Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil

PROBLEM

The Brazilian population lacks equitable access to specialized health care and diagnostic tests, especially in remote municipalities, where health professionals often feel isolated and staff turnover is high. Telehealth has the potential to improve patients' access to specialized health care, but little is known about it in terms of cost-effectiveness, access to services or user satisfaction.

APPROACH

In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, intended to connect university hospitals with the state's remote municipal health departments; support professionals in providing tele-assistance; and perform tele-electrocardiography and teleconsultations. The network uses low-cost equipment and has employed various strategies to overcome the barriers to telehealth use.

LOCAL SETTING

The Telehealth Network connects specialists in state university hospitals with primary health-care professionals in 608 municipalities of the large state of Minas Gerais, many of them in remote areas.

RELEVANT CHANGES

From June 2006 to October 2011, 782,773 electrocardiograms and 30 883 teleconsultations were performed through the network, and 6000 health professionals were trained in its use. Most of these professionals (97%) were satisfied with the system, which was cost-effective, economically viable and averted 81% of potential case referrals to distant centres.

LESSONS LEARNT

To succeed, a telehealth service must be part of a collaborative network, meet the real needs of local health professionals, use simple technology and have at least some face-to-face components. If applied to health problems for which care is in high demand, this type of service can be economically viable and can help to improve patient access to specialized health care.

[Satisfaction scales with health care to cardiovascular diseases: CARDIOSATIS--patient and team]

Satisfaction is an important measure of quality care, of adherence to the treatment and adequate use of health services. The objective here is to build two scales which evaluates team' and patients' satisfaction with cardiovascular disease treatment provided through a distance telecardiology project. The procedure followed international standards for development of measure instruments, including operational definition of satisfaction contents and its area for evaluation; item definition; pre-test and pilot study. The literature review, focal groups and discussion with specialists had delimited the domains to be included in the scales and the elaboration of its items. The CARDIOSATIS-Team included 15 items and the CARDIOSATIS-Patient included 11. Satisfaction was measured through a five-point Likert scale. The scales' items comprised satisfaction with physical structure, human resources, capacity of resolution, attention and care offered by the service and the satisfaction with the received/given care. The scales also included open questions. CARDIOSATIS scales have showed to be an easy and accessible instrument very well accepted by medical team and patients. Preliminary results presented good characteristics of validity and reliability.

Cost-benefit of the telecardiology service in the state of Minas Gerais: Minas Telecardio Project

BACKGROUND

Telecardiology is a tool that can aid in cardiovascular care, mainly in towns located in remote areas. However, economic assessments on this subject are scarce and have yielded controversial results.

OBJECTIVE

To evaluate the cost-benefit of implementing a Telecardiology service in remote, small towns in the state of Minas Gerais, Brazil.

METHODS

The study used the database from the Minas Telecardio (MTC) Project, developed from June 2006 to November 2008, in 82 towns in the countryside of the state. Each municipality received a microcomputer with a digital electrocardiograph, with the possibility of transmitting ECG tracings and communicating with the on-duty cardiologist at the University hospital. The cost-benefit analysis was carried out by comparing the cost of performing an ECG in the project versus the cost of performing it by patient referral to another city.

RESULTS

The average cost of an ECG in the MTC project was R$ 28.92, decomposed into R$ 8.08 for the cost of implementation and R$ 20.84 for maintenance. The cost simulation of the ECG with referral ranged from R$ 30.91 to R$ 54.58, with the cost-benefit ratio being always favorable to the MTC program, regardless of the type of calculation used for referral distance. The simulations considered the financial sponsor's and society's points-of-view. The sensitivity analysis with variation of calibration parameters confirmed these results.

CONCLUSION

The implementation of a Telecardiology system as support to primary care in small Brazilian towns is feasible and economically beneficial, and can be used as a regular program within the Brazilian public health system.

Satisfação de médicos com o cuidado às doenças cardiovasculares em municípios de Minas Gerais: Escala Cardiosatis-EQUIPE

OBJETIVOS: Avaliar as qualidades psicométricas de validade e confiabilidade da Escala CARDIOSATIS-Equipe, elaborada especificamente para avaliar a satisfação dos médicos com o atendimento pré-hospitalar às doenças cardiovasculares em municípios participantes de um projeto em Telessaúde e mensurar a satisfação dos médicos antes e depois da implantação do Projeto. MÉTODO: Aplicação do instrumento na linha de base e pós-implantação de um sistema de telecardiologia em 82 municípios de Minas Gerais. O estudo das qualidades psicométricas da escala incluiu: Validade de construto, por meio de análise fatorial; Análise de consistência interna pelo Alfa de Cronbach; Correlação de Pearson entre os itens; Correlação de Spearman entre os domínios e a escala Global; e Validade discriminante. RESULTADOS: A análise fatorial por meio da extração de componentes principais indicou a distribuição dos itens da escala em dois fatores que explicaram 66,5% da variância dos escores de satisfação, identificados como Estrutura de atendimento e diagnóstico e Satisfação com o cuidado prestado. O coeficiente alfa de Cronbach mostrou valores elevados para a escala Global (0,92) e para os fatores (0,84). As correlações item-domínio e item-escala global também se mostraram adequadas, variando de 0,59 a 0,89 e de 0,73 a 0,85, respectivamente. A escala mostrou boa capacidade de discriminar os dois momentos da aplicação (antes e depois), mostrando um aumento significativo da satisfação dos médicos para a maioria dos itens avaliados pelo instrumento (p < 0,05). CONCLUSÃO: pode-se concluir com este estudo que a introdução do sistema de telecardiologia melhorou a satisfação dos profissionais avaliados e que a Escala CARDIOSATIS-Equipe é um bom instrumento para se mensurar a satisfação dos profissionais com o atendimento às DCV. As boas características de validade e confiabilidade da escala colaboram para sua utilização em outros estudos.

Prevalência de transtornos mentais comuns e fatores associados em uma população assistida por equipes do Programa Saúde da Família

OBJETIVO: Avaliar a prevalência de casos suspeitos de transtornos mentais comuns em uma população assistida por uma equipe do Programa Saúde da Família e investigar os fatores associados à ocorrência dessa morbidade. MÉTODOS: Pesquisa de levantamento, de corte transversal. A amostra, composta por 277 sujeitos, foi obtida por meio do método de amostragem aleatória do tipo sistemática. Para a coleta de dados, foram aplicados o Self Report Questionnaire (SRQ-20) e um questionário sociodemográfico. RESULTADOS: A prevalência global de casos suspeitos de transtornos mentais comuns na população alvo foi de 43,70%. O sexo feminino apresentou uma taxa de prevalência significativamente mais elevada (48,37%), quando comparado ao sexo masculino (34,41%). A variável "renda familiar" apresentou uma relação inversa com a prevalência de transtornos mentais comuns. A análise de regressão logística indicou que apenas as variáveis "uso de medicamento" e "renda familiar" estavam associadas significativamente à suspeita de casos de transtornos mentais comuns. CONCLUSÕES: Os resultados apontaram uma elevada prevalência de transtornos mentais comuns nessa população alvo, comparativamente aos dados de outros estudos semelhantes, indicando a necessidade de um cuidado especial por parte da Atenção Primária à Saúde, em particular para as famílias caracterizadas pelos fatores associados ao transtornos mentais comuns apontados nesta investigação.

[Contact precautions in intensive care units: facilitating and inhibiting factors for professionals' adherence]

The objective of this study was to identify facilitating and limiting factors for professionals' compliance with contact precautions in an intensive care unit of a general hospital. This cross-sectional study was performed from May to October 2007, using a semi-structured questionnaire for data collection. Participants were 102 professionals, as follows: nursing technician (54.9%), nurse (12.7%), preceptor physician (10.8%), apprentice physiotherapist (8.8%), preceptor physiotherapist (7.8%) and resident physician (4.9%). The limiting factors for compliance with hand cleansing were forgetting, lack of knowledge, distance from sink, skin irritation, and lack of materials. The use of scrubs presented the most difficulty (45%) because they were not available at the shower box, were inappropriately stored, and due to the heat and collective use. Glove use was the practice most easily conducted in everyday practice. Results show the need to implement precaution measures to minimize the dissemination of resistant microorganisms.

Implementation of a cardiology care program in remote areas in Brazil: influence of governability

INTRODUCTION

A telecardiology remote cardiology medical care system was implemented in 82 municipalities of Minas Gerais State, Brazil to support basic network services in the early diagnosis and management of cardiovascular diseases.

OBJECTIVE

To investigate the factors associated with the implementation of this program in the municipalities.

METHOD

This 2006 ecological study involved 393 candidate municipalities to implement the system. The municipalities were divided into two groups: non-random intervention (n = 82) and comparative (n = 311). The social, structure, healthcare needs, and governability indexes of the two groups of municipalities were compared by descriptive and multiple regression analysis using the generalized estimation equation model.

RESULTS

After fitting for other characteristics, participation of the municipalities in the intervention was associated with a higher social responsibility index (OR: 2.44, CI: 1.50-3.96) and lower healthcare needs (OR: 2.29, CI: 1.24-4.22).

CONCLUSION

Greater efforts by municipality management was the key to attracting and implementing the remote cardiology intervention, even when fitted for lower healthcare needs, which suggests greater municipal political and social engagement. This translated to improved access to cardiovascular health care for Brazilian rural and remote populations in the intervention municipalities.

Implementation of a telecardiology system in the state of Minas Gerais: the Minas Telecardio Project

BACKGROUND

Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed.

OBJECTIVE

To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns.

METHODS

A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses.

RESULTS

During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers.

CONCLUSION

The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Intensive care unit professionals' knowledge and behavior related to the adoption of contact precautions

This study aimed to assess the knowledge and behavior of professionals working in Intensive Care Units (ICU) related to the adoption of contact precautions for the control of hospital infections (HI). This cross-sectional study used a semi-structured questionnaire to collect data. Descriptive and multivariate analyses were carried out, including logistic regression and decision tree using CHAID algorithm. A total of 102 professionals participated in the study, of whom 36.3% presented appropriate knowledge and 51% appropriate behavior in relation to HI control measures. Nursing professionals had almost four times more chance (OR = 3.58, CI 1.48-8.68) of presenting appropriate behavior than the remaining professionals. The multivariate analysis did not reveal variables associated with knowledge. No statistically significant association was found between knowledge and behavior (p = 0.196). These results suggest the need to implement educational activities so as to permit a balance between theory and professionals' practice concerning HI preventive measures, aiming to improve knowledge and behavior.

Qualidade de vida de pacientes com esquizofrenia internados em hospital de custódia

OBJETIVO: Investigar a qualidade de vida (QV) de pacientes com o diagnóstico de esquizofrenia que cumprem medida de segurança em regime fechado. MÉTODOS: Estudo epidemiológico com delineamento transversal, realizado com pacientes de um hospital de custódia. As entrevistas foram conduzidas utilizando questionário sociodemográfico e a escala de qualidade de vida Quality of Life Scale (QLS-BR), específica para pacientes com diagnóstico de esquizofrenia. Foi realizada análise descritiva e multivariada. A associação entre os escores de QV e as características clínicas, sociodemográficas e do delito foi obtida por análise multivariada, através da árvore de decisão, por meio do algoritmo Chi-squared Automatic Interaction Detector (CHAID). RESULTADOS: Participaram deste estudo 54 pacientes, sendo 90,7% do sexo masculino, com a média de idade de 40 anos. Todos os domínios de qualidade de vida, inclusive o global, apresentaram escores compatíveis com uma QV muito baixa. O domínio ocupacional apresentou-se como o mais comprometido. Maior duração da doença, ter cometido homicídio e estar com idade superior a 40 anos foram as variáveis associadas a uma baixa qualidade de vida pela análise multivariada. CONCLUSÃO: Evidenciou-se uma baixa QV dos pacientes que cumprem medida de segurança em regime fechado, realidade que precisa ser modificada a partir da viabilização de mudanças nas políticas brasileiras.

Ordinal logistic regression models: application in quality of life studies

Quality of life has been increasingly emphasized in public health research in recent years. Typically, the results of quality of life are measured by means of ordinal scales. In these situations, specific statistical methods are necessary because procedures such as either dichotomization or misinformation on the distribution of the outcome variable may complicate the inferential process. Ordinal logistic regression models are appropriate in many of these situations. This article presents a review of the proportional odds model, partial proportional odds model, continuation ratio model, and stereotype model. The fit, statistical inference, and comparisons between models are illustrated with data from a study on quality of life in 273 patients with schizophrenia. All tested models showed good fit, but the proportional odds or partial proportional odds models proved to be the best choice due to the nature of the data and ease of interpretation of the results. Ordinal logistic models perform differently depending on categorization of outcome, adequacy in relation to assumptions, goodness-of-fit, and parsimony.

A putative gene located at the MHC class I region around the D6S105 marker contributes to the setting of CD8+ T-lymphocyte numbers in humans

Significant associations between human leucocyte antigen (HLA)-A and -B alleles and CD8+ T-lymphocyte numbers have been reported in the literature in both healthy populations and in HFE-haemochromatosis patients. In order to address whether HLA alleles themselves or alleles at linked genes are responsible for these associations, several genetic markers at the MHC class I region were typed on a population of 147 apparently healthy unrelated subjects phenotypically characterized for their CD8+ and CD4+ T-lymphocyte numbers. By using a machine learning approach, a set of rules was generated that predict the number of CD8+ T-lymphocyte numbers on the basis of the information of the D6S105 microsatellite alleles only. We demonstrate that the previously reported associations with HLA-A and -B alleles are due to the presence of common long (up to 4 megabases long) haplotypes that increased in frequency recently due to positive selection and that encompass a region where a putative gene contributing to the setting of CD8+ T lymphocytes is located, in the neighbourhood of microsatellite locus D6S105, in the 6p21.3 region.

Sensitivity and applicability of the Brazilian version of the Brief Assessment of Cognition in Schizophrenia (BACS)

Cognitive assessment in schizophrenia has traditionally used batteries that are long and complex or differ widely in their content. The Brief Assessment of Cognition in Schizophrenia (BACS) has been developed to cover the main cognitive deficits of schizophrenia as well as to be easily and briefly administered, portable, sensitive and reliable.

Objectives

To investigate the applicability and sensitivity of the Brazilian Version of the BACS (Brazilian-BACS).

Methods

Performance of 20 stable patients with schizophrenia on the Brazilian-BACS was compared to 20 matched healthy controls.

Results

Applying the Brazilian-BACS required 43.4±8.4minutes for patients and 40.5±5.7 minutes for controls (p=0.17). All tests demonstrated significant differences between controls and patients (P<0.01). Pearson's correlation analysis and Cronbach's a evidenced a high internal consistency for patient performance. The cognitive deficit in the patients was approximately 1.5 standard deviations below controls. These results were consistent with those reported in the validation of the original version and in meta-analyses of similar studies.

Conclusions

The Brazilian-BACS displayed good applicability and sensitivity in assessing the major cognitive constructs that are impaired in schizophrenia. Thus, the Brazilian-BACS seems to be a promising tool for assessing cognition in patients with schizophrenia in Brazil.

Depressão na esquizofrenia: prevalência e relação com a qualidade de vida

O objetivo deste estudo foi mensurar a prevalência de depressão na esquizofrenia, investigando os fatores associados e sua relação com a qualidade de vida. Foi conduzido um estudo transversal com 150 pacientes ambulatoriais, a depressão foi mensurada pela Escala Calgary de Depressão na Esquizofrenia e a qualidade de vida por meio da escala Quality of Life Scale-Brasil. Foi encontrada uma prevalência de 56% de depressão maior. Pacientes com depressão maior apresentaram pior qualidade de vida na escala global e domínio ocupacional. A qualidade de vida global foi importante para a separação dos grupos na árvore de decisão. Em pacientes com pior qualidade de vida, presença de sintomas da doença, número de medicamentos e ausência de atividades no lar se associaram à depressão, enquanto para aqueles com melhor qualidade de vida, apenas duração da doença foi importante. Esta investigação sugere alta prevalência de depressão, além de mostrar sua repercussão na qualidade de vida. Recomenda-se a investigação da depressão associada à qualidade de vida no cuidado terapêutico destes pacientes.

Does net energy cost of swimming affect time to exhaustion at the individual's maximal oxygen consumption velocity?

AIM

The purpose of the present study was to examine the relationship between time limit at the minimum velocity that elicits the individual's maximal oxygen consumption (TLim-v VO2max) and three swimming economy related parameters: the net energy cost corresponding to v VO2max (Cv VO2max), the slope of the regression line obtained from the energy expenditure (E) and corresponding velocities during an incremental test (C(slope)) and the ratio between the mean E value and the velocity mean value of the incremental test (C(inc)). Complementarily, we analysed the influence of Cv VO2max, C(slope) and C(inc) on TLim-v VO2max by swimming level.

METHODS

Thirty swimmers divided into 10 low-level (LLS) (4 male and 6 female) and 20 highly trained swimmers (HTS) (10 of each gender) performed an incremental test for v VO2max assessment and an all-out TLim-v VO2max test.

RESULTS

TLim-v VO2max, v VO2max, Cv fVO2max, C(slope) and C(inc) averaged, respectively, 313.8+/-63 s, 1.16+/-0.1 m x s(-1), 13.2+/-1.9 J x kg(-1) x m(-1), 28+/-3.2 J x kg(-1) x m(-1) and 10.9+/-1.8 J x kg(-1) x m(-1) in the LLS and 237.3+/-54.6 s, 1.4+/-0.1 m x s(-1), 15.6+/-2.2 J x kg(-1) x m(-1), 36.8+/-4.5 J x kg(-1) x m(-1) and 13+/-2.3 J x kg(-1) x m(-1) in the HTS. TLim-v VO2max was inversely related to C(slope) (r = -0.77, P < 0.001), and to v VO2max (r = -0.35, P = 0.05), although no relationships with the Cv VO2max and the C(inc) were observed.

CONCLUSIONS

The findings of this study confirmed exercise economy as an important factor for swimming performance. The data demonstrated that the swimmers with higher and v VO2max performed shorter time in TLim-v VO2max efforts.

Qualidade de vida e dimensão ocupacional na esquizofrenia: uma comparação por sexo

A esquizofrenia afeta desfavoravelmente a qualidade de vida dos pacientes, mas seu impacto pode variar de acordo com o sexo. Diferenças relatadas têm orientado o planejamento de intervenções específicas. O objetivo deste estudo foi investigar a qualidade de vida por sexo em pacientes com esquizofrenia, explorando o domínio ocupacional. Foi conduzido um estudo transversal com pacientes em acompanhamento ambulatorial, mensurando a qualidade de vida por meio da Quality of Life Scale (QLS-BR). Comparações dos escores de qualidade de vida foram feitas, seguidas de análises multivariadas usando a árvore de classificação (CHAID) e a regressão logística ordinal. Os resultados apontam melhor qualidade de vida para mulheres (p < 0,05). No domínio ocupacional, o estado civil apresentou-se como a variável mais relevante: mulheres e homens solteiros apresentaram baixa qualidade de vida quando comparados com os casados, respectivamente OR = 4,5 (IC95%: 1,2-16,6) e OR=10,0 (IC95%: 2,9-33,3). Duração da doença (> 5 anos) outro marcador importante, porém no modelo logístico esta variável associou-se à baixa qualidade de vida somente para os homens (OR = 3,2; IC95%: 1,1-9,0). Mulheres apresentaram melhor qualidade de vida, sugerindo maior envolvimento ocupacional, possivelmente resultante de uma maior demanda social e em atividades do lar.

Factors associated with low quality of life in schizophrenia

Interest in quality of life in mental health care has been stimulated by the deinstitutionalization of psychiatric patients as well as a parallel interest in understanding the scope of their daily lives. This study aims to investigate the socio-demographic and clinical variables related to low quality of life, using a cross-sectional design to evaluate quality of life by means of the QLS-BR scale. We interviewed a sample of 123 outpatients from a reference mental health center in Divinópolis, Minas Gerais State, Brazil, clinically diagnosed with schizophrenia. Univariate and multivariate logistic regression analyses were carried out. The results showed that low quality of life is associated with one or more of the following: male gender, single marital status, low income plus low schooling, use of three or more prescribed psychoactive drugs, psychomotor agitation during the interview, and current follow-up care. The study identifies plausible indicators for the attention and care needed to improve psychiatric patient treatment.

Time Limit and V·O2Slow Component at Intensities Corresponding to V·O2max in Swimmers

The purpose of this study was to measure, in swimming pool conditions and with high level swimmers, the time to exhaustion at the minimum velocity that elicits maximal oxygen consumption (TLim at vVO(2)max), and the corresponding VO(2) slow component (O(2)SC). The vVO(2)max was determined through an intermittent incremental test (n = 15). Forty-eight hours later, TLim was assessed using an all-out swim at vVO(2)max until exhaustion. VO(2) was measured through direct oximetry and the swimming velocity was controlled using a visual light-pacer. Blood lactate concentrations and heart rate values were also measured. Mean VO(2)max for the incremental test was 5.09 +/- 0.53 l/min and the corresponding vVO(2)max was 1.46 +/- 0.06 m/s. Mean TLim value was 260.20 +/- 60.73 s and it was inversely correlated with the velocity of anaerobic threshold (r = -0.54, p < 0.05). This fact, associated with the inverse relationship between TLim and vVO(2)max (r = -0.47, but only for p < 0.10), suggested that swimmers' lower level aerobic metabolic rate might be associated with a larger capacity to sustain that exercise intensity. O(2)SC reached 274.11 +/- 152.83 l/min and was correlated with TLim (r = 0.54), increased ventilation in TLim test (r = 0.52) and energy cost of the respiratory muscles (r = 0.51), for p < 0.05. These data suggest that O(2)SC was also observed in the swimming pool, in high level swimmers performing at vVO(2)max, and that higher TLim seems to correspond to higher expected O(2)SC amplitude. These findings seem to bring new data with application in middle distance swimming.

HFE, the MHC and hemochromatosis: paradigm for an extended function for MHC class I

HFE was discovered as the hereditary hemochromatosis (HH) gene. It is located on chromosome 6 (6p21.3), 4Mb telomeric to the HLA-A locus, and its product has a structure similar to MHC class I molecules. HFE encodes two frequent mutations: C282Y and H63D. One of these (C282Y) is present in a large proportion of Caucasian HH patients. HFE has a tissue distribution compatible with a role in iron absorption (intestine), recycling (macrophages) and transport to the fetus (placenta).

Comparative study of the two more frequent HFE mutations (C282Y and H63D): significant different allelic frequencies between the North and South of Portugal

An earlier study of reference values of iron parameters in Portugal showed significant differences between populations from northern and southern villages. This study addresses the question of the geographical distribution in Portugal of the two main mutations (C282Y and H63D) of the hereditary hemochromatosis gene, HFE. For that purpose, a stratified sample of 640 anonymous dried blood spot samples was randomly selected from the major regions of Portugal: North, Center, Lisbon and the Tagus Valley, Alentejo and Algarve. Differences in the geographical distribution of these two mutations were observed thus confirming the presumed differences between the age of the two mutations which is compatible with the postulated Celtic/Nordic origin of the C282Y mutation. The finding of a significantly higher allelic frequency of the C282Y mutation in the North (0.058) than in the South (0.009) could also point to an effect of differential selective forces acting in the different geographical areas of the country. Data on archaeological, ethnographic and linguistic records and on the North/South distribution of Portuguese cattle breeds of European or African origin have also been reported. In addition to their interest for population genetics, the results represent a reminder of the need to take into account regional differences in the design of strategies for population screening of hereditary hemochromatosis.

Clinical and genetic heterogeneity in hereditary haemochromatosis: association between lymphocyte counts and expression of iron overload

To identify a new marker of expression of disease, independent of HFE genotype in patients with hereditary haemochromatosis (HHC), the total peripheral blood lymphocyte counts were analysed according to iron status in two groups of subjects with HFE mutations. The groups consisted of 38 homozygotes for C282Y, and 107 heterozygotes for the C282Y or compound heterozygotes for C282Y and H63D. For control purposes, total lymphocyte counts and iron status were also examined in 20 index patients with African dietary iron overload, a condition not associated with HFE mutations, and in 144 members of their families and communities. Mean lymphocyte numbers were lower in C282Y homozygous HHC index subjects with cirrhosis and higher iron stores than in those without cirrhosis and with lower iron burdens [(1.65 +/- 0.43) x 10(6)/mL vs. (2.27 +/- 0.49) x 10(6)/mL; p = 0.008]. Similarly, mean lymphocyte counts were significantly lower in C282Y heterozygotes and C282Y/H63D compound heterozygotes with iron overload and increased serum ferritin concentrations compared to those with normal serum ferritin concentrations (p < 0.05). Statistically significant negative correlations were found, in males, between lymphocyte counts and the total body iron stores, either in C282Y homozygous HHC patients (p = 0.031 in a multiple regression model dependent on age) and in C282Y heterozygotes or C282Y/H63D compound heterozygotes with iron overload (p = 0.029 in a simple linear model). In contrast, lymphocyte counts increased with increasing serum ferritin concentrations among the index subjects with African iron overload (r = 0.324, not statistically significant) and among the members of their families and communities (r = 0.170, p = 0.042). These results suggest that a lower peripheral blood lymphocyte count is associated with a greater degree of iron loading in HFE haemochromatosis but not in African iron overload, and they support the notion that the lymphocyte count may serve as a marker of a non-HFE gene that influences the clinical expression of HFE haemochromatosis.