Júlio Maria Fonseca Chebli

Insulin resistance in non-diabetic patients with chronic hepatitis C: what does it mean?

OBJECTIVES To determine the prevalence of insulin resistance (IR) in non-diabetic patients with chronic hepatitis C, and to assess the association between IR, laboratory parameters and histological findings. SUBJECTS AND METHODS Eighty-two patients had their serum analyzed for glucose, lipid profile, C-reactive protein (CRP), ferritin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), HOMA-IR, viral load and HCV genotype. Patients with HOMA-IR levels > 2.5 were considered as carriers of insulin resistance. RESULTS IR was observed in 27% of patients and was associated with age, waist circumference and body mass index. IR patients were more likely to have more advanced hepatic fibrosis and necroinflammatory activity, higher levels of aminotransferases and liver steatosis than patients without IR. CONCLUSIONS Insulin resistance is often present in patients with chronic hepatitis C, and this parameter is associated with more advanced HCV-related hepatic fibrosis.

Infecção pelo vírus da hepatite c em pacientes em hemodiálise: prevalência e fatores de risco

ABSTRACT – Context - Chronic renal disease patients on hemodialysis are at increased risk of infection by hepatitis C virus (HCV). High prevalence rates have been reported from dialysis units worldwide. Recent studies have shown an inverse relation between HCV infection and life expectancy of patients on hemodialysis and those undergoing renal transplant. Objectives - Assess the prevalence of and risk factors for HCV infection in patients undergoing hemodialysis. Methods - A cross-sectional study was undertaken from January to December, 2007. During this period, 236 patients were tested for anti-HCV antibodies with third generation ELISA. Those who tested positive further underwent qualitative PCR testing for HCV-RNA. A subject was considered HCV-infected if both tests (anti-HCV and HCV-RNA) were positive. Monthly serum ALT and the mean for the 12-month period were obtained from 195 patients. Two hundred eight (88.1%) patients answered a standardized questionnaire aiming to identify risk factors for HCV infection.CONTEXT Chronic renal disease patients on hemodialysis are at increased risk of infection by hepatitis C virus (HCV). High prevalence rates have been reported from dialysis units worldwide. Recent studies have shown an inverse relation between HCV infection and life expectancy of patients on hemodialysis and those undergoing renal transplant. OBJECTIVES Assess the prevalence of and risk factors for HCV infection in patients undergoing hemodialysis. METHODS A cross-sectional study was undertaken from January to December, 2007. During this period, 236 patients were tested for anti-HCV antibodies with third generation ELISA. Those who tested positive further underwent qualitative PCR testing for HCV-RNA. A subject was considered HCV-infected if both tests (anti-HCV and HCV-RNA) were positive. Monthly serum ALT and the mean for the 12-month period were obtained from 195 patients. Two hundred eight (88.1%) patients answered a standardized questionnaire aiming to identify risk factors for HCV infection. RESULTS Of the 236 subjects studied, 14.8% (35/236) tested positive for anti-HCV antibodies. Of these, 71.6% (25/35) tested positive for HCV-RNA. Chronic HCV infection was thus prevalent in 10.6% (25/236). Bivariate analysis showed time on hemodialysis, number of blood transfusions, previous peritoneal dialysis and previous sexually transmitted diseases to be the main risk factors for HCV infection. Yet multivariate analysis showed that just time on hemodialysis and previous sexually transmitted diseases were significantly associated with HCV infection. Patients on hemodialysis for over 10 years were 73.9 (CI 17.5-311.8) times as likely to have acquired HCV, compared with those on hemodialysis for up to 5 years. Patients with previous sexually transmitted diseases had a 4.8 times higher risk of HCV infection compared with those without previous sexually transmitted diseases. Mean serum ALT was significantly higher in HCV-infected patients (44.0 +/-13.5 U/L versus 33.5 +/- 8.0 U/L, P<0,001). CONCLUSION HCV infection was highly prevalent in the dialysis unit studied. Time on dyalitic treatment and previous sexually transmitted diseases were the main risk factors for HCV infection. HCV-infected patients on hemodialysis had higher serum ALT levels than those without chronic HCV infection.

Não-adesão ao tratamento em pacientes com doença de Crohn: prevalência e fatores de risco

CONTEXT Non-adherence to therapy, in any degree is a common event and occurs in several circumstances. It is one of most common cause of fail in therapy of chronic diseases and Crohns disease is not an exception. OBJECTIVE To evaluate in patients with Crohns disease the prevalence and the risk factors to non-adherence to therapy. METHODS From July 2006, for 12 months, were included prospectively, for non-adhesion to therapy 100 patients with Crohns disease that were assisted in a Center for Inflammatory Bowel Diseases of University Hospital of Federal University of Juiz de Fora, MG, in Brazil. A modified Morisky & Green Test for Measure of Adherence to Therapy was answered by all of them. According to test the patients were classified in two groups defined as adherence and non-adherence, respectively, and the last one was separated in intentional and non-intentional adhesion. Clinical, psychological and pharmacotherapeutics variables were sought to find the factors related to non-adherence. RESULTS Sixty four percent of total group were noticed to have a score of non-adherence to therapy according to used test and non-intentional was the most common type of behavior in such patients, and they demonstrated to be conscious of therapy. The comparison of adherent and non-adherent patients displayed a significant tendency to occurrence of non-adherence in younger (P = 0.07) and in non-white patients (P = 0.06). No correlation was observed in comparison of psychological and pharmacotherapeutics variables and non-adherence. CONCLUSIONS In patients with Crohns disease the prevalence of non-adherence to therapy is high (64%). The younger and non-white patients have higher propensity to non-adherence. In such circumstances efforts should be made to look for strategies to deal with this sort of people suffering from Crohns disease, trying to increase the degree of adherence in this sort of patients.

Diarréia nosocomial em unidade de terapia intensiva: incidência e fatores de risco

RACIONAL: Diarreia nosocomial parece ser comum em unidades de terapia intensiva, embora sua epidemiologia seja pouco documentada em nosso meio. OBJETIVO: Determinar a incidencia e fatores de risco de diarreia entre pacientes adultos internados em unidade de terapia intensiva. METODOS: Foram incluidos prospectivamente 457 pacientes no periodo entre outubro de 2005 e outubro de 2006. Dados demograficos, clinicos e bioquimicos, bem como aspecto e numero de evacuacoes eram registrados diariamente ate a saida do paciente do setor. RESULTADOS: Diarreia ocorreu em 135 (29,5%) pacientes, durando em media 5,4 dias. O tempo do seu inicio em relacao a internacao foi de 17,8 dias e casos similares de diarreia no mesmo periodo foram registrados em 113 (83,7%) pacientes. A mortalidade hospitalar foi maior nos pacientes com diarreia do que naqueles sem esta intercorrencia. Na analise multivariada atraves de modelo de regressao logistica, apenas o numero de antibioticos (OR 1,65; IC 95% = 1,39-1,95) e o numero de dias de antibioticoterapia (OR 1,16; IC 95% = 1,12-1,20) associaram-se estatisticamente com a ocorrencia de diarreia. Cada dia de acrescimo a mais da antibioticoterapia aumentou em 16% o risco de diarreia (IC 12% a 20%), enquanto a adicao de um antibiotico a mais ao esquema antimicrobiano aumentou as chances de ocorrencia de diarreia em 65% (IC 39% a 95%). CONCLUSAO: A incidencia de diarreia nosocomial na unidade de terapia intensiva e elevada (29,5%). Os principais fatores de risco para sua ocorrencia foram numero de antibioticos prescritos e duracao da antibioticoterapia. Alem das precaucoes entericas, a prescricao judiciosa e limitada de antimicrobianos, provavelmente reduzira a ocorrencia de diarreia neste setor.

HEPATITIS AND PNEUMONITIS DURIN ADALIMUMAB THERAPY IN CROHN’ DISEASE: mind the histoplasmosis!

CONTEXT Tumor necrosis factor-alpha (TNF-α) inhibitor therapy plays a pivotal role in the management of moderate to severe inflammatory bowel disease. Because of the role of TNF-α in the host defenses, anti-TNF therapy has been associated with an increase the risks of granulomatous infections. OBJECTIVE To report the first case of adalimumab-associated invasive histoplasmosis presenting as an acute hepatitis-like syndrome and febrile pneumonitis in a patient with Crohns disease. METHOD Case report of a patient with progressive histoplasmosis confirmed by percutaneous fine needle aspiration biopsy lung and urine Histoplasma antigen. RESULTS We present the case of a young man with CD who developed pneumonia and acute hepatitis-like features caused by Histoplasma capsulatum infection during adalimumab therapy. To the best of our knowledge, this acute hepatitis-like manifestation has never been reported as a presentation of the histoplasmosis in patients with Crohns disease. CONCLUSIONS This case underscores the potential risk for serious infection that may arise in this setting and should alert clinicians to the need to consider the histoplasmosis diagnosis in patients presenting with acute hepatitis-like syndrome associated with prolonged febrile illness or pneumonitis during therapy with anti-TNF-α antibodies.

POSITIVE CORRELATION BETWEEN DISEASE ACTIVITY INDEX AND MATRIX METALLOPROTEINASES ACTIVITY IN A RAT MODEL OF COLITIS

CONTEXT Inflammatory bowel disease, including ulcerative colitis and Crohns disease, comprising a broad spectrum of diseases those have in common chronic inflammation of the gastrointestinal tract, histological alterations and an increased activity levels of certain enzymes, such as, metalloproteinases. OBJECTIVES Evaluate a possible correlation of disease activity index with the severity of colonic mucosal damage and increased activity of metalloproteinases in a model of ulcerative colitis induced by dextran sulfate sodium. METHODS Colitis was induced by oral administration of 5% dextran sulfate sodium for seven days in this group (n=10), whereas control group (n=16) received water. Effects were analyzed daily by disease activity index. In the seventh day, animals were euthanized and hematological measurements, histological changes (hematoxylin and eosin and Alcian Blue staining), myeloperoxidase and metalloproteinase activities (MMP-2 and MMP-9) were determined. RESULTS Dextran sulfate sodium group showed elevated disease activity index and reduced hematological parameters. Induction of colitis caused tissue injury with loss of mucin and increased myeloperoxidase (P<0.001) and MMP-9 activities (45 fold) compared to the control group. CONCLUSIONS In this study, we observed a disease activity index correlation with the degree of histopathological changes after induction of colitis, and this result may be related mainly to the increased activity of MMP-9 and mieloperoxidase.

Acute diarrhea in hospitalized children of the municipality of juiz de fora, MG, Brazil: prevalence and risk factors associated with disease severity

CONTEXT Acute diarrhea is a common cause of hospitalization among children under 5 years of age. Knowing the prevalence and risk factors associated with the severity of acute diarrhea is essential to control morbidity and mortality. OBJECTIVE Describe the prevalence of demographic, epidemiologic and clinical features of children under 6 years of age hospitalized for acute diarrhea, and investigate the association between these determinants and the severity of the diarrheic episode. METHOD Retrospective, cross-sectional study, during the period from January, 2005 through December, 2008, in the municipality of Juiz de Fora, MG, Brazil. Files from 6,201 children from 0 to 6 years of age, hospitalized in two public teaching institutions (which account for 84% of all the hospitalizations in the municipality), were assessed. Acute diarrhea was defined as the presence of at least three evacuations of liquid or loose stools, within 24 hours, for a maximum period of 14 days. The patients with acute diarrhea were divided in two groups, according to disease severity, severe diarrhea being considered whenever hospitalization lasted for at least 4 days. Epidemiologic and clinical data were assessed and compared through the application of the chi-squared test and the binomial logistic regression model. RESULTS The prevalence rate for admission due to acute diarrhea was 8.4%. The factors significantly associated with the severity of the diarrheic episode were: age under 6 months (P = 0.01, OR = 2.762); disease onset during fall (P = 0.033, OR = 1.742), presence of fever (P = 0.017, OR = 1.715) and antibiotic use during hospitalization (P = 0.000, OR = 3.872). CONCLUSIONS Diarrhea is the third most common cause of hospitalization among children under 6 years of age in Juiz de Fora. Young age (under or equal to 6 months), fever, antibiotic use during hospitalization and disease onset during fall are risk factors associated with longer hospital stay.

Toxicidade da azatioprina na doença de Crohn: incidência, abordagem e evolução

OBJECTIVE: Azathioprine (AZA) is frequently used in Crohns disease (CD) therapy. This paper aimed to evaluate the frequency, evolution and management of AZA side effects in CD patients. METHODS: One hundred and six CD patients under AZA therapy were evaluated prospectively from January 2002 to December 2006. Clinical and demographic data were recorded, together with a monthly laboratory control of hematological or other adverse reactions by means of clinical evaluation. Comparison was carried out between groups with and without side effects. RESULTS: At least one adverse reaction was found in 56 (52.7%) of the patients studied and required a transient drug reduction; 18 (17%) had to definitely stop use of AZA, often because of hypersensitivity reactions. Nausea, vomit, although slight, occurred in 29 (27.4%). The black race and those with co-morbidities had more gastric intolerance than Caucasians and those without other associated disease (p=0.04). Leucopoenia was the more frequent side effect observed, occurring in 36 (34%). The period of AZA use was longer for patients with leucopoenia than for those without (p=0.001), while the mean dose of AZA was lower for those with leucopoenia when compared to non-leucopoenics (p=0.005). No serious infections, malignancy or death was noticed as a consequence of AZA use. CONCLUSION: In this study use of AZA in therapy for Crohns disease disclosed that the drug is satisfactorily safe as long as periodical clinical and laboratory supervision is carried out during treatment.

Alterações no teste ultra-rápido da urease e no exame anatomopatológico para Helicobacter pylori induzidas por drogas anti-secretoras

Background - One of the major problems when evaluating dyspeptic patients at public hospitals is the large interval between the consultation and the endoscopy, leading to the prescription of antisecretory drugs, what can be responsible for false results on examinations. Aim - To evaluate changes in ultrarapid urease test and histopathological examination for Helicobacter pylori by antisecretory drugs. Methods - In a prospective double-blind study, 50 patients with dyspeptic complaints and endoscopic diagnosis of peptic ulcer, erosive gastritis, esophagitis or duodenitis, with a positive urease test, were randomized to a 7-day course of treatment with either omeprazole 20 mg or ranitidine 300 mg a day. Before and after treatment, two biopsy specimens each were obtained from the antrum and corpus and an ultrarapid urease test and a histopathological examination for Helicobacter pylori were performed. Results - There were no significant changes in the results of ultrarapid urease test and histopathological examination for Helicobacter pylori after treatment with ranitidine. With omeprazole, we observed a decrease in positive results in ultrarapid urease test and histopathological examination for Helicobacter pylori in the antrum, but not in the corpus. Conclusion - Omeprazole, used for 7 days, can lead to negative results in ultrarapid urease test and histopathological examination for Helicobacter pylori in the antrum, and should not be employed in patients before the endoscopy is performed.

Severe hypoproteinemia as a harbinger of Ménétrier's disease in autoimmune pancreatitis

Ménétriers disease is an extremely rare disease of unknown etiology causing gastric mucosal hypertrophy and protein-losing gastropathy. Rare cases of this condition have been reported in patients with autoimmune diseases. However, to the best of our knowledge, Ménétriers disease associated with autoimmune pancreatitis (AIP) has never been reported. We described a case of severe hypoproteinemia as a harbinger of Ménétriers disease associated with AIP. The patient was successfully treated with octreotide and high-protein diet, which led to symptomatic remission and significant improvement in serum levels of albumin and recovery of the nutritional status. Thus, in AIP patients presenting with severe and persistent hypoproteinemia without apparent cause, clinicians need to consider Ménétriers disease in the differential diagnosis. In this setting, endoscopic evaluation with histological examination of gastric biopsy material, including a full-thickness mucosal biopsy of involved mucosa, may be helpful in promptly establishing the diagnosis and allowing appropriate and timely therapy.