Detection and quantification of hepatitis E virus in the absence of IgG and IgM anti-HEV in HIV-positive patients.

AIMS: To improve RT-qPCR with an internal control and a synthetic standard curve to detect HEV in HIV co-infected patients. METHODS AND RESULTS: A single-stranded RNA (ssRNA) and a double-stranded DNA (dsDNA) synthetic curve were designed, compared to the international reference panel for HEV genotypes, and tested to quantify and detect a reference panel for HEV genotypes. The detection limit of the RNA synthetic curve (50 copies per ml) was better than the DNA synthetic curve (100 copies per ml) and the WHO standard curve (250 copies per ml). Then, 280 serum samples from HIV-positive patients were tested for HEV RNA, which was detected in 3·6% of serum samples. The viral load ranged from 2 × 102 copies per ml to 4·78 × 108 copies per ml. HEV IgM/IgG antibodies were not detected in the RNA-positive patients. Sequencing analysis of HEV showed that the virus belongs to genotype 3 (HEV GT3). CONCLUSIONS: Real-time PCR was a useful tool to estimate co-infection with HEV/HIV, even in patients with low viral loads and undetectable anti-HEV IgG and IgM antibodies. SIGNIFICANCE AND IMPACT OF THE STUDY: Hepatitis E virus genotype 3 (HEV GT3) has been associated with silent chronic hepatitis and cirrhosis in HIV-positive subjects worldwide, but there is a lack of data on this co-infection in Brazil.

Identification of skin lesions through aminolaevulinic acid-mediated photodynamic detection.

Non-melanoma skin cancer is the most common cancer lesion worldwide. In Brazil, it represents 95% of all skin cancer lesions, and 25% of all tumor types. Early diagnosis allows treatment at initial stages of the disease, improving patient's prognosis. Thus, it is of great importance the development of techniques to aid diagnosis, such as marked fluorescence, which we propose here for early detection of skin cancer lesions. In this study, we use a photosensitive substance, aminolaevulinic acid (ALA), as biomarkers, and analyze its in situ fluorescence response to light excitation. The use of ALA as a biomarker precursor is interesting because it shows selectivity for protoporphyrin IX production/concentration in abnormal cells. Protoporphyrin IX shows high fluorescence yield when excited with UV-blue light. In this study, ALA solutions (at 5% and 10% concentrations) were applied to malignant (basal cell carcinoma) and potentially malignant skin lesions (actinic and seborrheic keratoses), aiming to investigate our ability in detecting and distinguishing them by using this technique. At regular time intervals (15, 30, 45 and 60min), fluorescence images were collected with a prototype system for widefield fluorescence imaging. ALA has provided a marked fluorescence that allowed significant discrimination of normal and tumor. Potentially malignant and benign lesions were all well-identified by their autofluorescence; photodynamic detection did not improve diagnostics. This technique also provided a better delineation of the lesion margins, which is very important for an effective treatment of malignant, potentially malignant and benign skin lesions.

O significado dos olhos nas representações sociais de clientes transplantados de córnea e suas implicações para o cuidado de si

Objetivou-se identificar o significado dos olhos nas representações sociais de clientes transplantados de córnea e suas implicações para o cuidado de si. Tratase de uma pesquisa descritiva qualitativa, adotando a Teoria das Representações Sociais na perspectiva de Moscovici. Fizeram parte deste estudo, 15 clientes submetidos a transplantes de córnea e que se encontravam em acompanhamento no Consultório de Oftalmologia do Ambulatório do Hospital Ophir Loyola, em Belém, PA. Os depoentes atribuíram significados diversos aos seus olhos, substanciados por sentimentos de tristeza e insatisfação, que contribuíram para mudanças significativas no cuidado de si. Há necessidade de se cogitar sobre o compromisso do enfermeiro com o cliente transplantado de córnea que, muitas vezes, encontra-se fragilizado, necessitando de um olhar mais atento...

The aim of this study was to identify the meaning of the eyes of customers in the social representations of corneal transplant and its implications for self-care. It is a descriptive and qualitative study, adopting the Social Representation Theory in the context of Moscovici. The sample comprised 15 clients who underwent corneal transplantation and were followed up in the office of the Ophthalmology Clinic of the Ophir Loyola Hospital, in Belem, Pará. The respondents attributed different meanings to their eyes; substantiated by feelings of sadness and dissatisfaction, that contributed to significant changes in self-care. There is need to think about the commitment of the nurse with the client cornea transplant, which often is fragile, requiring a closer look...

El objetivo fue identificar el significado de los ojos de los clientes en las representaciones sociales de trasplante de córnea y sus implicaciones para el autocuidado. Se trata de un estudio descriptivo cualitativo, adoptando laTeoría de las Representaciones Sociales en el contexto de Moscovici. La muestra es compuesta por 15 clientes que se sometieron a trasplante de córnea que se siguió en la oficina de la Clínica de Oftalmología del Hospital Ophir Loyola, en Belem, Pará. Los encuestados atribuyen diferentes significados a sus ojos, motivada por sentimientos de tristeza e insatisfacción, que han contribuido a cambios significativos en el auto-cuidado. Hay que pensar en el compromiso de la enfermera con el trasplante de cornea del cliente, que a menudo es frágil, lo que requiere una mirada más cercana...

[Treatment of HCV-associated cryoglobulinemic glomerulonephritis]. / Terapia della glomerulonefrite secondaria a crioglobulinemia HCV-correlata.

HCV-related membranoproliferative glomerulonephritis is the most common cause of hepatitis C-associated renal disease. Its treatment is still under debate and based on scant experimental evidence. The recommended therapeutic strategy depends on the severity of the kidney disease. The first-line treatment for patients with mild to moderate clinical and histological kidney damage is antiviral therapy with pegylated interferon alpha and ribavirin for 48 weeks combined with symptomatic treatment (diuretics, angiotensin converting enzyme inhibitors and angiotensin receptor blockers). In case of severe renal involvement (nephrotic syndrome, nephritic syndrome and/or progressive renal failure, high activity score of glomerulonephritis on light microscopy), the initial treatment may consist of sequential administration of immunosuppressive therapies (plasmapheresis, corticosteroids and cyclophosphamide) and antiviral agents, although no definitive data are yet available from the literature. B-cell depleting agents such as rituximab may be an alternative to conventional therapy in refractory or intolerant patients. Large randomized and controlled clinical trials are needed to establish guidelines for the treatment of HCV-related cryoglobulinemic glomerulonephritis.

Intrahepatic cholestatic jaundice related to administration of ranitidine. A case report with histologic and ultramicroscopic study.

Ranitidine may cause liver injuries ranging from transient, subclinical serum transaminases increase every 100-1,000 treated patients to cholestatic hepatitis in less than 1/100,000. Other H2-receptor antagonists are more dangerous: 11 toxic hepatitis cases have been reported as adverse effect after 1 year of marketed ebrotidine. A 75-year-old male with ischemic cardiopathy history was started on an 8 days treatment of oral ranitidine due to pirosis, without any other changes of therapy; 48 h after drug withdrawal, light-coloured stools, dark urine and icteric scleras developed. On hospital admission, 10 days later, physical examination showed slight hepatomegaly and severe jaundice with skin excoriations followed by serum mixed bilirubin further increase and aminotransferases activities mild rise. Total bilirubin peaked at 381.33 mmol/l (5.1-17.1) and progressively returned to normal, after discharge home, in 3 months and now, 1 year later, there is no sign of liver disease. Ultrasonographic biliary anomalies and the most frequent causes of liver damage were excluded. Liver biopsy confirmed ranitidine as the most likely cause of liver toxicity since histological and ultramicroscopical study revealed a drug-induced picture. We report a rare case of intrahepatic cholestasis jaundice related to ranitidine, a widely used drug. Diagnosis would need an ethically unacceptable rechallange test.

[Acute severe pancreatitis caused by anti-HIV drugs]. / Pancreatite acuta grave da farmaci anti-HIV.

Acute pancreatitis in patients with HIV infection is infrequent and often not recognized. Autopsies performed on patients died for different pathologies show pancreatic lesions approximately in 50% of cases. The etiological factors associated with acute pancreatitis are related to HIV infection and particularly to drugs used to treat the syndrome or to prevent opportunistic infections. We report a case in a 38 years old male patient with AIDS without risk factors for acute pancreatitis in which the disease developed while taking Stavudine, Lamivudine and Indinavir. His conditions improved with intensive medical therapy. The subsequent medical course became complicated. The patient died after 75 days for severe abdominal haemorrhage. A review of the literature reports several cases of A.P. in HIV patients mainly related to opportunistic infections. Many authors regard the medical treatment of HIV syndrome as etiological factor but a casual relationship was never demonstrated. The aim of the present paper is to underline that besides Lamivudine also Stavudine and Indinavir might be related to acute pancreatitis. Clinical and laboratory investigations in HIV patients are therefore indicated for an earlier diagnosis and treatment.

[The role of surgery in the treatment of appendicular abscesses]. / Il ruolo della chirurgia nel trattamento degli ascessi appendicolari.

The management of appendiceal abscesses is still discussed and many different approaches are nowadays adopted. The aim of this study was to analyze retrospectively our experience with this disease to value the results of drainage of the abscess and appendectomy in one stage in presence of appendiceal abscesses. We studied 44 patients consecutively observed in our Department of General Surgery all submitted to drainage of the abscess and appendectomy for acute appendicitis with periappendiceal abscess. Preoperative ultrasonography showed an accuracy of 85.7% in detecting the presence of an abscess. Mean size of the abscesses were 5 cm (from a minimum of 3 cm to a maximum of 9 cm). The mean duration of surgical operation was 48 minutes (min 35'-max 95'), with a mean in-hospital stay of 6.2 days. Morbidity rate was 9% and was due in 75% of cases to wound infection and in 25% of cases to wound dehiscence. Neither major morbidity nor mortality were observed. In consideration of the results the authors conclude that even in presence of an appendiceal abscess, appendectomy with abscess drainage is not only a safe operation with a low morbidity rate but the procedure of choice allowing a significative reduction of hospitalization and health cost.

[Fistulectomy with closure by first intention in the treatment of perianal fistulae]. / La fistulectomia con chiusura per prima intenzione nel trattamento delle fistole perianali.

The authors report in a retrospective study their experience in the treatment of anal fistulas suggesting the total exercises of the fistula with primary closure of external and internal anal sphincters and rectal mucosa. In our department of surgery between 1987 and 1993, 36 patients (22 males and 14 females) with anal fistulas (17 intersphincteric, 15 trans-sphincteric and suprasphincteric) were treated with this technique. Postoperative in-hospital stay ranged between 2 and 5 days (mean 3.1) and surgical healing needed 12-15 days. A dehiscence of distal tract was observed in 3 cases (8.2%). in these cases secondary closure of the wound needed 24-28 days. All the patients controlled at follow-up (it lasted at least 1 year) did not show rectal incontinence for gas or stools. The authors conclude that total exeresis with primary closure is a safe procedure indicated in the treatment of anal fistula not associated to inflammatory bowel disease in consideration of earlier healing and minor costs.

[Trends in the incidence of acute appendicitis in Italy during the past 30 years]. / Andamento dell'incidenza dell'appendicite acuta in Italia negli ultimi 30 anni.

The incidence and mortality rate of acute appendicitis for the years 1955 and 1987 were calculated on the basis of data used by ISTAT. In 1955 the incidence was 5.7 per 1000 whereas in 1987 this had fallen to 3.7 per 1000. In both years examined there was a prevalence of females (in 1987 females accounted for 4.3 per 1000 in comparison to 3 per 1000 recorded for for males). In 1987 the lowest incidence was recorded in the over 60 years olds, whereas the highest incidence was in males between 1 and 14 years old (7.57 per 1000) and females between 15 and 24 years old (12.17 per 1000). Mortality diminished from 0.42% in 1955 to 0.05% in 1987. The highest rate of mortality was recorded in those patients over 60 years old (1.5%).

Primary sclerosing cholangitis: an analysis of 37 retrospective cases.

The clinical and laboratory findings of 37 patients with primary sclerosing cholangitis (PSC) were reviewed. Mean age was 43.8 years, sex ratio between males and females was 3:1; IBD was present in 91% of patients with 51% having ulcerative colitis, 23% unclassified colitis and 17% Crohn's disease. Twenty-seven patients (73%) were symptomatic presenting most commonly with fatigue, pruritus and hepato-splenomegaly. Cholangiography revealed abnormalities affecting both extrahepatic and intrahepatic biliary ductal systems in 51.8% of cases, and only the intrahepatic or extrahepatic biliary tree, respectively in 11.1% and in 37% of cases. The last prevalence was very high compared with that previously known. Clinical and biochemical data, when compared between asymptomatics and symptomatics, demonstrated a significant difference only for alkaline phosphatase which increased in the symptomatic group and for prothrombin activity which decreased among symptomatic patients. Nevertheless, predictive value of sALP for the presence of PSC was high when pts were pooled together with a randomly selected group of 36 non-affected persons that underwent ERCP for suspected primary sclerosing cholangitis: sensitivity was 94% and specificity 78%.