Incidence and risk factors for osteoporotic non-vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing and Health (SPAH) study

We ascertained the incidence of non-vertebral fracture in a low-income Brazilian elderly cohort. To the best of our knowledge, this is the first population-based study to demonstrate the frequency of non-vertebral fracture in elderly Latin Americans. Age, prior fracture, and bone mineral density (BMD) at hip were predictors of fracture.

INTRODUCTION

No data on incidence of osteoporotic non-vertebral fracture have been reported in low-income countries where the population's aging has been faster. Even in developed countries, currently available prospective data on major fracture rates beyond hip are scarce. The aim of this study is to describe the incidence and risk factors for non-vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

Seven hundred seven older adults (449 women, 258 men) were evaluated at baseline and after a mean follow-up of 4.3 ± 0.8 years. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. New non-vertebral fracture (hip, proximal humerus, rib, forearm) was determined during the follow-up. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of non-vertebral fracture was 1562.3/100,000 (1085.7-2248.1/100,000) person-years (pyr) in women and 632.8/100,000 (301.7-1327.3/100,000) in men. Concerning to hip fractures, the incidence was 421.2/100,000 (210.7-842.3/100,000) pyr in women and 89.9/100,000 (12.7-638.5/100,000) in men. In a multivariate analysis, age (RR 2.07, 95% CI 1.13-3.82, p = 0.019, each 10-year increase), prior non-vertebral fracture (RR 3.08, 95% CI 1.36-6.95, p = 0.007), and total hip BMD (RR 1.68, 95% CI 1.11-2.56, p = 0.015, each 1 SD decrease) were predictors of new non-vertebral fracture. In men, fitting a model of risk factors for fracture was prevented by the limited number of events in male sample.

CONCLUSION

This is the first population-based study to ascertain the incidence of major non-vertebral fractures in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, and hip BMD were predictors of the short-term incidence of fracture.

Anti-inflammatory effects of essential oils from Mangifera indica

Mangifera indica is widely found in Brazil, and its leaves are used as an anti-inflammatory agent in folk medicine. The aim of this study is to perform composition analysis of essential oils from the M. indica varieties, espada (EOMIL1) and coração de boi (EOMIL2), and confirm their anti-inflammatory properties. Twenty-three volatile compounds were identified via gas chromatography-mass spectrometry (GC-MS) in two essential oils from the leaves. Paw edema and myeloperoxidase (MPO) activity were evaluated using the carrageenan-induced paw model, while leukocyte migration was analyzed using the pleurisy model. At oral doses of 100 and 300 mg/kg, the essential oils significantly reduced edema formation and the increase in MPO activity induced by carrageenan in rat paws. For a dose of 300 mg/kg EOMIL1, 62 ± 8% inhibition of edema was observed, while EOMIL2 led to 51 ± 7% inhibition of edema. At a dose of 100 mg/kg, the inhibition was 54 ± 9% for EOMIL1 and 37 ± 7% for EOMIL2. EOMIL1 and EOMIL2 significantly reduced MPO activity at doses of 100 mg/kg (47 ± 5 and 23 ± 8%, respectively) and 300 mg/kg (50 ± 9 and 31 ± 7%, respectively). In the pleurisy model, inhibitions were also observed for EOMIL1 and EOMIL2 in the leukocyte migration test. The results of the present study show that essential oils from M. indica differ in chemical composition and anti-inflammatory activity in rats.

Visceral fat measured by DXA is associated with increased risk of non-spine fractures in nonobese elderly women: a population-based prospective cohort analysis from the São Paulo Ageing & Health (SPAH) Study

The present study investigates the relationship between visceral fat measured by dual-energy X-ray absorptiometry (DXA) and the incidence of non-spine fractures in community-dwelling elderly women. We demonstrated a potential negative effect of visceral fat on bone health in nonobese women.

INTRODUCTION

The protective effect of obesity on bone health has been questioned because visceral fat has been demonstrated to have a deleterious effect on bone. The aim of this study was to investigate the association of visceral fat measured by DXA with the incidence of non-spine fractures in community-dwelling elderly women.

METHODS

This longitudinal prospective population-based cohort study evaluated 433 community-dwelling women aged 65 years or older. A specific clinical questionnaire, including personal history of a fragility fracture in non-spine osteoporotic sites, was administered at baseline and after an average of 4.3 years. All incidences of fragility fractures during the study period were confirmed by affected-site radiography. Visceral adipose tissue (VAT) was measured in the android region of a whole-body DXA scan.

RESULTS

The mean age was 72.8 ± 4.7 years, and 28 incident non-spine osteoporotic fractures were identified after a mean follow-up time of 4.3 ± 0.8 years. According to the Lipschitz classification for nutritional status in the elderly, 38.6 % of women were nonobese (BMI ≤ 27 kg/m²) and 61.4 % were obese/overweight. Logistic regression models were used to estimate the relationship between VAT and non-spine fractures in elderly women. After adjusting for age, race, previous fractures, and BMD, VAT (mass, area, volume) had a significant association with the incidence of non-spine fractures only in nonobese elderly women (VAT mass: OR, 1.42 [95 % CI, 1.09-1.85; p = 0.010]; VAT area: OR, 1.19 [95 % CI, 1.05-1.36; p = 0.008]; VAT volume: OR, 1.40 [95 % CI, 1.09-1.80; p = 0.009]).

CONCLUSION

This study suggests a potential negative effect of visceral adiposity on bone health in nonobese women.

Associations between OPG and RANKL polymorphisms, vertebral fractures, and abdominal aortic calcification in community-dwelling older subjects: the Sao Paulo Ageing & Health Study (SPAH)

This is the first study analyzing concomitantly osteoprotegerin (OPG)/receptor activator of nuclear factor kappa B ligand (RANKL) polymorphisms and OPG/RANKL serum levels and their association with bone mineral density (BMD), vertebral fractures, and vascular aortic calcification in a cohort of 800 subjects in community-dwelling older individuals.

INTRODUCTION

Osteoprotegerin (OPG) and RANKL play an important role in osteoclast activation and differentiation as well as in vascular calcification. At present, there are no studies of OPG or RANKL gene polymorphisms in Brazilian older populations. The aim of this study was to evaluate OPG/RANKL polymorphism and their association with vertebral fractures (VFs) and aortic calcification.

METHODS

Eight hundred subjects (497 women/303 men) were genotyped for the OPG 1181G>C (rs2073618), 163C>T (rs3102735), 245T>G (rs3134069), and 209G>A (rs3134070) and RANKL A>G (rs2277438) single-nucleotide polymorphisms (SNPs). VFs were evaluated by spine radiography (Genant's method). Aortic calcification was quantified using Kauppila's method.

RESULTS

The isolated genotype analyses and single-allele frequency data showed association of OPG 163C, 245G, and 209A alleles with presence of VFs (P < 0.05). Multiple logistic regression of subjects with absence of VFs vs. those with VFs (grades II/III) revealed only OPG 209A homozygosity as a risk factor for higher-grade VFs (odds ratio (OR) = 4.17, 95 % CI 1.03-16.93, P = 0.046). Regarding aortic calcification, the isolated genotype analysis frequency data revealed a significant association of OPG 1181G, 163C, 245G, and 209A alleles with absent aortic calcification (P < 0.05). Multiple logistic regression data confirmed that the OPG 209A allele was protective for aortic calcification (OR = 0.63, 95 % CI 0.45-0.88, P = 0.007) and the OPG 1181C allele was a risk factor for aortic calcification (OR = 1.26, 95 % CI 1.00-1.58, P = 0.046).

CONCLUSION

This study showed that the OPG 209AA genotype was a risk factor for higher-grade VFs, the OPG 209A allele was protective for aortic calcification, and the OPG 1181C was a risk factor for aortic calcification, supporting the involvement of OPG polymorphisms in the analyzed phenotypes and the concept that the related pathogenesis is multifactorial.

Contributions to the knowledge of amphibians and reptiles from Volta Grande do Xingu, northern Brazil

The region of Volta Grande do Xingu River, in the state of Pará, presents several kinds of land use ranging from extensive cattle farming to agroforestry, and deforestation. Currently, the Belo Monte Hydroelectric Power Plant affects the region. We present a checklist of amphibians and reptiles of the region and discuss information regarding the spatial distribution of the assemblies based on results of Environmental Programmes conducted in the area. We listed 109 amphibian (Anura, Caudata, and Gymnophiona) and 150 reptile (Squamata, Testudines, and Crocodylia) species. The regional species richness is still considered underestimated, considering the taxonomic uncertainty, complexity and cryptic diversity of various species, as observed in other regions of the Amazon biome. Efforts for scientific collection and studies related to integrative taxonomy are needed to elucidate uncertainties and increase levels of knowledge of the local diversity.

Bone impairment assessed by HR-pQCT in juvenile-onset systemic lupus erythematosus

High-resolution peripheral quantitative computed tomography (HR-pQCT) analysis of female juvenile-onset systemic lupus erythematosus (JoSLE) patients revealed trabecular/cortical bone damage and reduced bone strength primarily at the distal radius compared to healthy controls. We demonstrated for the first time that JoSLE patients with vertebral fracture (VF) present trabecular impairment at the distal radius.

INTRODUCTION

This study investigated the volumetric bone mineral density (vBMD), microarchitecture, and biomechanical features at the distal radius and tibia using HR-pQCT and laboratory bone markers in JoSLE patients compared to controls to determine whether this method discriminates JoSLE patients with or without VF.

METHODS

We compared 56 female JoSLE patients to age- and Tanner-matched healthy controls. HR-pQCT was performed at the distal radius and tibia. Serum levels of the amino-terminal pro-peptide of type I collagen, the C-terminal telopeptide of type I collagen, intact parathormone, sclerostin, and 25-hydroxyvitamin D (25OHD) were evaluated. VFs were analyzed using VFA-dual-energy X-ray absorptiometry (DXA) (Genant's method).

RESULTS

Reduced density and strength parameters and microarchitecture alterations of cortical and trabecular bones were observed in JoSLE patients compared to controls, primarily at the distal radius (p < 0.05). Patients with VF exhibited a significant decrease in trabecular bone parameters solely at the distal radius (Total.BMD, p = 0.034; Trabecular.BMD [Tb.BMD], p = 0.034; bone volume (BV)/trabecular volume (TV), p = 0.034; apparent modulus, p = 0.039) and higher scores for disease damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI), p = 0.002). Bone metabolism markers were similar in all groups. Logistic regression analysis of parameters that were significant in univariate analysis revealed that Tb.BMD (OR 0.98, 95 % CI 0.95-0.99, p = 0.039) and SLICC/ACR-DI (OR 7.37, 95 % CI 1.75-30.97, p = 0.006) were independent risk factors for VF.

CONCLUSION

In conclusion, this study is the first demonstration of bone microstructure and strength deficits in JoSLE patients, particularly at the distal radius. Our results demonstrated that VF was associated with trabecular radius alteration and emphasized the potential detrimental effect of disease damage on this condition.

Persistent hypovitaminosis D and loss of hip bone mineral density over time as additional risk factors for recurrent falls in a population-based prospective cohort of elderly persons living in the community. The São Paulo Ageing & Health (SPAH) Study

We performed concomitant evaluation of clinical, laboratory, and bone mineral density (BMD) parameters as potential risk factors for falls in a population-based prospective cohort of older adults, since previous studies have focused mostly in clinical risk factors. Loss of hip BMD and persistent hypovitaminosis D were associated with recurrent falls in community-dwelling elderly.

INTRODUCTION

Few studies have performed a concomitant evaluation of clinical data, laboratory bone parameters, and bone mineral density (BMD) to determine more accurately the contribution of each of these variables to risk of falls in elderly persons. We investigated the association between bone parameters and recurrent falls in a population-based prospective cohort of community-dwelling older adults.

METHODS

A total of 705 elderly individuals (448 women, 257 men) were evaluated with clinical data, BMD, and laboratory bone tests at baseline and after a mean follow-up of 4.3 ± 0.8 years. Individuals with recurrent falls (≥2 falls in the previous year from the date of the second evaluation) were considered chronic fallers. Logistic regression models were used to identify independent risk factors for recurrent falls.

RESULTS

The frequency of chronic fallers was 16.5%. In multivariate analyses, risk factors for recurrent falls were visual impairment (odds ratio (OR) = 2.49, 95% confidence interval (CI) 1.30-4.74, p = 0.006), use of psychotropic drugs (OR = 2.47, 95% CI 1.37-4.49, p = 0.003), clinical fracture (OR = 2.78, 95% CI 1.48-5.20, p = 0.001), persistently low 25-hydroxyvitamin D (25OHD) (<20 ng/mL) (OR = 1.71, 95% CI 1.10-2.64, p = 0.016), and loss of total hip BMD during the study (OR = 1.21, 95% CI 1.17-1.25, p = 0.035 for each 4% decrease).

CONCLUSIONS

In addition to traditional clinical risk factors for falls, loss of hip BMD and hypovitaminosis D were associated with recurrent falls in community-dwelling elderly persons. Thus, recognizing these factors is essential to preventing falls and improving the outcomes of this population.

Lower P1NP serum levels: a predictive marker of bone loss after 1 year follow-up in premenopausal systemic lupus erythematosus patients

SUMMARY

Predictors of bone mineral density (BMD) loss are additional tools in the management of osteoporosis in premenopausal women with systemic lupus erythematosus (SLE). This study provides original evidence that N-terminal propeptide of type 1 collagen (P1NP), the most specific bone formation marker, is a predictor of BMD loss in this group of women.

INTRODUCTION

SLE is associated with a high risk of low bone mass/fractures but this risk is still controversial in premenopausal women. Our aim was to determine the 1 year incidence of BMD loss in premenopausal SLE women and the value of bone turnover markers as predictors of this complication.

METHODS

This study enrolled a convenience sample of 63 premenopausal SLE patients. BMD was evaluated by dual X-ray absorptiometry at lumbar spine and hip at baseline and after 12 months. BMD changes above the least significant change were considered significant. Serum levels of P1NP and CTX (electrochemiluminescence), OPG, and RANKL (ELISA) were determined at baseline.

RESULTS

Mean age was 31.1±6.8 years, and disease duration was 5.25±3.8 years. 36.5 % of patients presented BMD loss and 17.5 % BMD gain at lumbar spine and/or hip. Patients were divided in three groups: BMD loss (BL), no BMD change (NC), and BMD gain (BG). Patients with BL and NC received similar cumulative/mean/maximum glucocorticoid doses during the study, but patients with BG received lower doses (p<0.05). Baseline P1NP levels were different in the groups (BL: 36.95±23.37 vs. NC: 54.63±30.82 vs. BG: 84.09±43.85 ng/mL; p=0.031 BL vs. NC, p<0.001 BL vs. BG, and p=0.039 NC vs. BG). There was no difference in CTX, OPG, or RANKL levels. After multivariate analysis, P1NP remained as an independent risk factor for BMD loss (p<0.03).

CONCLUSIONS

This study provides original evidence that lower levels of P1NP, the most specific bone formation marker, are predictive of BMD loss over 12 months in premenopausal SLE patients.

Incidence and risk factors for osteoporotic vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing & Health (SPAH) Study

We ascertained the incidence and predictors of radiographic vertebral fracture in a Brazilian elderly cohort, since no data in this field have been reported in low-income countries. This is the first population-based study to demonstrate the high frequency of vertebral fracture in elderly Latin Americans. Age, prior fracture, BMD, and bone turnover were predictors of fracture.

INTRODUCTION

Vertebral fractures are associated with increased future fracture risk and mortality. No data on incidence of osteoporotic vertebral fracture have been reported in low-income countries where the population's aging has been faster. Thus, we sought to describe the incidence and risk factors for radiographic vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

707 older adults (449 women and 258 men) were evaluated with spinal radiographs obtained at baseline and after a mean follow-up of 4.3 ± 0.8 years. New vertebral fracture was defined as distinct alteration in the morphology of vertebrae resulting in higher grade of deformity on the second radiograph when compared to the baseline radiograph. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of vertebral fracture was 40.3/1,000 person-years in women and 30.6/1,000 in men. In women, three models of risk factors for fracture were fitted: (1) age (relative risks (RR) 2.46, 95 % confidence interval (CI) 1.66-3.65), previous osteoporotic fracture (RR 1.65, 95 % CI 1.00-2.71), and lumbar spine BMD (RR 1.21, 95 % CI 1.03-1.41); (2) age (RR 2.25, 95 % CI 1.52-3.34) and femoral neck BMD (RR 1.42, 95 % CI 1.11-1.81); (3) age (RR 2.11, 95 % CI 1.41-3.15) and total hip BMD (RR 1.56, 95 % CI 1.21-2.0). In men, the highest quartile of cross-linked C-telopeptide (CTx) (RR 1.96, 95 % CI 0.98-3.91) and prior fracture (RR 2.10, 95 % CI 1.00-4.39) were predictors of new vertebral fracture.

CONCLUSIONS

This is the first population-based study to ascertain the incidence of vertebral fracture in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, BMD, and bone turnover were predictors of the short-term incidence of vertebral fracture.

Biological activities of sulfated polysaccharides from tropical seaweeds

Sulfated polysaccharides from 11 species of tropical marine algae (one edible specie of Rhodophyta, six species of Phaeophyta and four species of Chlorophyta) collected from Natal city coast (Northeast of Brazil) were evaluated for their anticoagulant, antioxidant and antiproliverative in vitro activities. In the activated partial thromboplastin time (APTT) test, which evaluates the intrinsic coagulation pathway, seven seaweeds presented anticoagulant activity. Dictyota cervicornis showed the highest activity, prolonging the coagulation time to double the baseline value in the APTT with only 0.01 mg/100 microl of plasma, 1.4-fold lesser than Clexane, a low molecular weight heparin. In the protrombin time (PT) test, which evaluates the extrinsic coagulation pathway, only Caulerpa cupresoides showed anticoagulant activity. All species collected showed antioxidant activities. This screening emphasized the great antioxidant potential (total capacity antioxidant, power reducing and ferrous chelating) of four species: C. sertularioide; Dictyota cervicornis; Sargassum filipendula and Dictyopteris delicatula. After 72 h incubation, HeLa cell proliferation was inhibited (p<0.05) between 33.0 and 67.5% by S. filipendula; 31.4 and 65.7% by D. delicatula; 36.3 and 58.4% by Caulerpa prolifera and 40.2 and 61.0% by Dictyota menstrualis at 0.01-2mg/mL algal polysaccharides. The antiproliferative efficacy of these algal polysaccharides were positively correlated with the sulfate content (r=0.934). Several polysaccharides demonstrated promising antioxidant, antiproliferative an/or anticoagulant potential and have been selected for further studies on bioguided fractionation, isolation and characterization of pure polysaccharides from these species as well as in vivo experiments are needed and are already in progress.

Susceptibility of different triatomine species to Trypanosoma rangeli experimental infection

Trypanosoma rangeli is a kinetoplastid protozoan parasite that has been found in the majority of Latin American countries, overlapping its distribution area with that of Trypanosoma cruzi, the causative agent of Chagas disease. This parasite shares the same reservoirs and vectors as T. cruzi. Triatomines from genus Rhodnius are considered the most susceptible hosts to infection. In this work, we report the susceptibility of different triatomine species (Rhodnius neglectus, Panstrongylus megistus, Triatoma infestans, T. sordida, T. braziliensis, and T. vitticeps) to experimental infection by T. rangeli isolated from Didelphis albiventris in a highly endemic region for Chagas disease. An intense parasitism was evidenced in feces (56% to 81%) of the majority of the species studied on the 10th day after infection, decreasing during the period of the experiment (30 days). T. vitticeps did not present parasites in feces at any time. All triatomine species presented parasites in the hemolymph. In T. vitticeps and P. megistus, this parasitism was scarce (6.3% and 6.6%, respectively). In the other species, the parasitism was variable (62.5% to 100%). Triatomine mortality varied between 3% to 40%, increasing during the infection in all species studied. The lowest mortality was observed for T. infestans. Also, we showed that only trypomastigotes forms from salivary glands, and hemolymph were infective for mice. We conclude that all triatomine species used were susceptible to infection by T. rangeli at different levels. There was no direct correlation between intensity of parasitism and mortality.

Antihypertensive, vasodilator and antioxidant effects of a vinifera grape skin extract

Cumulative evidence suggests that moderate wine consumption exerts a cardioprotective effect. We investigated the occurrence of an antihypertensive effect of an alcohol-free hydroalcoholic grape skin extract (GSE) obtained from skins of a vinifera grape (Vitis labrusca) in experimental rodent hypertension models. The vasodilator effect of GSE (polyphenols concentration 55.5 mg g(-1)) was also assessed in the isolated mesenteric vascular bed of Wistar rats and the antioxidant effect was studied on lipid peroxidation of hepatic microsomes. Oral administration of GSE significantly reduced systolic, mean and diastolic arterial pressure in Wistar rats with desoxycorticosterone acetate-salt and N(G)-nitro-L-arginine methyl ester (L-NAME) induced experimental hypertension. In the rat isolated mesenteric vascular bed pre-contracted with norepinephrine, bolus injections of GSE induced endothelium-dependent vasodilatation that was substantially inhibited by L-NAME, but not by indometacin, tetraethylammonium or glibenclamide. Lipid peroxidation of hepatic microsomes estimated as malondialdehyde production was concentration-dependently inhibited by GSE. In conclusion, the antihypertensive effect of GSE might be owing to a combination of vasodilator and antioxidant actions of GSE. These findings also suggest that the beneficial effect of moderate red wine consumption could be owing to an antihypertensive action induced by compounds occurring in the skin of vinifera grapes.

Haemophilus influenzae resistance in Latin America: systematic review of surveillance data

Haemophilus influenzae is a relevant cause of morbidity and mortality among children under 5 years of age in the developing world. In Latin America, H. influenzae type b (Hib) conjugate vaccine and surveillance of H. influenzae antimicrobial susceptibility have been implemented in recent years. We have undertaken a systematic review and a pooled analysis on H. influenzae antimicrobial resistance, including reports of 15 Latin America countries over a 10-year period (1990-2000). We have found that 450 (21.4%) of 2,100 invasive isolates were beta-lactamase producers compared to 145 (14.5%) of 998 isolates of noninvasive isolates (p < 0.05). Ampicillin resistance was detected among 783 (21.9%) of 3,577 invasive isolates compared to 111 (17.2%) of 646 noninvasive strains (p < 0.05). In contrast, 568 (41.9%) of 1,355 noninvasive strains were trimethoprim-sulfamethoxazole (TMP-SMX) resistance against 241 (26.9%) of 897 invasive ones (p < 0.05). Therefore, TMP-SMX resistance was more common in nonsterile fluids than in sterile fluids. Over time, rates of beta-lactamase-producing strains were stable in Brazil and Mexico, whereas rates of TMP-SMX resistance were increasing in Brazil. It is predictable that following the Hib immunization, Latin America countries will be faced with increased nontypeable H. influenzae infection. Although standing by the nontypeable H. influenzae vaccine, in this novel epidemiological scenario of post-Hib vaccination in Latin America settings there is a need to improve H. influenzae resistance monitoring to guide clinicians to choose efficacious antimicrobial therapy.

Lower faecal egg excretion in chemically-induced diabetic mice infected with Schistosoma mansoni due to impaired egg maturation

The effect of streptozotocin-induced diabetes mellitus was studied in mice infected with Schistosoma mansoni. Faecal egg excretion was lower in diabetic mice but worm load and total amount of eggs in the intestine tissue were equal to the control group. Evaluation of an oogram showed a great number of immature dead eggs and a low number of mature eggs in diabetic mice. It was therefore concluded that faecal egg excretion was lower in diabetic mice due to impaired egg maturation.

Hypomagnesemia in critically ill cancer patients: a prospective study of predictive factors

Hypomagnesemia is the most common electrolyte disturbance seen upon admission to the intensive care unit (ICU). Reliable predictors of its occurrence are not described. The objective of this prospective study was to determine factors predictive of hypomagnesemia upon admission to the ICU. In a single tertiary cancer center, 226 patients with different diagnoses upon entering were studied. Hypomagnesemia was defined by serum levels <1.5 mg/dl. Demographic data, type of cancer, cause of admission, previous history of arrhythmia, cardiovascular disease, renal failure, drug administration (particularly diuretics, antiarrhythmics, chemotherapy and platinum compounds), previous nutrition intake and presence of hypovolemia were recorded for each patient. Blood was collected for determination of serum magnesium, potassium, sodium, calcium, phosphorus, blood urea nitrogen and creatinine levels. Upon admission, 103 (45.6%) patients had hypomagnesemia and 123 (54.4%) had normomagnesemia. A normal dietary habit prior to ICU admission was associated with normal Mg levels (P = 0.007) and higher average levels of serum Mg (P = 0.002). Postoperative patients (N = 182) had lower levels of serum Mg (0.60 +/- 0.14 mmol/l compared with 0.66 +/- 0.17 mmol/l, P = 0.006). A stepwise multiple linear regression disclosed that only normal dietary habits (OR = 0.45; CI = 0.26-0.79) and the fact of being a postoperative patient (OR = 2.42; CI = 1. 17-4.98) were significantly correlated with serum Mg levels (overall model probability = 0.001). These findings should be used to identify patients at risk for such disturbance, even in other critically ill populations.

Influences of handedness and gender on the grooved pegboard test

We studied performance on the Grooved Pegboard Test upon repeated trials and transfer of training between the hands in the first trial. The classification of handedness was based on the writing hand. We employed three trials for each hand and two different protocols for the order in which the hands started the test. For the three trials combined, women were faster than men. From the first to the second trial, there was an improvement in performance for both sexes. Within the first trial, sex differences reached significance and the protocol interacted with handedness. In this trial, only left-handed men were found to benefit from previous opposite-hand performance. It is speculated that a larger corpus callosum in left-handed men allows for the greater transfer of training between the hands.

The effects of hand preference and gender on finger tapping performance asymmetry by the use of an infra-red light measurement device

We used an infra-red device to study the effects of gender and handwriting preference on manual asymmetry in tapping rate and intertap variability. Our sample (n=102) consisted of approximately equal number of subjects with respect to gender (52 women and 50 men) and handedness (52 right-handers and 50 left-handers). Data on overall performance indicated that men performed more quickly and regularly than women. The index used for measuring manual asymmetry was the difference between the hands as a proportion of the total. Therefore, the asymmetry index was adjusted to remove the influence of overall performance. The analyses based on asymmetry scores indicated a significant handedness effect: right-handers showed greater manual asymmetries than left-handers for both tapping rate and intertap variability. In addition, right handers exhibited a significant greater asymmetry for intertap variability than tapping rate. Taken together, these data may reflect greater hemispheric differences in right-handers, specially for intertap variability.

Monitoring human cytomegalovirus viral load in peripheral blood leukocytes of renal transplant recipients by a simple limiting dilution-PCR assay

To assess the clinical relevance of a semi-quantitative measurement of human cytomegalovirus (HCMV) DNA in renal transplant recipients within the typical clinical context of a developing country where virtually 100% of both receptors and donors are seropositive for this virus, we have undertaken HCMV DNA quantification using a simple, semi-quantitative, limiting dilution polymerase chain reaction (PCR). We evaluated this assay prospectively in 52 renal transplant patients from whom a total of 495 serial blood samples were collected. The samples scored HCMV positive by qualitative PCR had the levels of HCMV DNA determined by end-point dilution-PCR. All patients were HCMV DNA positive during the monitoring period and a diagnosis of symptomatic infection was made for 4 of 52 patients. In symptomatic patients the geometric mean of the highest level of HCMV DNAemia was 152,000 copies per 10(6) leukocytes, while for the asymptomatic group this value was 12,050. Symptomatic patients showed high, protracted HCMV DNA levels, whereas asymptomatic patients demonstrated intermittent low or moderate levels. Using a cut-off value of 100,000 copies per 10(6) leukocytes, the limiting dilution assay had sensitivity of 100%, specificity of 92%, a positive predictive value of 43% and a negative predictive value of 100% for HCMV disease. In this patient group, there was universal HCMV infection but relatively infrequent symptomatic HCMV disease. The two patient groups were readily distinguished by monitoring with the limiting dilution assay, an extremely simple technology immediately applicable in any clinical laboratory with PCR capability.

Early electrocardiographic abnormalities in Trypanosoma cruzi-seropositive children

As part of a major epidemiologic study on Chagas' disease, we compared the prevalence of electrocardiographic (ECG) abnormalities among 141 school children 7-12 years of age and seropositive for Trypanosoma cruzi, and 282 age-, sex-, and school-matched seronegative children in an endemic area in Brazil. The prevalence of ECG abnormalities was 11.3% among seropositive children and 3.5% among seronegative children (odds ratio = 3.5, 95% confidence interval [CI] = 1.5-8.4). The prevalence rate of ECG alterations was 10.7% for seropositive males versus 8.9% for seropositive females. Complete right bundle branch block (CRBBB), which is highly suggestive of Chagas' disease cardiopathy, was diagnosed in nine (6.4%) seropositive children and in only one (0.3%) seronegative child (odds ratio = 18.5, 95% CI = 2.3-146.5, attributable fraction = 58.3%). Five incident new cases of CRBBB were diagnosed after a 36-month follow-up of seropositive children who were enrolled in an independent clinical field trial. No case of frequent and/or multifocal ventricular premature beats was found in the cohort of children. The surprisingly high frequency of early ECG abnormalities, which indicates a rapid evolution from infection to disease, suggests the existence of endemic areas with a particular accelerated disease progression that was not described before. Under such conditions, a public health chemotherapy program focusing on the treatment of young seropositive children would be recommended.

Hypometria in Parkinson's disease: automatic versus controlled processing

OBJECTIVES

The aim was to investigate whether patients with Parkinson's disease (PD) make movements that are of smaller amplitude when required to attend to a secondary task at the same time as performing a motor task.

METHODS

Thirteen patients with idiopathic Parkinson's disease (mean age, 67.1 yrs) and 14 healthy control subjects (mean age, 66.2 yrs) were tested. The motor task was repeated opposition of the thumb and forefinger and the secondary task was a lexical decision task.

RESULTS

The PD patients made hypometric movements, and the amplitude was further decreased when they performed the secondary task at the same time. There was no significant change for the control subjects.

CONCLUSION

The unpaced motor task was less automatic for the PD patients than for the control subjects, and hence more subject to interference from a secondary task. We relate this to the underactivation of the supplementary motor cortex (SMA).

Loss of CA1 cells following global ischaemia correlates with spatial deficits in the circular platform task

The effect of 15 min, four-vessel-occlusion (4-VO) ischaemia on performance by rats in the circular platform task (CPT) was investigated. Possible correlations between the extent of hippocampal cell loss and behavioural disruption were evaluated. Sham-operated controls (n=10) and 4-VO ischaemic animals (n=32) were required to escape from a 1.2 m diameter, brightly illuminated, white surface into a dark goal box located under one of 18 equally-spaced, 9 cm diameter holes arranged around the circumference (3 trials per day). The goal box was maintained in a single, fixed, rewarded location relative to the extramaze cues for 7 days (days 16-22 post-ischaemia). During the reversal test, the goal box was transferred to a new location 140 degrees from the initial point and kept in this new position from day 23 through day 25 post-ischaemia. Ischaemic rats were slower to find the goal box than sham-operated controls; this learning deficit correlated with the degree of neuronal loss in the CA1, but not in the CA2, CA3 and CA4 subfields and presubiculum of the hippocampal formation. During the reversal test, ischaemic rats persisted in searching for the goal box at the initially rewarded location. The circular platform task provides a good model for behavioural studies following transient forebrain ischaemia in the rat.

Micrographia in Parkinson's disease: the effect of providing external cues

OBJECTIVE

To investigate whether micrographia in patients with Parkinson's disease is lessened either by giving visual targets or by continually reminding them that they should write with a normal amplitude.

METHODS

Eleven patients with Parkinson's disease (mean age 65.4 years) were compared with 14 control subjects (mean age 67.1 years). The subjects wrote with a stylus on a graphics tablet. There were three conditions: free writing, writing with dots to indicate the required size, and writing with continuous verbal reminders ("big"). Each condition was performed twice.

RESULTS

The patients wrote with a more normal amplitude when given either the visual cues or the auditory reminders. This improvement persisted when, shortly afterwards, the patients wrote freely without external cues. The increase in amplitude was achieved mainly by an increase in movement time rather than in peak velocity.

CONCLUSION

Whereas the visual cues directly specified the required amplitude the auditory reminders did not. One effect of external cues is that they draw attention to the goal, and thus encourage the patients to write less automatically.

Peptic disease and Helicobacter pylori are highly prevalent in patients with the indeterminate form of Chagas' disease: report of 21 cases

Given that chagasic patients in the indeterminate form of this disease, can have abnormal motility of the digestive tract and immunologic abnormalities, we decided to assess the frequency of peptic disease and Helicobacter pylori (Hp) infection in these individuals. Twenty-one individuals, 13 males and 8 females, mean age 37.6 +/- 11.1 years, were examined. Biopsies of the duodenum, antrum, lesser and greater gastric curvature and esophagus were performed. The endoscopic findings were of chronic gastritis in 20 (95.2%) patients, duodenal ulcer in 3 (14.3%), gastric and duodenal ulcer in 3 (14.3%), gastric ulcer alone in 1 (4.8%), esophagitis in 5 (23.8%), and duodenitis in 5 (23.8%). The diagnosis of infection by the Hp was done by the urease test and histologic examination. Hp infection was found in 20 (95.2%) individuals: in 20 out of them in the antrum, in 17 in the lesser curvature, and in 17 in the greater curvature. Hp was not found in the esophagus and duodenum. The only individual with no evidence of infection by Hp was also the only one with normal endoscopic and histologic examinations. The histologic examinations confirmed the diagnoses of gastric ulcer as peptic, chronic gastritis in 20 patients, duodenitis in 14, and esophagitis in 9. In this series the patients had a high frequency of peptic disease, which was closely associated with Hp infection.

Competitive inhibition models of lexical-semantic processing: experimental evidence

A modified Neisser word-search (search II) was administered to patients with Parkinson's disease (PD), and significant deficits were found. Given the assumption that the processes are lexical, we interpret the results as support for the claim that there is competition between semantically related words in speech production (Wheeldon, 1989). A related verbal task-switching experiment (continuous series II) is also presented. Although PDs are impaired on task switching, there are double dissociations between verbal task switching (continuous series II) and lexical retrieval (search II). The relationship between performance on these tasks and on verbal fluency is also addressed.

[Pregnancy, puerperium and cerebrovascular disease]

Six patients who presented cerebrovascular disease during puerperium or pregnancy were studied. One of them presented hemorrhagic stroke caused by intracerebral bleeding due to pre-eclampsia. Three patients presented ischemic stroke, they all had positive serologic reactions for Chagas' disease, but only two of them had clinical cardiopathy; one of these patients had anticardiolipin antibody. The other two patients presented cerebral venous thrombosis of sagittal sinus. Both were smokers and one of them used oral contraceptive. We emphasize the importance of clinical investigation to seek for the common causes of cerebrovascular disease in young people, with special attention to Chagas disease in Brazil.

[Hexachlorocyclohexane contamination in urban areas of the south eastern region of Brazil]

A factory for producing the pesticide hexachlorocyclohexane (HCR) in its technical grade (mix of the alpha, beta, gamma, and delta isomers), that belonged to the former Institute of Malaria Sciences, then Ministry of Education and Health, located in the "Cidade dos Meninos", county of Duque de Caxias, State of Rio de Janeiro, was closed down in 1955. Part of its production and wastes - many tons this mix - were left behind on the site. The action of winds and rain as well as the movement of the local inhabitants - approximately 1,000 people, including 400 children, have caused the scaltering of this agent. Blood specimens from the inhabitants showed a high human contamination levels, with the highest concentration (beta isomers) being found in people living within a 100 meter radius of the ruin of the factory. Local soil and pasture samples taken at distances of less than 100 m from the ruin of the former factory showed HCH isomer concentrations of the order of thousands of ppb, thus providing evidence of high environmental contamination.

A prospective randomized evaluation of three schedules of mesna administration in patients receiving an ifosfamide-containing chemotherapy regimen: sustained efficiency and simplified administration

Chemotherapy with oxazaphosphorines, such as ifosfamide, is often limited by unacceptable urotoxicity. Without uroprotection hemorrhagic cystitis becomes dose-limiting. Mesna, a thiol compound, is a drug able to bind the toxic metabolites, forming nontoxic compounds in the urine. A total of 122 patients were enrolled in this study and 228 chemotherapy cycles with an ifosfamide-containing regimen were performed (225 evaluable). Mesna was given at the same total dose as the ifosfamide in all arms. On arm A, mesna was given i. v. in equal doses 15 min before and 4 h and 8 h following the ifosfamide dose. On arm B, mesna was given in three equivalent doses 15 min before (i.v.) and 4 h (i.v.) and 8 h (p.o., double dose) following ifosfamide. On arm C, mesna was given i.v. in two equal doses given 15 min before and 4 h following. The incidence of urotoxicity was very low (lower than 15%) in the three arms, 0% in A, 1.36% in B and 2.70% in C. All three arms were equally efficient. Schedule C was considered superior to the others, since it was equally effective, simpler and more convenient.

Frequency of cholelithiasis in alcoholics

In order to determine the frequency of biliary lithiasis in alcoholic patients without signs of hepatic cirrhosis, we submitted 106 male alcoholics (mean age, 42.2 +/- 11.2 years) to ultrasound examination of the biliary system. Cholelithiasis was present in 6 (5.6%). We did not observe any association between the quantity of ethanol consumed and/or the time of consumption and the presence of cholelithiasis. There was no significant difference between the frequency of cholelithiasis in these patients and that found in autopsies carried out on 716 male patients (6%) at the Hospital de Clínicas, Universidade Federal de Uberlândia, during the period 1982 to 1993. Thus, we conclude that in the cases we examined, alcoholism did not represent a risk factor for biliary lithogenesis.

An urban outbreak of visceral leishmaniasis in Natal, Brazil

The epidemiological pattern of visceral leishmaniasis in north-eastern Brazil is changing. The disease was typically seen in rural, endemic areas, but is now occurring as an epidemic in the city of Natal where 316 cases have been reported since 1989; 49% were in children less than 5 years of age. The principle clinical and laboratory findings were weight loss, fever, hepato-splenomegaly, anaemia, leucopenia and hypergammaglobulinaemia. Elevated transaminases and hyperbilirubinaemia were also observed. The diagnosis was confirmed in 87% of cases by identifying amastigotes in aspirates from bone marrow or spleen. Five isolates were identified as Leishmania (L.) chagasi by isoenzyme analysis. The mortality rate was 9%; all deaths occurred during the first week in hospital. One person had concurrent human immunodeficiency virus infection. Among 210 household contacts and neighbours of patients from the endemic area examined for evidence of L. (L.) chagasi infection, 6 additional cases of visceral leishmaniasis were diagnosed. Thirty-eight percent of house-mates and neighbours gave a positive Montenegro skin test reaction, indicating prior subclinical infection.

The new stentless aortic valve: clinical results of the first 100 patients

From May 1990 to August 1993, 100 patients underwent aortic valve replacement using the stentless porcine aortic valve. There were 69 males and 31 females. The mean age was 36 (range 11-76) years. Of 70 patients under 40 years of age, 20 were less than 20 years old. Indications included rheumatic heart sequelae in 55 patients (first valve replacement), prosthetic failure in 20, endocarditis in 13, congenital aortic bicuspid valve in four, degenerative disease in four and senile calcified aortic valves in four. Twenty patients had aortic annular related pathology. There were 15 associated surgical procedures. Forty-three patients required aortic root enlargement. There were approximately equal numbers of patients in New York Heart Association (NYHA) functional classes III and IV. The hospital mortality rate was 6%; 14 patients who experienced hospital morbidity had a full recovery. Two late reoperations were performed in patients with primary valve endocarditis; their recovery was uneventful. Four late deaths were not valve related. Comparative echo Doppler analysis before and after operation demonstrated good improvement of left ventricular function in nearly all patients. The valve was competent in 96% of patients and the remainder displayed minor jets without haemodynamic significance. The valve coaptation was stable in all patients. Use of the stentless porcine aortic valve in this first 100 patients has provided excellent clinical results with a follow-up of 41 months. Further follow-up and close observation will be required to analyse the outcome of this new valve and procedure with time.

Role of the amygdala and periaqueductal gray in anxiety and panic

The amygdala (AM) and the periaqueductal gray (PAG) represent the rostral and the caudal pole, respectively, of a longitudinally organized neural system, that is responsible for the integration of behavioral and physiological manifestations of defensive reactions against innate and learned threats. Microinjection of benzodiazepine (BZD) anxiolytics, GABAA receptor agonists or 5-HT receptor antagonists into the AM has anxiolytic effects in conflict tests and other models of conditioned fear, while similar administration of 5-HT or of a 5-HT1A receptor agonist has anxiogenic effects. On the other hand, in the test of electrical stimulation of the PAG, microinjection of 5-HT, 5-HT mimetics, or of drugs that enhance the action of endogenous 5-HT into the same brain area has an antiaversive effect, like BZD and GABAA agonists. Furthermore, microinjection of midazolam, of the NMDA receptor antagonist AP-7, or of the 5-HT1A/1B receptor blocker propranolol increased the exploration of the open arms of the elevated plus-maze, having therefore an anxiolytic effect. These results point to an inhibitory role of the GABA-BZD system in both the AM and the PAG. In contrast, 5-HT seemingly enhances conditioned fear in the AM, while inhibiting unconditioned fear in the PAG. Thus, 5-HT2/1C antagonists reportedly release punished behavior when injected into the AM, whereas they antagonized the antiaversive effect of 5-HT, zimelidine and 5-HT1A/1B receptor blockers in the PAG. Since reported clinical studies revealed that one of such compounds, ritanserin, relieves generalized anxiety but tends to aggravate panic disorder, a relationship may be established between the AM and anxiety and the PAG and panic.

A randomized clinical trial with high dose of chloroquine for treatment of Plasmodium falciparum malaria in Brazil

This clinical trial compared parasitological efficacy, levels of in vivo resistance and side effects of oral chloroquine 25 mg/Kg and 50 mg/Kg in 3 days treatment in Plasmodium falciparum malaria with an extended followed-up of 30 days. The study enrolled 58 patients in the 25 mg/Kg group and 66 in the 50 mg/Kg group. All eligible subjects were over 14 years of age and came from Amazon Basin and Central Brazil during the period of August 1989 to April 1991. The cure rate in the 50 mg/Kg group was 89.4% on day 7 and 71.2% on day 14 compared to 44.8% and 24.1% in the 25 mg/Kg group. 74.1% of the patients in the 25 mg/Kg group and 48.4% of the patients in the 50 mg/Kg group had detectable parasitaemia at the day 30. However, there was a decrease of the geometric mean parasite density in both groups specially in the 50 mg/Kg group. There was 24.1% of RIII and 13.8% of RII in the 25 mg/Kg group. Side effects were found to be minimum in both groups. The present data support that there was a high level resistance to chloroquine in both groups, and the high dose regimen only delayed the development of resistance and its administration should not be recommended as first choice in malaria P. falciparum therapy in Brazil.

Stenosing ureteritis in a child with necrotizing vasculitis

Although vasculitidis may involve several organs and tissues, ureteral involvement is rare. The present report describes a case of a female child with ureteral stenosis in whom a diagnosis of necrotizing vasculitis was made.

Surveillance of Trypanosoma cruzi transmission by serological screening of schoolchildren

The seroprevalence of Trypanosoma cruzi infection among children is a sensitive indicator for assessing the effectiveness of programmes for control of Chagas disease. In this study we report the result of a cross-sectional serological survey carried out among schoolchildren living in a poor rural area in central Brazil. Eluates of blood collected on filter-paper were tested for anti-T. cruzi antibodies using immunofluorescence, haemagglutination, and enzyme-linked immunosorbent assays. The overall seroprevalence of T. cruzi infection was 7.9%, which compared with the findings of the national survey carried out in 1975-80 indicates that a twofold-to-threefold reduction in prevalence has occurred over the last 10 years. This is consistent with a reduction of transmission in the area, probably related to vector control efforts. Based on our results, the incidence of new cases was estimated to be 44 per annum in the study region. In rural areas with a scattered population, surveillance of T. cruzi transmission by serological screening of children at school entry is more practical and economical than entomological evaluation for assessing both the risk of transmission in the community and the efficacy of vector control measures. A sample size of around 1000 schoolchildren is sufficient to detect prevalences as low as 2%, and such an approach would be practical and applicable to most areas where Chagas disease is endemic.

Physical activity, opportunity for reinfection, and sibling history of heart disease as risk factors for Chagas' cardiopathy

A case-control study was conducted to examine whether physical activity, sibling history of heart disease (HHD), and length of residence in an area endemic for Chagas' disease were associated with the risk of developing Chagas' cardiopathy. Two hundred forty-seven cases of Chagas' heart disease and 345 seropositive subjects with normal ECG (controls) were selected in a population survey in Goiânia, Brazil. Prevalence ratios for exposure variables were estimated for cases in relation to controls and for subgroups of seropositives with selected ECG abnormalities in relation to controls. Increasing age and male sex were consistently and significantly related to an increased risk of ECG abnormalities. HHD was significantly associated with ECG alterations in 3 of the 5 comparison subgroups (any ECG alteration, right bundle branch block, and left anterior hemiblock). No association was found between length of residence in an area endemic, physical activity, and ECG abnormalities. A sample of 529 seronegative subjects were also examined and the interaction between exposure variables and seropositivity was tested to assess whether the associations found were specific for seropositives. Males were at greater risk of any ECG alteration and left anterior hemiblock in relation to females if they were seropositive. An increasing risk of ventricular premature beats with age was clearer for seropositive than for seronegative subjects. Subjects with HHD were at an increased risk of ECG abnormalities and this was greater in those with a positive serological test (P less than 0.05). The findings suggest a possible geographical clustering or a familial aggregation of cases of Chagas' heart disease.

Exercise electrocardiogram tests in manual workers with and without antibodies to Trypanosoma cruzi: a population-based study

Blood pressure, heart rate and electrocardiographic responses to exercise were compared in a group of 125 subjects with antibodies to Trypanosoma cruzi and in 153 seronegative subjects, randomly selected from persons with no evidence of heart disease in a resting electrocardiogram during a cross-sectional survey among apparently healthy manual workers. The mean heart rates and diastolic and systolic blood pressures of those in each group did not differ statistically at different phases of the exercise test and there was no evidence of a difference in physical fitness between those in the 2 groups. An abnormal test was recorded in 26.2% of seropositive, and in 16.1% of seronegative, subjects (odds ratio adjusted for age, sex and body mass index [OR] = 2.0, 95% confidence interval [95% CI] = 1.1-3.8). No significant difference was observed between the 2 groups in the occurrence of hypertensive response to exercise (6.4% among seropositives and 5.9% among seronegatives), ST depression greater than 1 mm (0.8% and 2.0%), supraventricular premature beats (4.8% and 2.6%) or conduction defects (0.8% and 1.3%). Complex ventricular premature beats were recorded more often in seropositive subjects (12.8% and 3.9%; OR = 3.7, 95% CI = 1.4-9.8, P less than 0.01). The risk of an abnormal test increased with age in both groups. A history of cardiovascular symptoms, gender and body mass was not associated with the risk of an abnormal response in the test. The findings suggest that exercise testing might be a routine procedure when subjects with antibodies to T. cruzi are being assessed for participation in potentially high risk activities, such as heavy manual work.

Autoimmune sensorineural hearing loss: a preliminary experimental study

The aim of this study was to compare cochlear alterations produced by induction of anti-type II collagen antibodies with alterations produced by passive transfer of anticochlear antibodies. Guinea pigs (GP) were used. The anticochlear antibodies were obtained by injecting GP membranous cochlea plus Freund's adjuvant into rabbits. After partial purification of the immunoglobulins, the antibodies (20 mg) were injected intramuscularly into 10 normal GP. A second group of 10 normal GP received intramuscular injections of purified chicken type II collagen (1 mg) plus Freund's adjuvant. A control group of 10 normal GP was studied under the same conditions without any stimulus. The cochlea function was analysed with brainstem evoked audiometry (BERA). The structural study was carried out by immunofluorescent and hematoxylin preparations. The results showed structural alterations in both experimental groups (loss of nucleus in the spiral ganglion); however, significant changes in the BERA were not found. Only increase of the latency of wave I could be seen. These preliminary results support the hypothesis that antibodies to collagen type II may play an important role in human autoimmune sensorineural hearing loss, but the possible existence of other cochlear antigens is discussed.

Trypanosoma cruzi infection and electrocardiographic findings among active manual workers. A population-based study in central Brazil

In a cross sectional survey of the prevalence of Trypanosoma cruzi infection among urban unskilled workers in Goiânia, Brazil, blood samples from 6222 manual workers from seven institutions were examined for anti-Trypanosoma cruzi antibodies by immunofluorescence, ELISA and haemagglutination tests. ECGs were performed and a clinical history was taken from 624 seropositive and a random sample of 529 seronegative subjects. Abnormal ECGs were found in 15.1% of individuals without Trypanosoma cruzi antibodies and in 44.4% of those with antibodies (p less than 0.001). In general, cardiovascular symptoms reported were not associated with seropositivity nor with ECG alterations but dizziness and dyspnoea were more often reported among those with an abnormal tracing (p less than 0.01). The prevalence of ECG abnormalities increased with age in both groups but was higher among those seropositive in all age groups. An odds ratio of 2.0 (95% Cl 1.2-3.1) and 2.9 (95% Cl 1.5-6.3) of ECG abnormalities, for each decade of life, was estimated for seropositive and seronegative subjects, respectively. Relative risks (based on the odds ratios) for various specific ECG abnormalities, comparing seropositive to seronegative individuals, were calculated after adjustment for age, sex and institution. The odds ratio for complete right bundle branch block was 49.9 (95% CL 12.2-203.4); for left anterior hemiblock was 4.1 (2.8-6.0); for large Q/QS waves was 4.2 (2.4-7.3) and for first degree A-V block was 8.5 (2.6-28.1).

[Catatonic syndrome caused by autoimmune disease: spontaneous remission]

The psychiatric manifestations of systemic lupus erythematosus and other autoimmune diseases, which may precede by many years systemic involvement, should be held in mind by both the internist and psychiatrist. This case report focuses on a female catatonic patient without metabolic disturbances, whose evolution did not suggest a schizophrenic disorder. Immune complexes were demonstrated to be present in cerebrospinal fluid (CSF) obtained during psychotic crisis and immunologic tests showed circulating immune complexes with a positive antinuclear factor. (1/800) and a nucleolar pattern with immunofluorescence. The psychiatric picture receded concomitantly with a fall in CSF immune complexes and with an increase in circulating immune complexes, without the administration of immunosuppressive drugs. The catatonic syndrome is a rare manifestation in patients with autoimmune disease and few cases have been reported without systemic manifestation. This report emphasizes the need for increased awareness of the psychiatric effects brought about by autoimmune diseases and shows that CSF immune complexes are valuable markers for their diagnosis.

Seroprevalence of Trypanosoma cruzi infection among unskilled urban workers in central Brazil

A cross-sectional survey of the prevalence of Trypanosoma cruzi infection was carried out among urban unskilled workers in an endemic area in central Brazil as part of a study to assess the health impact of Chagas disease and to identify risk factors for the evolution of cardiopathy. Blood samples from 5425 male and female workers, aged 15-61 years, from 5 public institutions, were screened by indirect immunofluorescence, enzyme-linked immunosorbent assay and indirect haemagglutination for antibodies to T. cruzi. Seroprevalence varied from 8.8% to 15.6% in the different institutions and increase with age up to 55 years. More stable jobs were associated with lower seroprevalence. Migrants from São Paulo and Minas Gerais presented higher prevalence and a relative risk associated with seropositivity in relation to workers from Goiás of 2.2 (95% confidence limits, 1.4-3.5) and 1.9 (1.6-2.3), respectively.

Anticardiolipin antibodies in patients with infectious diseases

IgG or IgM anticardiolipin antibodies were present in the sera of 67% of 33 patients with Hansen's disease, in 53% of 30 patients with tuberculosis and in 50% of 16 patients with endocarditis. Despite the high frequency of these antibodies, no patient had a history of thrombosis or abortion. Anti-denatured DNA antibodies were tested in patients with tuberculosis and patients with Hansen's disease. Only in the latter group did we observe a statistically significant association between anticardiolipin and anti-denatured DNA antibodies. Anticardiolipin binding activity, however, could not be inhibited by preincubation of sera with a variable concentration of denatured DNA. These data suggest that: a) Anticardiolipin antibodies in infectious diseases do not necessarily participate in the pathogenesis of thrombotic or obstetric complications; b) Anti-denatured DNA and anticardiolipin antibodies in the population studied do not have a cross-reaction.

Chronic active hepatitis associated with anti-liver-kidney microsome antibody type 1

A 3 years old girl presented with clinical feature of an acute hepatitis-like illness, with jaundice, hepatosplenomegaly, high alanine aminotransferase activity (ALT) and high gamma-globulin values. We were able to demonstrate high titre of anti-liver-kidney microsome antibodies type 1 (LKMA1) in the serum of this patient using immunofluorescence, ELISA (Enzyme-linked immunoabsorbent assay) and Western blot (WB) analysis. This observation together with the liver morphology and after excluding other possible causes of hepatitis established the diagnosis of chronic active hepatitis associated with anti-LKM1 antibody. Immunosuppressive therapy was therefore started immediately.