[Show abstract][Hide abstract] ABSTRACT: Introduction:
The prevalence of sexual dysfunction (SD) and dissatisfaction with sexual life (DSL) in patients with chronic hepatitis C virus infection (CHC) was jointly investigated via a thorough psychopathological analysis, which included dimensions such as fatigue, impulsiveness, psychiatric comorbidity, health-related quality of life (HRQL) and sociodemographic and clinical characteristics.
Male and female CHC patients from an outpatient referral center were assessed using the Brief Fatigue Inventory, the Barrat Impulsiveness Scale, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale, the Hamilton Anxiety Scale (HAM-A), and the World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF). Structured psychiatric interviews were performed according to the Mini-International Neuropsychiatric Interview. SD was assessed based on specific items in the BDI (item 21) and the HAM-A (item 12). DSL was assessed based on a specific question in the WHOQOL-BREF (item 21). Multivariate analysis was performed according to an ordinal linear regression model in which SD and DSL were considered as outcome variables.
SD was reported by 60 (57.1%) of the patients according to the results of the BDI and by 54 (51.4%) of the patients according to the results of the HAM-A. SD was associated with older age, female gender, viral genotype 2 or 3, interferon-α use, impulsiveness, depressive symptoms, antidepressant and benzodiazepine use, and lower HRQL. DSL was reported by 34 (32.4%) of the patients and was associated with depressive symptoms, anxiety symptoms, antidepressant use, and lower HRQL.
The prevalence of SD and DSL in CHC patients was high and was associated with factors, such as depressive symptoms and antidepressant use. Screening and managing these conditions represent significant steps toward improving medical assistance and the HRQL of CHC patients.
Revista da Sociedade Brasileira de Medicina Tropical 10/2014; 47(5):564-72. DOI:10.1590/0037-8682-0147-2014 · 0.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
To assess correlates of hepatitis B among adults with mental illness under care in Brazil.
Cross-sectional national multicenter study of 2,206 patients with mental illnesses randomly selected from 26 public mental health services. Sociodemographic and behavioral data were obtained from face-to-face interviews and psychiatric diagnoses from medical charts. Serology testing was conducted and prevalence rate ratios were estimated by log-binomial regression.
The weighted prevalence of current HBV infection (HBsAg +) and previous HBV exposure (anti-HBc +) were 2.0% (95%CI: 1.5%-2.7%) and 17.1% (95%CI: 16.0%-19.0%), respectively. Correlates of HBsAg + included male gender, younger age (18–29 y.o.), unstable place of residence, intellectual disability, main psychiatric diagnosis of dementia, presence of other medical comorbitidy, use of alcohol/drugs during sex, more than one sexual partner, and use of cocaine. Correlates of anti-HBc + included male gender, older age (≥ 30 y.o.), black skin color, lower education, unstable place of residence, currently hospitalized, intellectual disability, history of any STD or syphilis, poor HIV knowledge, history of imprisonment and sexual violence.
Hepatitis B is an important comorbidity among psychiatric patients in Brazil. Screening for HBV, effective prevention and intervention strategies, including universal HBV immunization, should be routine practices in these mental health services.
General hospital psychiatry 07/2014; 36(4). DOI:10.1016/j.genhosppsych.2014.03.001 · 2.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aimed to assess the prevalence of, and associated factors with, anal intraepithelial neoplasia (AIN) among HIV-positive men evaluated at public health services in Brazil.
This is a multicenter cross-sectional study of HIV-positive male patients attending 6 public AIDS referral clinics in urban Brazil. Participants were interviewed for sociodemographic and behavioral characteristics. Anal swab specimens were collected for anal cytology and HPV DNA testing using L1 polymerase chain reaction. Univariate and multivariate analyses were performed to evaluate risk factors associated with the presence of low-grade squamous intraepithelial lesion (LSIL) and/or high-grade squamous intraepithelial lesion (HSIL).
Anal swabs were collected from 343 participants. Prevalence of LSIL/HSIL was 24.8%. The majority (60.1%) reported sexual intercourse with both men and women in their lifetime. At least 36.7% had 1 or more oncogenic HPV types. Four variables were independently associated with the presence of LSIL/HSIL in multivariate analysis: history of sex with both men and women (odds ratio [OR] = 4.8) or men only (OR = 6.2) compared with those having sex with women only; current cigarette smoking (OR = 2.2); current CD4 level between 200 and 500 cells/mm (OR = 2.9) or below 200 cells/mm (OR = 3.8) compared with CD4 level above 500 cells/mm; and presence of oncogenic anal HPV infection (OR = 9.6).
We found a high prevalence of AIN among HIV-positive men in Brazil. This population may serve as an important bridge population to women with implications for anogenital HPV infection in both men and women. Our findings confirm the need to assess screening programs for AIN among high-risk groups, similar to those used to prevent cervical cancer.
[Show abstract][Hide abstract] ABSTRACT: Introduction:
Chronic hepatitis C virus infection patients have higher rates of psychiatric disorders than the general population. Chronic hepatitis C virus infection is known to be associated with impaired health related quality of life. To our knowledge, there is no previous research of health related quality of life in chronic hepatitis C patients that combined structured psychiatric interview and careful psychopathological evaluation, including depression, anxiety and fatigue instruments. The aim of this study was to evaluate health related quality of life of chronic hepatitis C patients and to investigate the association with sociodemographic, psychopathological and psychiatric factors.
Materials and methods:
Eighty-one individuals with chronic hepatitis C virus infection receiving care at a Brazilian public university-based outpatient service for infectious diseases were enrolled in the study. The World Health Organization Quality of Life Scale Brief Version was used to assess health related quality of life. Standard psychiatric interview (Mini International Neuropsychiatric Interview-Plus) was conducted to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric diagnosis. Further instruments completed psychopathological investigation: Beck Depression Inventory, Hospital Anxiety and Depression Scale, Brief Fatigue Inventory, Hamilton Depression Scale and Hamilton Anxiety Scale. Pearson Chi-Square and Kruskal-Wallis were performed for categorical and continuous univariate analysis, respectively. Correlation between psychopathological and health related quality of life scores was performed according to Spearman's correlation. Multivariate analysis was performed according to stepwise forward ordinal logistic regression. The significance threshold was fixed at α=0.05.
Depressive disorders were associated with worse scores in overall health related quality of life and in all domains. Fatigue was associated with lower scores in physical and psychological domains, and married status with higher scores in psychological health related quality of life. We found strong correlation among scores of depression, fatigue and health related quality of life.
Depression and fatigue must be properly investigated and managed in HCV patients in order to improve HRQL. WHOQOL-BREF proved to be a useful instrument to assess HRQL in HCV patients.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 07/2013; 17(6). DOI:10.1016/j.bjid.2013.03.008 · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
To investigate impulsiveness among chronic hepatitis C (CHC) patients and its association with sociodemographic, clinical, and psychopathological factors.
Ninety one CHC individuals were enrolled in a cross-sectional study at a Brazilian public university-based outpatient’s service for infectious diseases. They were assessed using Barrat Impulsiveness Scale, Brief Fatigue Inventory, Beck Depression Inventory and Hamilton Anxiety Scale. Structured psychiatric interview was performed according to the Mini International Neuropsychiatric Interview. Multivariate analysis was performed according to linear stepwise forward regression.
The total score of impulsiveness according to BIS in studied population was 64.6 ± 9.8. The scores for the non-planning, cognitive-attentional and motor domains were 23.8 ± 5, 19.4 ± 2.9, and 21.4 ± 5, respectively. Impulsiveness was associated with lower educational level, current IFN use, attention deficit hyperactivity disorder, alcohol use disorder, mixed anxiety and depressive disorder, specific phobia, bipolar spectrum disorders and anxiety symptoms. During IFN treatment, impulsiveness was also associated with suicide risk.
Impulsiveness was frequent in CHC patients and was associated with several psychopathological alterations. Impulsiveness management should be considered when attending CHC patients.
General hospital psychiatry 01/2013; 36(3). DOI:10.1016/j.genhosppsych.2013.12.006 · 2.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The objective was to assess factors associated with previous exposure to hepatitis C virus (HCV) infection among Brazilian adults in mental health centers.
A cross-sectional national multicenter study of 2087 psychiatric patients randomly selected from 26 public mental health services was conducted between 2005 and 2007 in Brazil. An interview was conducted for obtaining sociodemographic, clinical and behavioral data. Psychiatric diagnoses were obtained from medical charts. Serology testing was conducted using anti-HCV. The magnitude of the associations was estimated by the prevalence rate ratio under Poisson distribution. Multivariate analysis for previous HCV exposure was carried out by weighted Poisson regression.
The weighted prevalence of previous HCV exposure was 2.53% (95% confidence interval: 2.22-2.83). Factors associated with previous exposure to HCV infection included male gender; age ≥ 40 years; history of sexually transmitted infections; current tobacco use; lifetime injecting drug use; exchange of money/drugs for sex; and main psychiatric diagnoses of psychoses and bipolar disorders, substance use disorders or dementia.
Our results indicate a high prevalence of previous exposure to HCV in this population of Brazilian psychiatric patients. Most factors statistically associated with HCV were demographic or behavioral related, indicating a potential high-vulnerability profile. Screening for HCV in high-risk patients should be routine practices in these mental health services in Brazil.
General hospital psychiatry 12/2012; 35(2). DOI:10.1016/j.genhosppsych.2012.11.005 · 2.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To conduct a cost-effectiveness analysis of drug alternatives with rescue therapy in case of relapse due to viral resistance for the treatment of patients with chronic hepatitis B (CHB).
Hypothetical cohort of patients with CHB, HBeAg-negative, without clinical or histological evidence of cirrhosis, detectable HBV DNA, histological diagnosis of the disease, positive serum HBsAg for longer than six months, high levels of alanine aminotransferase (ALT) (twice as high as the upper limit of normality) and mean age of 40 years. A Markov model was developed for chronic hepatitis B (HBeAg- negative) with a 40-year time horizon. Costs and benefits were discounted at 5%. Annual rates of disease progression, costs due to complications and the efficacy of medicines were obtained from the literature. One-way and probabilistic sensitivity analysis evaluated uncertainties.
Initiation of treatments with entecavir resulted in an increase of 0.35 discounted life-years gained compared to lamivudine. The incremental cost-effectiveness ratio was R$16,416.08 per life-years gained. In the sensitivity analysis, the incremental cost-effectiveness ratio was more sensitive to variation in the probability of transition from chronic hepatitis B to compensated cirrhosis, discount rate and medicine prices (± 10%). In the probabilistic sensitivity analysis, the acceptability curve showed that beginning treatment with entecavir was the most cost-effective alternative in comparison with the use of lamivudine.
The availability of entecavir is economically attractive as part of early treatment for patients with chronic hepatitis B without HIV co-infection.
Revista de saude publica 12/2012; 46(6):942-9. DOI:10.1590/S0034-89102012000600003 · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To settle the best cutoffs for inventories to diagnose depression in chronic hepatitis C (CHC) patients.
Seventy-five CHC patients were assessed using a standard psychiatric interview (Mini International Neuropsychiatric Interview) to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depression diagnosis and the following inventories: the Beck Depression Inventory (BDI), its short form for Primary Care (BDI-PC) and the Hospital Anxiety and Depression Subscale for Depression (HAD-D). According to the receiver operative characteristic (ROC) curve, the best cutoff to screen for depression was settled, and sensitivity, specificity, and positive and negative predictive values were calculated. Agreement between each inventory and the diagnosis of depression was calculated through Cohen's Kappa. Internal consistency was measured through Cronbach's alpha.
Twenty-one (28%) individuals met criteria for a depressive disorder. BDI, BDI-PC and HAD-D best scores were settled at 18, 5 and 8 points, respectively. They showed the following discriminative properties: sensitivity 81%, 76.2%, 85.7%; specificity 92.6%, 88.9%, 77.8%; positive predictive value 81%, 72.7%, 60%; negative predictive value 92.6%, 90.6%, 93.3%, respectively. ROC curve areas were similar between BDI and BDI-PC, but slightly lower for HAD-D. The agreement between inventories and DSM-IV depression diagnosis was substantial for BDI (0.91) and BDI-PC (0.91) and moderate for HAD-D (0.86). Internal consistency was 0.90, 0.86 and 0.75, respectively.
BDI, BDI-PC and HAD-D showed good discriminative properties to screen for depression in CHC patients and should be considered in clinical practice.
General hospital psychiatry 01/2012; 34(1):40-5. DOI:10.1016/j.genhosppsych.2011.09.002 · 2.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The incidence of anal cancer has increased in developed countries. There is evidence that high-grade anal intraepithelial neoplasia and anal cancer are both linked to some human papillomavirus (HPV) infections. There are scarce data on anal cancer or male anal HPV infection in Brazil.
The purpose of this study was to assess the prevalence of anal HPV infection and associated risk factors, stratified by oncogenic and nononcogenic types, in a sample of HIV-seropositive men in Brazil.
Multicenter cross-sectional study of HIV-seropositive male patients attending public AIDS clinics in urban Brazil. Participants were interviewed for sociodemographic and behavioral characteristics. Anal HPV specimens were collected with a moistened Dacron swab inserted into the anal and stored in ThinPrep solution. HPV DNA-positive samples were typed by dot-blot hybridization. The prevalences of oncogenic and nononcogenic HPV types were calculated and multinomial logistic regression was used to assess independent predictors of HPV infection.
: Among 445 men, 65.6% were positive for HPV DNA in the anal canal. Oncogenic types were detected in 40.7%. Logistic regression indicated that lifetime history of sexual intercourse only with men or with men and women; receptive anal intercourse in the last 12 months; and CD4 lymphocyte count below 200 cells per cubic millimeter were independently associated with the detection of anal HPV infection.
The high prevalence of anal HPV infection in this cross-sectional study underscores the need for studying and implementing screening programs of high-risk groups in Brazil.
[Show abstract][Hide abstract] ABSTRACT: The host immune response plays an important role in viral clearance in patients who are chronically infected with hepatitis C virus (HCV) and are treated with interferon and ribavirin. Activation of the immune system involves the release of pro and anti-inflammatory molecules that can be measured in plasma samples. The present study aimed to evaluate the association between pretreatment plasma levels of chemokines and soluble tumor necrosis factor receptors (sTNF-R) and the virological response in treated patients with chronic hepatitis C infection. Forty-one chronically-infected HCV patients that were being treated with interferon-α (IFN-α) plus ribavirin were included in the study. Socio-demographic, clinical and laboratory data were collected and pretreatment plasma levels of chemokine CCL2, CCL3, CCL11, CCL24, chemokine CXCL9, CXCL10, sTNF-R1 and sTNF-R2 were measured. The virological response was assessed at treatment week 12, at the end of treatment and 24 weeks after treatment. Pretreatment CXCL10 levels were significantly higher in patients without an early virological response (EVR) or sustained virological response (SVR) compared to responders [512.9 pg/mL vs. 179.1 pg/mL (p = 0.011) and 289.9 pg/mL vs. 142.7 pg/mL (p = 0.045), respectively]. The accuracy of CXCL10 as a predictor of the absence of EVR and SVR was 0.79 [confidence interval (CI) 95%: 0.59-0.99] and 0.69 (CI 95%: 0.51-0.87), respectively. Pretreatment plasma levels of the other soluble inflammatory markers evaluated were not associated with a treatment response. Pretreatment CXCL10 levels were predictive of both EVR and SVR to IFN-α and ribavirin and may be useful in the evaluation of candidates for therapy.
Memórias do Instituto Oswaldo Cruz 02/2011; 106(1):38-43. DOI:10.1590/S0074-02762011000100006 · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Host immune response seems to be mainly responsible for the progression of liver disease among patients with hepatitis C virus (HCV) infection. Immune activation involves the release of cytokines and their receptors that can be measured in plasma samples. The study aimed to evaluate the association between plasma levels of chemokines and soluble tumor necrosis factor receptors (sTNFR) and liver histological changes among patients with chronic HCV infection. Seventy-one treatment-naive patients were included. Plasma levels of CCL2, CCL3, CCL11, CCL24, CXCL9, CXCL10, sTNFR1, and sTNFR2 were measured and liver histological findings were reviewed. Plasma levels of CXCL9, sTNFR1, and sTNFR2 were significantly associated with liver fibrosis, with higher median levels found among patients with moderate/severe fibrosis (F >or= 2) if compared to those with no or mild fibrosis (p = 0.014; p = 0.012; p = 0.009, respectively). Plasma sTNFR2 levels were significantly associated with necroinflammatory activity, with higher median levels among patients with moderate/severe activity (A >or= 2) if compared to those with no or mild activity (2.34 ng/mL vs. 1.99 ng/mL; p = 0.019). In conclusion, plasma levels of CXCL9, sTNFR1, and sTNFR2 were independently associated with liver histological changes, suggesting a role of TNF activation and Th1-type cell-mediated immune response in the pathogenesis of HCV infection.
European Journal of Clinical Microbiology 09/2010; 29(9):1153-61. DOI:10.1007/s10096-010-0981-4 · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study evaluated the role of HA as a marker of liver fibrosis in patients with hepatitis C on haemodialysis.
This is a cross-sectional study in which 52 patients were divided into two groups: Group 1: patients with hepatitis C and end-stage renal disease (ESRD) undergoing haemodialysis (n = 23); and Group 2: patients with hepatitis C without ESRD (n = 29). Plasma levels of HA were associated with histological data of the samples obtained by liver biopsy and classified by METAVIR group scoring system.
Higher plasma levels were significantly correlated to significant liver fibrosis (METAVIR > F2). In Group 1, the HA cutoff to discriminate significant fibrosis was 984.8 ng/mL, with accuracy, sensitivity and specificity of 80.8%, 83.0%, and 70.0%, respectively. In Group 2, the HA cutoff was 222.3 ng/mL, with accuracy, sensitivity and specificity of 74.5%, 70.0%, and 94.0%, respectively.
HA was an accurate noninvasive marker in predicting significant fibrosis in patients with hepatitis C on haemodialysis.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 08/2010; 14(4):335-41. DOI:10.1016/S1413-8670(10)70071-4 · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic hepatitis B is one of the most frequent infectious disease in the world and represents a serious problem of public health
A systematic review of randomized clinical trials was conducted to evaluate the efficacy of the nucleoside/nucleotide analogues (adefovir, entecavir and telbivudine) used for the treatment of chronic hepatitis B. The databases PubMed and LILACS were consulted, among others
Twenty nine articles published between January/1970 to December/2009 were selected
All nucleoside/nucleotide analogues demonstrate upper or similar efficacy to lamivudine. The entecavir can be appropriate for patients with chronic hepatitis B, HBeAg positive and negative treatment-naive as alternative to lamivudine, considering its low potential of viral resistance. The addition of adefovir to lamivudine presented good results in lamivudine resistant patients. The use of entecavir and telbivudine in those patients presents risk of crossed resistance. TBV is one of the most recent antivirals available, but antiviral resistance already documented represents limitation to its use as therapeutic option to LAM. Adverse events of nucleoside/nucleotide analogues were similar in characteristics, gravity and incidence when compared to the lamivudina and placebo.
Revista da Sociedade Brasileira de Medicina Tropical 07/2010; 43(4):440-51. DOI:10.1590/S0037-86822010000400021 · 0.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pegylated interferon-alpha combined with ribavirin is the current gold standard treatment for chronic hepatitis C. Illicit drug dependence is not a rare co-morbidity among chronic hepatitis C population, what can make antiviral treatment an outmost challenge. Despite high sustained virological response rate following antiviral treatment, serious psychiatric adverse reactions may occur, like depression and suicide attempt. We report a patient with recurrent depressive disorder, previous history of suicide attempt and illicit drug dependence. We discuss the singularities and challenges of managing this patient in order to complete the antiviral treatment.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 10/2009; 13(5):387-90. DOI:10.1590/S1413-86702009000500015 · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hepatitis C is an important burden worldwide being an important cause of cirrhosis and liver cancer in different parts of the world. Host immune response, especially T helper type 1 (Th1) cell-mediated, seems to play an important role in disease progression but is also crucial for viral elimination following specific therapy. Immune activation can be evaluated using peripheral levels of different cytokines, such as different chemokines (e.g. CCL5, CXCL10) and tumor necrosis factor alpha (TNF-alpha), and their soluble receptors (e.g. soluble TNF-alpha receptors 1 (sTNF-R1) and 2 (sTNF-R2). This review article focuses on the potential use of peripheral inflammatory markers as predictors of liver histological changes and therapeutic response among patients with chronic hepatitis C.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 10/2009; 13(5):375-82. DOI:10.1590/S1413-86702009000500013 · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is evidence that patients with mental illness have increased prevalence of sexually transmitted infections, but data in Brazil are scarce. The objective of this study was to determine the prevalence of HIV, hepatitis C and B, and syphilis among patients with mental illness in Brazil.
A multicenter representative sample of adults with mental illness was randomly selected from 26 mental health institutions throughout Brazil. Sociodemographic, sexual behavior and clinical data were obtained from person-to-person interviews and blood was collected for serology testing. Seroprevalence with 95% confidence limits were obtained correcting for sampling scheme.
Of the 2,475 patients interviewed, 2,238 had blood collected. Most participants were sexually active ever (88.8%) or in the last 6 months (61.6%), female (51.9%), and single (66.6%). Half of the sample had less than 5 years of schooling and the mean monthly individual income was low (US$ 210.00). Condom use was very low either during lifetime (8%) or in the last 6 months (16%). Overall seroprevalence were 1.12%, 0.80%, 1.64%, 14.7% and 2.63% for, respectively, syphilis, HIV, HBsAg, anti-HBc and anti-HCV.
Seroprevalences found were higher than other populations with representative studies in Brazil, with high rates of sexual risk behavior. This is of public health concern, and prevention and care strategies for sexually transmitted infections among psychiatric patients should urgently be implemented by health authorities.
Revista Brasileira de Psiquiatria 04/2009; 31(1):43-7. DOI:10.1590/S1516-44462009000100011 · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The potential impact of the hepatitis C virus (HCV) on clinical, immunological and virological responses to initial highly active antiretroviral therapy (HAART) of patients infected with human immunodeficiency virus (HIV) is important to evaluate due to the high prevalence of HIV-HCV coinfection. A historical cohort study was conducted among 824 HIV-infected patients starting HAART at a public referral service in Belo Horizonte, Brazil, to assess the impact of HCV seropositivity on appearance of a new AIDS-defining opportunistic illness, AIDS-related death, suppression of viral load, and an increase in CD4-cell count. A total of 76 patients (9.2%) had a positive HCV test, 26 of whom (34.2%) had a history of intravenous drug use. In multivariate analysis, HCV seropositivity was associated with a smaller CD4-cell recovery (RH=0.68; 95% CI [0.49-0.92], but not with progression to a new AIDS-defining opportunistic illness or to AIDS-related death (RH=1.08; 95% CI [0.66-1.77]), nor to suppression of HIV-1 viral load (RH=0.81; 95% CI [0.56-1.17]) after starting HAART. These results indicate that although associated with a blunted CD4-cell recovery, HCV coinfection did not affect the morbidity or mortality related to AIDS or the virological response to initial HAART.
The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 07/2008; 12(3):173-9. DOI:10.1590/S1413-86702008000300003 · 1.30 Impact Factor