0.001), epistaxis (5.7% vs. 0.8%, p = 0.033), hematemesis (13% vs. 4.6%, p = 0.006), myalgia (91.5% vs. 84.5%, p = 0.038), hematuria (54.8% vs. 37.6%, p = 0.011), metabolic acidosis (18% vs. 9.2%, p = 0.016) and hypoalbuminemia (17.8% vs. 7.5%, p = 0.005). The independent risk factors associated with thrombocytopenia during the hospital stay were lengthy disease (OR: 1.2, p = 0.001) and acute kidney injury (OR: 6.6, p = 0.004). Mortality was not associated with thrombocytopenia at admission (12.5% vs. 12.6%, p = 1.000) or during the hospital stay (12.6% vs. 11.3%, p = 0.748). CONCLUSIONS: Thrombocytopenia is a frequent complication in leptospirosis, and this condition was present in more than half of patients at the time of hospital admission. Lengthy disease and acute kidney injury are risk factors for thrombocytopenia. There was no significant association between thrombocytopenia and mortality. .

Zinc, vitamin A, and glutamine supplementation in Brazilian shantytown children at risk for diarrhea results in sex-specific improvements in verbal learning

OBJECTIVE: To identify the impact of supplemental zinc, vitamin A, and glutamine, alone or in combination, on long-term cognitive outcomes among Brazilian shantytown children with low median height-for-age z-scores. METHODS: A randomized, double-blind, placebo-controlled trial was conducted in children aged three months to nine years old from the urban shanty compound community of Fortaleza, Brazil. Demographic and anthropometric information was assessed. The random treatment groups available for cognitive testing (total of 167 children) were: (1) placebo, n = 25; (2) glutamine, n = 23; (3) zinc, n = 18; (4) vitamin A, n = 19; (5) glutamine+zinc, n = 20; (6) glutamine+vitamin A, n = 21; (7) zinc+vitamin A, n = 23; and (8) glutamine+zinc+vitamin A, n = 18. Neuropsychological tests were administered for the cognitive domains of non-verbal intelligence and abstraction, psychomotor speed, verbal memory and recall ability, and semantic and phonetic verbal fluency. Statistical analyses were performed using SPSS, version 16.0. ClinicalTrials.gov: NCT00133406. RESULTS: Girls receiving a combination of glutamine, zinc, and vitamin A had higher mean age-adjusted verbal learning scores than girls receiving only placebo (9.5 versus 6.4, p = 0.007) and girls receiving zinc+vitamin A (9.5 versus 6.5, p = 0.006). Similar group differences were not found between male study children. CONCLUSIONS: The findings suggest that combination therapy offers a sex-specific advantage on tests of verbal learning, similar to that seen among female patients following traumatic brain injury.

Valores positivos e desenvolvimento do adolescente: perfil de jovens paulistanos / Valores positivos y el desarrollo del adolescente: perfil de jóvenes paulistanos / Positive values and adolescent development: a profile in São Paulo city

A presente pesquisa é parte do projeto "Os valores positivos e o desenvolvimento do adolescente", que se iniciou com a adaptação cultural do questionário Search Institute Profiles of Student Life. Seu objetivo foi mapear valores positivos presentes em adolescentes paulistanos, visando gerar informações que permitam planejar ações de promoção de saúde para jovens, suas famílias e comunidades. O instrumento adaptado foi aplicado em 2725 jovens paulistanos, de 11 a 19 anos, de ambos os sexos, provenientes de todas as regiões da cidade de São Paulo, categorizados de acordo com o Índice Paulista de Vulnerabilidade Social. Os resultados indicaram a presença um número baixo de valores, diferenças associadas mais à idade e ao sexo do que ao IPVS e, principalmente, a necessidade de revisão de nossas estratégias de promoção de saúde, que poderiam basear-se no desenvolvimento de valores positivos.

This research is part of the project "The positive values and the adolescent development: from vulnerability to responsibility" that begun with the cultural adaptation of Search Institute Profiles of Student Life: Attitudes and Behaviors, an instrument that aims to access the developmental assets present in adolescents of specific groups, proven to be very useful as a base from where to start planning actions to promote better lives to communities, families and their children. The adapted form of the instrument has been applied in a sample of 2725 adolescents from all regions of SP City, males and females, from 11 to 19 years, categorized by their social vulnerability (IPVS, SEADE, 2005) to design a map of positive values present in this population. The data showed that young people present a low number of positive values and that its variability is linked to sex and age, more than to social vulnerability. It also turns evident the necessity to review our health promotion strategies based in risk taking behaviors and grounded it in the promotion of positive values.

La presente pesquisa es parte de lo proyeto "Los valores positivos y el desarrollo del adolescente" , que se ha iniciado com la adaptación cultural de lo instrumento Search Institute Profiles of Student Life. Lo objetivo fue mapear valores positivos presentes en jóvenes de la ciudad de São Paulo, para el desarrollo de acciones promotoras de salud para los jóvenes, sus famílias y comunidad. Lo instrumento adaptado fue aplicado a 2725 adolescentes, de 11 a 19 años, de ambos los sexos y en tres niveles de vulnerabilidad social: baja, mediana y alta. Los resultados han indicado la presencia de bajo número de valores positivos, diferencias más associadas a la edad y sexo y menos a la vulnerabilidad social y, especialmente, la necesidad de uma revisión de nuestras estratégias para la promoción de la salud, que podrían estar basadas en el desarrollo de valores positivos.

Clinical presentation and renal evaluation of human visceral leishmaniasis (kala-azar): a retrospective study of 57 patients in Brazil

Visceral leishmaniasis is an endemic disease caused by various species of Leishmania. We made a retrospective study of 57 consecutive patients with visceral leishmaniasis in Brazil. Patients with visceral leishmaniasis were identified using the registries of the São José Infectious Diseases Hospital. The sample was divided into two groups: patients with serum creatinine (Scr) <1.3mg/dL and Scr > 1.3mg/dL. We compared these two groups for differences in clinical manifestations and laboratory features. Patients' mean age was 28 ± 18 years old; 74 percent were male. The main clinical symptoms and signs presented in the initial evaluation were: fever (97 percent), splenomegaly (96.4 percent), weight loss (95.5 percent), pallor (93.6 percent), cough (89.7 percent), hepatomegaly (87.2 percent), asthenia (83.3 percent), anorexia (82.9 percent) and vomiting (73.9 percent). Acute renal failure was found in 15 patients (26.3 percent) and eight of these patients had ARF before amphotericin B administration. The mean age was higher in the group with Scr > 1.3mg/dL. Death occurred in three cases; all deaths occurred with Scr > 1.3mg/dL. There were no significant differences in the frequencies of the clinical symptoms and signs between the two groups. The laboratory data and demographic characteristics were significantly worse in the Scr > 1.3mg/dL group. Renal dysfunction is an important feature of this disease; it is associated with important morbidity and can increase mortality.

Aloimunidade contra antígenos HLA de classe I em pacientes com síndromes mielodisplásicas e anemia aplástica / Aloimmunity against HLA class I antigens in patients with myelodisplastic syndrome and aplastic anemia

As síndromes mielodisplásicas (SMD) e a anemia aplástica (AA) apresentam citopenias periféricas necessitando, com freqüência, de reposições transfusionais contínuas de concentrados de hemácias e/ou de concentrados de plaquetas. O objetivo do presente estudo foi verificar a ocorrência de anticorpos anti-HLA de classe I em pacientes portadores das SMD e AA atendidos no ambulatório de Hematologia do Hemoce/UFC. Foram analisados 110 pacientes, sendo 70 com SMD e 40 com AA. A pesquisa de anticorpos anti-HLA de classe I foi realizada frente a um painel (PRA), utilizando-se a técnica de microlinfocitotoxicidade dependente do complemento. Vinte (28,6 por cento) dos 70 pacientes com as SMD e 18 (45 por cento) dos 40 pacientes com AA desenvolveram anticorpos anti-HLA contra o PRA. Esses pacientes que receberam uma carga de antígenos estranhos advindos de múltiplas transfusões de vários doadores de CH e/ou CP, geralmente desenvolvem aloanticorpos contra os antígenos HLA presentes na superfície das plaquetas e dos leucócitos que contaminam esses concentrados. A produção desses anticorpos pode trazer sérias complicações para o tratamento dos pacientes com SMD e AA. As avaliações sistemáticas para detecção de anticorpos anti-HLA após a reposição transfusional podem ser valiosas para adoção de estratégias transfusionais mais adequadas para esta população de pacientes.

Patients with myelodysplastic syndromes (MDS) or aplastic anemia (AA) present peripheral cytopenias and require continuous transfusions of red cell and/or platelet concentrates. The objective of this study is to verify the existence of anti-HLA class 1 antibodies in patients with MDS and AA treated at the hematology Out patient Clinic of Hemoce/UFC. A total of 110 patients were analyzed, 70 with MDS and 40 with AA. Anti-HLA class 1 antibody detection was achieved with an antibody reactivity panel using the complement-dependent microlymphocytotoxicity technique. A total of 20 (28.6 percent) of the 70 patients with MDS and 18 (45 percent) of the 40 patients with AA developed anti-HLA antibodies against the antibody panel. In general, patients who received a load of foreign antigens originating from multi-donor red cell and platelet concentrate transfusions, developed alloantibodies against the HLA antigens that exist on the surface of platelets and on white blood cells that contaminate these concentrates. The production of these antibodies may cause serious complications in the treatment of MDS and AA patientss.

Valores positivos e desenvolvimento do adolescente: uma perspectiva dos pais / Positive values and adolescent development: a parents' perspective

A presente pesquisa é parte do projeto Os valores positivos e o desenvolvimento do adolescente. Foi planejada com o objetivo de compreender se os valores que os pais julgavam importante transmitir aos adolescentes, estavam em consonância com aqueles propostos pelo Questionário Profiles of Student Life: Attitudes and Behaviors. Para tanto, os pais foram questionados sobre o que julgavam importante transmitir aos filhos, as estratégias utilizadas e os resultados esperados e percebidos. Foram realizadas entrevistas semi-estruturadas com mães e pais paulistanos, categorizados de acordo com seu índice de vulnerabilidade social. Os resultados indicaram que os valores que os pais buscavam transmitir aos adolescentes estavam em consonância com aqueles propostos pelo referido questionário. Utilizando-se de estilos parentais classificados como democráticos e/ou autoritários, os pais avaliaram haverem sido bem sucedidos como educadores, posição esta que se refletiu na imagem positiva que ofereceram dos filhos. Os resultados também evidenciaram que, além da família, independentemente de seu índice de vulnerabilidade social, faz-se necessário o envolvimento da comunidade no processo de desenvolvimento de estratégias que visam a promover valores positivos nos jovens.

Células dendríticas foliculares: imunofenotipagem no linfoma de Hodgkin clássico esclerose nodular / Dendritic follicular cells: immunophenotyping in classic Hodgkin's lymphoma nodular sclerosis

O linfoma de Hodgkin clássico esclerose nodular (LHCEN), de origem linfóide da célula B do centro germinativo (CG), apresenta agregados de células dendríticas foliculares (CDF), célula Hodgkin/Reed Sternberg e variantes, células B formando complexos relacionados ao CG, sugerindo uma associação entre esclerose nodular e formação do centro germinativo. O objetivo desse estudo foi avaliar a célula dendrítica folicular, por imunofenotipagem com o anticorpo fascina, em biópsia de linfonodo periférico ou massa do mediastino de pacientes com LHCEN previamente diagnosticados, procurando identificar critérios como fatores prognósticos. Foram selecionados 38 pacientes, 55,2 por cento do sexo masculino com relação M:F de 1,23: 1 e a idade com média de 29,3 anos; 52,6 por cento em estádios clínicos I-II, sendo 68,4 por cento com sintomas B. Foram analisados 38 espécimes de biópsias, sendo 57,9 por cento do subtipo esclerose nodular II. O estudo imuno-histoquímico mostrou 100 por cento de positividade para o CD30 e 68,4 por cento para o CD15. As CDFs foram identificadas pelo anticorpo fascina, considerado padrão-ouro, através da técnica imunoenzimática indireta peroxidase-anti-peroxidase estreptavidina-avidina-biotina (PAP-Strept ABC), realizada em lâminas pré-tratadas do material de biópsia incluído em blocos de parafina. Foi evidenciado padrão CDF1 em 7,9 por cento, CDF2 em 47,4 por cento e CDF3 em 44,7 por cento. Não houve relação entre a presença da CDF e sexo, idade, estádio clínico e resposta ao tratamento, mas foi demonstrada uma tendência para associação (p=0,056) entre CDF os subtipos LHCEN. Os pacientes com presença de célula dendrítica folicular foram acompanhados por maior período, com média de 32,9 meses, com associação estatisticamente significativa (p=0,001).

Classic nodular sclerosis HodgkinÆs lymphoma (CNSHL) is a lymphoid neoplasm of germinal center (GC) B cells, presenting with aggregates of follicular dendritic cells (FDC), Hodgkin/Reed Sternberg cells and variants and B cells forming complexes related to the GC. This suggests an association between nodular sclerosis and GC formation. The goal of this study was to evaluate the follicular dendritic cells by immunophenotyping with fascin from lymph node or mediastinal mass biopsies of patients previously diagnosed as having CNSHL, in order to attempt to identify criteria as prognostic factors. Thirty-eight patients were selected. A total of 55.2 percent were male with a M:F ratio of 1.23:1 and a mean age of 29.3 years. 52.6 percent were in clinical stage I-II and 68.4 percent had symptoms B. Thirty-eight biopsy specimens were analysed and 57.9 percent were nodular sclerosis II. Immuno­phenotyping showed 100 percent positivity for CD30 and 68.4 percent for CD15. The FDC were identified by fascin, using the peroxidase-antiperoxidase streptavidin-avidin-biotin indirect immuno­enzimatic technique, which was performed on pre-treated slides with the biopsy specimens embedded in paraffin blocks. Fascin was considered to be the gold-standard. The CDF1 pattern was present in 7.9 percent, CDF2 in 47.4 percent and CDF3 in 44.7 percent. There was no association between the presence of the FDC and gender, age, clinical stage, response to treatment, but a tendency for association (p=0.056) between the subtypes of CNSHL. Patients with FDC present in their biopsies were followed up for a longer period of time - about 32.9 months. This enabled a significant statistical association (p=0.001) between the presence of FDC and length of follow-up.

Comparison of sweat rate during graded exercise and the local rate induced by pilocarpine

Centrally stimulated sweat rate produced by graded exercise until exhaustion was compared to the local sweat rate induced by pilocarpine, often used as a sweating index for healthy individuals. Nine young male volunteers (22 ± 4 years) were studied in temperate environment in two situations: at rest and during progressive exercise with 25 W increases every 2 min until exhaustion, on a cycle ergometer. In both situations, sweating was induced on the right forearm with 5 ml 0.5 percent pilocarpine hydrochloride applied by iontophoresis (1.5 mA, 5 min), with left forearm used as control. Local sweat rate was measured for 15 min at rest. During exercise, whole-body sweat rate was calculated from the body weight variation. Local sweat rate was measured from the time when heart rate reached 150 bpm until exhaustion and was collected using absorbent filter paper. Pharmacologically induced local sweat rate at rest (0.4 ± 0.2 mg cm-2 min-1) and mean exercise-induced whole-body sweat rate (0.4 ± 0.1 mg cm-2 min-1) were the same (P > 0.05) but were about five times smaller than local exercise-induced sweat rate (control = 2.1 ± 1.4; pilocarpine = 2.7 ± 1.2 mg cm-2 min-1), indicating different sudorific mechanisms. Both exercise-induced whole-body sweat rate (P < 0.05) and local sweat rate (P < 0.05) on control forearm correlated positively with pilocarpine-induced local sweat rate at rest. Assuming that exercise-induced sweating was a result of integrated physiological mechanisms, we suggest that local and whole-body sweat rate measured during graded exercise could be a better sweating index than pilocarpine.