Ethnicity and cutaneous melanoma in the city of Sao Paulo, Brazil: a case-control study

Background

Over the last century the incidence of cutaneous melanoma has increased worldwide, a trend that has also been observed in Brazil. The identified risk factors for melanoma include the pattern of sun exposure, family history, and certain phenotypic features. In addition, the incidence of melanoma might be influenced by ethnicity. Like many countries, Brazil has high immigration rates and consequently a heterogenous population. However, Brazil is unique among such countries in that the ethnic heterogeneity of its population is primarily attributable to admixture. This study aimed to evaluate the contribution of European ethnicity to the risk of cutaneous melanoma in Brazil.

Methodology/Principal Findings

We carried out a hospital-based case-control study in the metropolitan area of Sao Paulo, Brazil. We evaluated 424 hospitalized patients (202 melanoma patients and 222 control patients) regarding phenotypic features, sun exposure, and number of grandparents born in Europe. Through multivariate logistic regression analysis, we found the following variables to be independently associated with melanoma: grandparents born in Europe—Spain (OR = 3.01, 95% CI: 1.03–8.77), Italy (OR = 3.47, 95% CI: 1.41–8.57), a Germanic/Slavic country (OR = 3.06, 95% CI: 1.05–8.93), or ≥2 European countries (OR = 2.82, 95% CI: 1.06–7.47); eye color—light brown (OR = 1.99, 95% CI: 1.14–3.84) and green/blue (OR = 4.62; 95% CI 2.22–9.58); pigmented lesion removal (OR = 3.78; 95% CI: 2.21–6.49); no lifetime sunscreen use (OR = 3.08; 95% CI: 1.03–9.22); and lifetime severe sunburn (OR = 1.81; 95% CI: 1.03–3.19).

Conclusions

Our results indicate that European ancestry is a risk factor for cutaneous melanoma. Such risk appears to be related not only to skin type, eye color, and tanning capacity but also to others specific characteristics of European populations introduced in the New World by European immigrants.     

Direct Costs of Dengue Hospitalization in Brazil: Public and Private Health Care Systems and Use of WHO Guidelines

Background

Dengue, an arboviral disease, is a public health problem in tropical and subtropical regions worldwide. In Brazil, epidemics have become increasingly important, with increases in the number of hospitalizations and the costs associated with the disease. This study aimed to describe the direct costs of hospitalized dengue cases, the financial impact of admissions and the use of blood products where current protocols for disease management were not followed.

Methods and Results

To analyze the direct costs of dengue illness and platelet transfusion in Brazil based on the World Health Organization (WHO) guidelines, we conducted a retrospective cross-sectional census study on hospitalized dengue patients in the public and private Brazilian health systems in Dourados City, Mato Grosso do Sul State, Brazil. The analysis involved cases that occurred from January through December during the 2010 outbreak. In total, we examined 8,226 mandatorily reported suspected dengue cases involving 507 hospitalized patients. The final sample comprised 288 laboratory-confirmed dengue patients, who accounted for 56.8% of all hospitalized cases. The overall cost of the hospitalized dengue cases was US $210,084.30, in 2010, which corresponded to 2.5% of the gross domestic product per capita in Dourados that year. In 35.2% of cases, blood products were used in patients who did not meet the blood transfusion criteria. The overall median hospitalization cost was higher (p = 0.002) in the group that received blood products (US $1,622.40) compared with the group that did not receive blood products (US $550.20).

Conclusion

The comparative costs between the public and the private health systems show that both the hospitalization of and platelet transfusion in patients who do not meet the WHO and Brazilian dengue guidelines increase the direct costs, but not the quality, of health care.     

Impact of a Reference Center on Leprosy Control under a Decentralized Public Health Care Policy in Brazil

ObjectiveWe evaluated the profile of patients referred to the Fiocruz Outpatient Clinic, a reference center for the diagnosis and treatment of leprosy in Rio de Janeiro, RJ, and analyzed the origins and outcomes of these referrals.MethodsThis is an observational retrospective study based on information collected from the Leprosy Laboratory database at Fiocruz, Rio de Janeiro, RJ, Brazil. A total of 1,845 suspected leprosy cases examined at the reference center between 2010 and 2014 were included. The originating health service referrals and diagnostic outcomes were analyzed as well as the clinical and epidemiological data of patients diagnosed with leprosy.ResultOur data show that the profile of the patients treated at the Clinic has changed in recent years. There was an increase in both the proportion of patients with other skin diseases and those who had visited only one health service prior to our Clinic. Among the total 1,845 cases analyzed, the outcomes of 1,380 were linked to other diseases and, in 74% of these cases, a biopsy was not necessary to reach a diagnostic conclusion. A decrease in new leprosy case detection among our patients was also observed. Yet, among the leprosy patients, 40% had some degree of disability at diagnosis.ConclusionThe results of the present study demonstrated the importance of referral centers in support of basic health services within the decentralization strategy. But, the success of the program depends on the advent of new developmental tools to augment diagnostic accuracy for leprosy. However, it should be emphasized that for new diagnostic methods to be developed, a greater commitment on the part of the health care system regarding research is urgently needed.     

Disability life expectancy for the elderly, city of Sao Paulo, Brazil, 2000: gender and educational differences

There is evidence that 'health life expectancy' (expected number of years to be lived in health) differs by socioeconomic status. Time spent in health or disability plays a critical role in the use of health care services. The objective of this study was to estimate 'disability life expectancy' by age, gender and education attainment for the elderly of the city of S?o Paulo, Brazil, in the year 2000. Data came from the SABE database, population censuses and mortality statistics (SEADE Foundation). Life expectancy with disability was calculated using Sullivan's method on the basis of the current probability of death and prevalence of disability by educational level. The prevalence of disability increased with age, for both sexes and both levels of educational attainment studied. Men showed a lower prevalence of disability, in general, and persons with lower educational attainment showed a higher prevalence of disability. Regarding life expectancy, women could expect to live longer than men, with and without disability. For both sexes, the percentage of life expectancy lived with disability decreased with increasing educational attainment. With increasing educational attainment, the sex differences in the percentage of remaining years to be lived with disability increased for most ages. Finally, the percentage of remaining years to be lived with disability increased with age for males and females, except for males with high educational attainment between the ages 70-75 and 75-80. The results may serve as a guide for public policies in the country, since health problems faced by older persons, such as disability, are the result of a number of past experiences during their life-times, such as health care, housing conditions, hygiene practices and education. Education influences health behaviours and is related, to some extent, to all these factors. Therefore, improvements in education for the disadvantaged may improve health.     

Incidence and Severity of Leifsonia xyli subsp. xyli Infection of Sugarcane in Sao Paulo State,Brazil

Sugarcane covers 8.53 million hectares with production of 596.63 million tonnes in Brazil. Despite its importance, little information is available on ratoon stunt (RSD), caused by Leifsonia xyli subsp xyli (Lxx). Our objective was to examine the incidence and severity of Lxx among sugarcane cultivars in 2009, 2010 and 2011. Sap from 100 stalks from each field was sent for a routine RSD analyses that allowed examination of Lxx incidence. The presence of bacterium was checked by dot blot enzyme immunoassay to detect its presence and relative concentration. Analyses of 187 fields from 35 cultivars in 2009, 166 fields from 33 cultivars in 2010 and 221 fields from 30 cultivars in 2011 found Lxx incidence of 23.6% of fields of 23 cultivars in 2009, 27.1% of fields of 15 cultivars in 2010 and 25.8% of fields of 15 cultivars in 2011. RB867515, the major cultivar in Sao Paulo, had within‐field incidence of up to 70% in 2009, 48% in 2010 and 88% in 2011. Highest incidence and populations of Lxx infection were found for cvs RB867515, RB855453, SP81‐3250, RB855536 and RB92579, demonstrating their susceptibility to RSD.     

Molecular typing and antifungal susceptibility of clinical sequential isolates of Cryptococcus neoformans from Sao Paulo State, Brazil

The antifungal susceptibility profiles and the genetic variability of 83 sequential clinical isolates of Cryptococcus neoformans, including four Cryptococcus gattii isolates, obtained from 38 Sao Paulo AIDS patients with cryptococcal meningitis were assessed by electrophoretic karyotyping and random amplified polymorphic DNA (RAPD) analysis. The majority of the Cryptococcus neoformans isolates were highly susceptible to amphotericin B and fluconazole. Twenty percent of the minimum inhibitory concentration values for amphotericin B varied from 0.5 to 1 micro g mL(-1). For fluconazole, 22% occurred in the range 8-16 mug mL(-1). Sequential isolates from nine patients showed a trend towards lower susceptibility to fluconazole, flucytosine, itraconazole and amphotericin B. The results of molecular typing by electrophoretic karyotyping and RAPD analysis showed the presence of 22 electrophoretic karyotypes (EK) and 15 RAPD profiles that were highly correlated. Our results provided evidence for the occurrence of genetic changes in some strains associated with microevolution during the course of infection. We also observed both microevolution and simultaneous coinfection with two distinct Cryptococcus neoformans strains in one patient. In some patients, we found changed EK- and RAPD patterns in association with increased MIC values.     

Isomucor (Mucoromycotina): a new genus from a Cerrado reserve in state of Sao Paulo, Brazil

During a survey of mucoralean fungi from a Cerrado reserve (Brazilian savanna) some isolates of a Mucor-like fungus were isolated from soil plates. Characterization based on morphological, physiological and molecular data from translation elongation factor (EF-1α), 28S (D1/D2) and ITS1-5.8S-ITS2 rDNA sequences was made. The isolates produce lateral branches bearing multispored sporangiola in addition to the multispored sporangia and a uniformly septate mycelium as the main differentiating characteristics. To our surprise this fungus possesses two EF-1α genes 1.4 and 1.5 kb long. Evidence from the analyzed datasets supports the delimitation of a new genus and the inclusion of Mucor fuscus based on 28S and ITS rDNA data.     

Toxoplasma gondii isolates: multilocus RFLP-PCR genotyping from human patients in Sao Paulo State, Brazil identified distinct genotypes

This study investigated the genetic characteristics of Toxoplasma gondii samples collected from 62 patients with toxoplasmosis in Sao Paulo State, Brazil. DNA samples were isolated from blood, cerebrospinal fluid and amniotic fluids of 25 patients with cerebral toxoplasmosis and AIDS, two patients with acute toxoplasmosis, 12 patients with ocular toxoplasmosis, six newborns with congenital toxoplasmosis and 17 pregnant women with acute infection. Diagnosis of toxoplasmosis was based in clinical, radiological and laboratory features. Genotyping was performed using multilocus PCR–RFLP genetic markers including SAG1, SAG2, 5′- and 3′-SAG2, alt.SAG2, SAG3, BTUB, GRA6, C22-8, c29-2, L358, PK1 and Apico. Among the 62 clinical samples, 20 (32%) were successfully genotyped at eight or more genetic loci and were grouped to three distinct genotypes. Eighteen samples belonged to ToxoDB Genotype #65 and the other two samples were identified as ToxoDB Genotypes #6 and #71, respectively (http://toxodb.org/toxo/). Patients presenting Genotypes #6 and #71 had severe and atypical cerebral toxoplasmosis, characterized by diffuse encephalitis without extensive brain lesions. These results indicate that T. gondii Genotype #65 may have a high frequency in causing human toxoplasmosis in Sao Paulo State, Brazil. This unusual finding highlights the need to investigate the possible association of parasite genotypes with human toxoplasmosis.     

Health Care Costs,Utilization and Patterns of Care following Lyme Disease

BackgroundLyme disease is the most frequently reported vector borne infection in the United States. The Centers for Disease Control have estimated that approximately 10% to 20% of individuals may experience Post-Treatment Lyme Disease Syndrome – a set of symptoms including fatigue, musculoskeletal pain, and neurocognitive complaints that persist after initial antibiotic treatment of Lyme disease. Little is known about the impact of Lyme disease or post-treatment Lyme disease symptoms (PTLDS) on health care costs and utilization in the United States.Objectives1) to examine the impact of Lyme disease on health care costs and utilization, 2) to understand the relationship between Lyme disease and the probability of developing PTLDS, 3) to understand how PTLDS may impact health care costs and utilization.MethodsThis study utilizes retrospective data on medical claims and member enrollment for persons aged 0-64 years who were enrolled in commercial health insurance plans in the United States between 2006-2010. 52,795 individuals treated for Lyme disease were compared to 263,975 matched controls with no evidence of Lyme disease exposure.ResultsLyme disease is associated with $2,968 higher total health care costs (95% CI: 2,807-3,128, p<.001) and 87% more outpatient visits (95% CI: 86%-89%, p<.001) over a 12-month period, and is associated with 4.77 times greater odds of having any PTLDS-related diagnosis, as compared to controls (95% CI: 4.67-4.87, p<.001). Among those with Lyme disease, having one or more PTLDS-related diagnosis is associated with $3,798 higher total health care costs (95% CI: 3,542-4,055, p<.001) and 66% more outpatient visits (95% CI: 64%-69%, p<.001) over a 12-month period, relative to those with no PTLDS-related diagnoses.ConclusionsLyme disease is associated with increased costs above what would be expected for an easy to treat infection. The presence of PTLDS-related diagnoses after treatment is associated with significant health care costs and utilization.     

The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety''s impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.     

Status of Aceria guerreronis Keifer (Acari: Eriophyidae) as a Pest of Coconut in the State of Sao Paulo, Southeastern Brazil

The coconut mite, Aceria guerreronis Keifer, is one of the main pests of coconut palms (Cocos nucifera) in northeastern Brazil. The objective of this study was to evaluate the levels of the coconut mite and other mites on coconut palms in the state of S?o Paulo and to estimate the possible role of predatory mites in the control of this pest. The effect of cultivated genotypes and sampling dates on the mite populations was also estimated. We sampled attached fruits, leaflets, inflorescences, and fallen fruits. The coconut mite was the main phytophagous mite found on attached and fallen fruits, with average densities of 110.0 and 20.5 mites per fruit, respectively. The prevalent predatory mites on attached and fallen fruits were Proctolaelaps bulbosus Moraes, Reis & Gondim Jr. and Proctolaelaps bickleyi (Bram), both Melicharidae. On leaflets, the tenuipalpids Brevipalpus phoenicis (Geijsks) and Tenuipalpus coyacus De Leon and the tetranychid Oligonychus modestus (Banks) were the predominant phytophagous mites. On both leaflets and inflorescences, the predominant predatory mites belonged to the Phytoseiidae. Neoseiulus baraki (Athias-Henriot) and Neoseiulus paspalivorus (De Leon), predators widely associated with the coconut mite in northeastern Brazil and several other countries, were not found. The low densities of the coconut mite in S?o Paulo could be related to prevailing climatic conditions, scarcity of coconut plantations (hampering the dispersion of the coconut mite between fields), and to the fact that some of the genotypes cultivated in the region are unfavorable for its development.     

Onychomycosis in São Paulo,Brazil

Onychomycosis is a fungal infection of the nails with broad aetiological scope, and it represents 18–40% of all onychopathies and 39% of all superficial mycotic infections. From July 1996 to December 1999, samples of nails were collected from 588 patients with presumptive diagnosis of onychomycosis at the Dermatology and Mycology Divisions EPM\UNIFESP, Brazil, and the diagnosis was confirmed in 247 of these cases. The most common pathogens isolated in this study were yeasts in 52% of positive cultures (Candida albicans 18.3%, Candida parapsilosis 13.8%, other species of Candida 15.4% and other yeasts 4.6%), followed by dermatophytes in 40.6% of positive cultures (the most commonly isolated organisms were Trichophyton rubrum in 33.2%, followed by Trichophyton mentagrophytes in 6.3% and others 1.2%). Non-dermatophyte moulds were isolated in 7.4% of positive cultures (Fusarium spp. 4.5%, Nattrassia mangiferae 2.3% and Aspergillus spp. 0.6%). Distal and lateral subungual onychomycosis (DLSO) was the commonest clinical pattern 44.6% followed by free edge onycholysis (FEO) 38.8% and others. In conclusion, this study demonstrated that T. rubrum is the main agent causing onychomycosis in toenails, and species of genus Candida were the main agents isolated in fingernail onychomycosis in our region.     

Gliotoxin contamination in and pre- and postfermented corn, sorghum and wet brewer's grains silage in Sao Paulo and Rio de Janeiro State, Brazil

Aims: The aim of this study was to determine total fungal counts and the relative density of Aspergillus fumigatus and related species in silage samples intended for bovines before and after fermentation as well as to monitor the natural occurrence of gliotoxin in silage samples (pre‐ and postfermentation). Methods and methods: The survey was performed in farms located in São Paulo and Rio de Janeiro States in Brazil. In addition, the ability of A. fumigatus strains and related species strains to produce gliotoxin was also evaluated. A total of 300 samples were taken, immediately after opening of the silo (3–5 months) and during the ensiling period. Fungal counts were done by the surface‐spread method. Gliotoxin production ability of isolates and natural contamination were determined by HPLC. Results: All postfermented samples had a total number of moulds exceeding 1 × 10⁴ CFU g^?1, with Aspergillus sp. as the most prevalent genus. Frequency of strains, among A. fumigatus and related species, was able to produce gliotoxin was similar in pre‐ and postfermented samples, except for sorghum, which showed differences between both kinds of samples. The highest toxin levels were produced by strains isolated from postfermented samples. More than 50% of the samples showed gliotoxin contamination levels that exceeded concentrations known to induce immunosuppressive and apoptotic effects in cells. Conclusions: The present data suggest that care should be taken because gliotoxin contamination in feedstuffs could affect productivity and also present a health risk for herds. Significance and Impact of the Study: Gliotoxin was found at quite important concentrations levels in pre‐ and postfermented substrates and its presence could therefore probably affect the productivity and health of herds. Current conservation and management practices do not avoid contamination with A. fumigatus on silage. Therefore, farm workers should be adequately protected during its handling.