The use of growth hormone to treat endocrine-metabolic disturbances in acquired immunodeficiency syndrome (Aids) patients

Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions.As primeiras descrições da síndrome da imunodeficiência adquirida (Aids) associavam-se à síndrome de emaciamento, e os distúrbios metabólicos às alterações na composição corporal. Após a introdução da terapia anti-retroviral altamente ativa (HAART), houve declínio na desnutrição, e surge a lipodistrofia como importante distúrbio metabólico. A Aids também se caracteriza por distúrbios hormonais, principalmente no eixo hormônio de crescimento/fator de crescimento insulina-like tipo 1 (GH/IGF-1). O uso do GH recombinante humano (hrGH) foi inicialmente indicado na síndrome de emaciamento, a fim de aumentar a massa muscular. Embora também não existam dúvidas quanto aos efeitos do hrGH na lipodistrofia, a diminuição na sensibilidade à insulina limita o seu uso, o qual ainda não está oficialmente aprovado. A diversidade nos esquemas de tratamento é outro limitante do uso dessa medicação em pacientes com Aids. Esta revisão apresenta os principais distúrbios endócrino-metabólicos associados à Aids e ao uso do hrGH nessas condições.Universidade Federal de São Paulo (UNIFESP) Departamento de Pediatria Serviço de Endocrinologia PediátricaUniversidade Estadual de Campinas Faculdade de Ciências Médicas Departamento de PediatriaUnicamp FCM Departamento de PediatriaUNIFESP, Depto. de Pediatria Serviço de Endocrinologia PediátricaSciEL

Reducing public health costs with infant formulas: oral food challenge and misdiagnosed or outgrown cow’s milk protein allergy

Background: Accurate diagnosis and appropriate management of cow’s milk protein allergy (CMPA) are crucial for avoiding unnecessary prescription of infant formulas. Here, we aimed to use the oral food challenge (OFC) for CMPA confirmation and for assessing development of natural tolerance to milk, in children with clinical CMPA diagnosis. We also assessed the economic impact in public health-care costs of reducing the prescription of infant formulas (provided by the São Paulo State’s public health service, in Brazil, until two years of age) after ruling out CMPA diagnosis in children with negative OFC results. Methods: We reviewed medical records of 76 children [41 males, median age = 2.0 years (0.8-5.0)] who underwent OFC from January 2016 to June 2018, 30 of whom were ≤2 years old. Results: Before OFC, 52 (68.4%), 20 (26.3%) and five (5.3%) children were diagnosed with non-IgE-mediated, IgE-mediated and mixed CMPA, respectively. Most children were fed with aminoacid-based formulas (n=29, 38%). OFC was negative in 58 (76%) children, thus ruling out CMPA diagnosis. Out of 18 (24%) OFC-positive children, most (n=10, 56%) had gastrointestinal symptoms. After ruling out CMPA diagnosis, a mean of 152.3 formula cans (2,161.14 US dollars) were saved per children by the public health service. The total amount saved was 64,834.27 US dollars. Conclusions: OFC proved important not only for ruling out misdiagnosed CMPA, but also for preventing the indiscriminate use of infant formulas, which, in turn, had positive consequences for public health costs.Objetivos: O diagnóstico preciso e o manejo apropriado da alergia à proteína do leite de vaca (alergia ao leite, AL) são cruciais para evitar a prescrição desnecessária de fórmulas infantis. Aqui, tivemos o objetivo de usar o teste de provocação oral aberto (TPOA) para a confirmação do diagnóstico de AL e para avaliar o desenvolvimento de tolerância natural ao leite, em crianças com diagnóstico clínico de AL. Também avaliamos o impacto nos custos de saúde pública da redução da prescrição de fórmulas infantis (fornecidas pelo serviço de saúde do estado de São Paulo até os dois anos de idade) após descartar o diagnóstico de AL em crianças com TPOA negativo. Métodos: Revisamos prontuários de 76 crianças [41 do sexo masculino, mediana de idade = 2. anos (0,8-5,0)] submetidas ao TPOA de janeiro de 2016 a junho de 2018, 30 das quais tinham dois anos de idade ou menos. Resultados: Antes do TPOA, 52 (68.4%), 20 (26.3%) e cinco (5.3%) crianças foram diagnosticadas com AL não mediada por IgE, mediada por IgE e de mecanismo misto, respectivamente.  A maioria das crianças era alimentada com fórmulas baseadas em aminoácidos (n=29, 38%). O TPOA foi negativo em 58 (76%) crianças, descartando, assim, o diagnóstico de AL. De 18 (24%) crianças positivas para o TPOA, a maioria (n=10, 56%) tinha sintomas gastrointestinais. Após descartar o diagnóstico de AL, uma média de 152,3 latas de fórmula (R$8.644,57) foram economizadas, por criança, pelo serviço público de saúde. O montante total economizado foi de R$ 259.337,09. Conclusão: O TPOA se mostrou importante, não apenas para descartar o diagnóstico de AL, como também para evitar o uso indiscriminado de fórmulas infantis, o que, por sua vez, teve consequências positivas para os custos de saúde pública

Experiência inicial de um hospital universitário utilizando a telemedicina na promoção de educação através de vídeo-conferências

Telehealth and telemedicine services are advancing rapidly, with an increasing spectrum of information and communication technologies that can be applied broadly to the population's health, and to medical education. The aim here was to report our institution's experience from 100 videoconferencing meetings between five different countries in the Americas over a one-year period. Retrospective study at Universidade Estadual de Campinas. Through a Microsoft Excel database, all conferences in all specialties held at our institution from September 2009 to August 2010 were analyzed retrospectively. A total of 647 students, physicians and professors participated in telemedicine meetings. A monthly mean of 8.3 (± 4.3) teleconferences were held over the analysis period. Excluding holidays and the month of inaugurating the telemedicine theatre, our teleconference rate reached a mean of 10.3 (± 2.7), or two teleconferences a week, on average. Trauma surgery and meetings on patient safety were by far the most common subjects discussed in our teleconference meetings, accounting for 22% and 21% of the total calls. Our experience with telemedicine meetings has increased students' interest; helped our institution to follow and discuss protocols that are already accepted worldwide; and stimulated professors to promote telemedicine-related research in their own specialties and keep up-to-date. These high-technology meetings have shortened distances in our vast country, and to other reference centers abroad. This virtual proximity has enabled discussion of international training with students and residents, to increase their overall knowledge and improve their education within this institution13013236Serviços de telessaúde e telemedicina estão avançando rapidamente, com um espectro cada vez maior de tecnologias da informação e comunicação que podem ser aplicadas de forma ampla para a saúde da população, bem como para a educação médica. O objetivo deste artigo é relatar a experiência da nossa instituição com 100 reuniões por videoconferência entre cinco diferentes países das Américas no período de um ano. Estudo retrospectivo na Universidade Estadual de Campinas. Através de um banco de dados do Microsoft Excel, foram analisadas retrospectivamente todas as conferências realizadas em nossa instituição, de setembro de 2009 a agosto de 2010, em todas as especialidades. Um total de 647 alunos, médicos e professores participaram das reuniões de telemedicina. Em média, 8,3 (± 4,3) teleconferências foram realizadas mensalmente durante o período analisado. Excluindo os feriados e o mês de inauguração do anfiteatro de telemedicina, as nossas taxas de teleconferência atingiram a média de 10,3 (± 2,7), ou duas teleconferências sobre uma média semanal. Cirurgia do Trauma e reuniões sobre segurança dos pacientes foram, de longe, os temas mais comuns discutidos em nossas reuniões de teleconferência, correspondendo por 22% e 21% do total de chamadas. Nossa experiência com as reuniões de telemedicina aumentou o interesse dos alunos, ajudou a nossa instituição a acompanhar e discutir protocolos que já são aceitos em todo o mundo e estimulou nossos professores a promover pesquisas relacionadas à telemedicina em suas próprias especialidades, mantendo-os atualizados. Essas reuniões com envolvimento de alta tecnologia encurtaram as distâncias dentro de nosso país vasto e com outros centros de referência no exterior. Esta proximidade virtual permitiu discussões com alunos e residentes sobre estágios internacionais a fim de aumentar seu conhecimento global e melhorar a sua educação dentro da própria instituiçã

The use of growth hormone to treat endocrine-metabolic disturbances in acquired immunodeficiency syndrome (Aids) patients

Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions.As primeiras descrições da síndrome da imunodeficiência adquirida (Aids) associavam-se à síndrome de emaciamento, e os distúrbios metabólicos às alterações na composição corporal. Após a introdução da terapia anti-retroviral altamente ativa (HAART), houve declínio na desnutrição, e surge a lipodistrofia como importante distúrbio metabólico. A Aids também se caracteriza por distúrbios hormonais, principalmente no eixo hormônio de crescimento/fator de crescimento insulina-like tipo 1 (GH/IGF-1). O uso do GH recombinante humano (hrGH) foi inicialmente indicado na síndrome de emaciamento, a fim de aumentar a massa muscular. Embora também não existam dúvidas quanto aos efeitos do hrGH na lipodistrofia, a diminuição na sensibilidade à insulina limita o seu uso, o qual ainda não está oficialmente aprovado. A diversidade nos esquemas de tratamento é outro limitante do uso dessa medicação em pacientes com Aids. Esta revisão apresenta os principais distúrbios endócrino-metabólicos associados à Aids e ao uso do hrGH nessas condições.525818832Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions

Lack Of Association Between Nutritional Status And Change In Clinical Category Among Hiv-infected Children In Brazil.

Malnutrition is common among HIV-infected children. Our objective was to study the occurrence of malnutrition and its relationship with changes in clinical category among HIV-infected children. Longitudinal study, at the Pediatrics Department and Pediatrics Investigation Center (CIPED), Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp). We reviewed the hospital records of 127 vertically HIV-infected children. Anthropometric measurements were obtained at the beginning of follow-up, at clinical category change and five months later. These were converted to z-scores of weight/age, height/age and weight/height. Data were presented as means, standard deviations, frequency counts and percentages. The Wilcoxon and Kruskal-Wallis tests and odds ratios were used in the analysis. We found that 51 (40.2%) were undernourished and 40 (31.5%) were stunted, with higher risk of being included in clinical category C. There was an association between nutritional condition and the clinical categories of the Centers for Disease Control classification (1994), and with age at symptom onset (except for height z-score). During follow-up, 36 patients (28.4%) changed their clinical category, which occurred early among the undernourished patients. The group that changed its clinical category maintained the same z-score distribution for weight, height and weight/height throughout follow-up. Aids manifestation severity was associated with nutritional status and with age at symptom onset, but change in clinical category was not followed by worsening of nutritional status.12362-

The distances covered by basketball referees in a match increase throughout the competition phases, with no change in physiological demand

It is crucial to know the demands on basketball referees, in different match periods (MPs) and phases of competition, for planning referee training and subsequent successful refereeing. To measure and evaluate the distance covered by referees in a match by measuring the number of interruptions, percentage of heart rate (%HR), and blood lactate concentration ([lac]) in different phases of competition and in different MPs. We studied the qualifying (QP), semifinal (SP), and final (FP) phases of a total of 12 matches (four matches in each phase) of the 2009-2010 Brazilian Basketball League. Distance covered, number of match interruptions, and referees' %HR and [lac] were analyzed. We compared the results between competition phases and between MPs (1st MP, 2nd MP, 3rd MP, and 4th MP). Regarding the distances covered, we observed significant differences (P < 0.05) in the 1st, 2nd, and 3rd MPs between the FP and the other two phases (SP and QP) throughout the match, between each phase; in the 4th MP, a significant difference was found when comparing the QP and the other two phases. Comparing the periods within each phase, we found that a greater distance was covered in the 4th MP in relation to the 3rd MP during the FP. No significant differences were found among the remaining variables. The distances covered by referees in a basketball match increase throughout competition phases. This information is essential for planning of training and for the subsequent success of a referee.It is crucial to know the demands on basketball referees, in different match periods (MPs) and phases of competition, for planning referee training and subsequent successful refereeing. To measure and evaluate the distance covered by referees in a match by measuring the number of interruptions, percentage of heart rate (%HR), and blood lactate concentration ([lac]) in different phases of competition and in different MPs. We studied the qualifying (QP), semifinal (SP), and final (FP) phases of a total of 12 matches (four matches in each phase) of the 2009-2010 Brazilian Basketball League. Distance covered, number of match interruptions, and referees' %HR and [lac] were analyzed. We compared the results between competition phases and between MPs (1st MP, 2nd MP, 3rd MP, and 4th MP). Regarding the distances covered, we observed significant differences (P < 0.05) in the 1st, 2nd, and 3rd MPs between the FP and the other two phases (SP and QP) throughout the match, between each phase; in the 4th MP, a significant difference was found when comparing the QP and the other two phases. Comparing the periods within each phase, we found that a greater distance was covered in the 4th MP in relation to the 3rd MP during the FP. No significant differences were found among the remaining variables. The distances covered by referees in a basketball match increase throughout competition phases. This information is essential for planning of training and for the subsequent success of a referee419319

Hepatotoxicity In Hiv-infected Children And Adolescents On Antiretroviral Therapy.

Adverse drug reactions are a significant problem in patients on antiretroviral therapy (ART). We determined liver enzyme elevation frequencies in HIV-infected children and adolescents receiving ART, and their association with risk factors. Cross-sectional study, at the Pediatrics Immunodeficiency Division, University Hospital, Universidade Estadual de Campinas. Medical records of 152 children and adolescents (54.6% male; median age 7.48 years) were analyzed, with a mean of 2.6 liver enzyme determinations per patient. Clinically, patients were classified in categories N (6), A (29), B (78) and C (39). Serum levels of aspartate aminotransferase and alanine aminotransferase were evaluated. Hepatotoxicity was scored as grade 1 (1.1-4.9 times upper limit of normality, ULN), grade 2 (5.0-9.9 times ULN), grade 3 (10.0-15.0 times ULN) and grade 4 (> 15.0 times ULN). To assess hepatotoxicity risk factors, odds ratios (OR) and adjusted odds ratios (aOR) for age, gender, TCD4+ cell count, viral load and medication usage were calculated. We observed grade 1 hepatotoxicity in 19.7 % (30/152) patients. No cases of grade 2, 3 or 4 were detected. There was a significant association between hepatotoxicity and use of sulfonamides (OR, 3.61; 95% confidence interval (CI), 1.50-8.70; aOR, 3.58; 95% CI, 1.44-8.85) and antituberculous agents (OR, 9.23; 95% CI, 1.60-53.08; aOR, 9.05; 95% CI, 1.48-55.25). No toxicity was associated with ART. One fifth of patients experienced mild hepatotoxicity, attributed to antituberculous agents and sulfonamides. Our results suggest that ART was well tolerated.125205-

Quality of sleep and quality of life in adolescents infected with human immunodeficiency virus

Objectives: To assess sleep characteristics of adolescents infected by HIV, and to ascertain whether psychosocial aspects are associated to the quality of sleep. Methods: A cross-sectional study assessing 102 HIV-infected adolescents of both genders, aged between 10 and 20 years-old and 120 Controls. Data collection was performed by applying the Sleep Disturbance Scale for Children, the Epworth Sleepiness Scale, and the Pediatric Quality of Life Inventory. Results: A sleep disturbance prevalence of 77.4% was found in patients, and a 75% prevalence in controls, and there was correlation between quality of sleep and of life. HIV-infected adolescents scored higher for sleep breathing disorders and had higher prevalence of excessive daytime sleepiness. Conclusions: HIV-infected adolescents had similar quality of sleep compared to healthy adolescents. This may be explained by the steady improvements in daily living as a result of successful anti-retroviral therapy, and by the vulnerability that affects Brazilian adolescents living in major urban centers.Coordenacao do Aperfeicoamento do Pessoal de Nivel Superior (CAPES)Coordenacao de Aperfeicoamento do Pessoal de Nivel Superior (CAPES)Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP)Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP