Roberto Martinez

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, San Paulo, São Paulo, Brazil

Are you Roberto Martinez?

Claim your profile

Publications (71)194.95 Total impact

  • Source
    Roberto MARTINEZ
    [Show abstract] [Hide abstract]
    ABSTRACT: The epidemiological characteristics of paracoccidioidomycosis were reviewed and updated. The new endemic areas in Brazil were discussed in the section regarding the geographic distribution of the mycosis. Subclinical infection with Paracoccidioides brasiliensis was discussed on the basis of skin test surveys with antigens of the fungus, seroepidemiological studies, and disease cases outside Latin America. Large case series permitted a comparison of the prevalence of the mycosis in different regions, its estimated incidence and risk factors for the development of the disease. Aspects modulating the expression of the clinical forms of paracoccidioidomycosis are also presented. This review also deals with diseases associated with the mycosis, opportunistic paracoccidioidomycosis, lethality, mortality and infection and disease in animals. © 2015, Instituto de Medicina Tropical de Sao Paulo. All rights reserved.
    Preview · Article · Sep 2015 · Revista do Instituto de Medicina Tropical de São Paulo
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Polymyxins are antimicrobial agents capable of controlling carbapenemase-producing Klebsiella pneumoniae infection. We report a cluster of four patients colonized or infected by polymyxin-resistant and Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae. Three patients were hospitalized in adjacent wards, and two were admitted to the intensive care unit. The index case maintained prolonged intestinal colonization by KPC-producing K. pneumoniae. Three patients received polymyxin B before the isolation of polymyxin-resistant K. pneumoniae. Colonization by KPC-producing K. pneumoniae and previous use of polymyxin B may be causally related to the development of polymyxin-resistant microorganisms.
    Full-text · Article · Jun 2015 · Revista da Sociedade Brasileira de Medicina Tropical
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective To describe magnetic resonance imaging (MRI) findings in musculoskeletal paracoccidioidomycosis (PCM).Methods Retrospective case series study after IRB approval. Two musculoskeletal radiologists reviewed in consensus the MRI findings of 11 patients with microbiologically and/or pathologically proven osteoarticular PCM. The MRI evaluation included discrimination of abnormalities in joints, bones, and soft tissues.ResultsMean age of patients was 29 years (10 – 55 years), 8 men and 3 women. Musculoskeletal involvement was the only or the primary presentation of the disease in 7 patients (63%). Osteomyelitis was the most common presentation, with 7 cases (63%). Primary arthritis was found in 1 patient (9%). Isolated extra-articular soft tissue PCM was found in 3 patients: myositis (2) and subcutaneous infection (1). All cases showed regions with signal intensity higher than or similar to the signal of muscle on T1-weighted images. Penumbra sign was present in 5 cases (45%). T2-weighted images showed reactive soft tissue edema in 8 cases (72%). Post gadolinium images showed peripheral (8/9) or heterogeneous (1/9) enhancement. Synovial enhancement was present in all cases of joint involvement (6/6). Lipomatosis arborescens was documented in 1 case of chronic knee involvement.Conclusion To our knowledge, this is the first case series describing MRI findings of musculoskeletal PCM. Musculoskeletal involvement was the primary presentation of the disease in most cases and therefore neoplasms were initially in the differential diagnosis. Osteomyelitis was the most common presentation, often with secondary involvement of joint and or soft tissue.This article is protected by copyright. All rights reserved.
    Full-text · Article · Jun 2015 · Tropical Medicine & International Health
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate predictive indices for candidemia in an adult intensive care unit (ICU) and to propose a new index. A prospective cohort study was conducted between January 2011 and December 2012. This study was performed in an ICU in a tertiary care hospital at a public university and included 114 patients staying in the adult ICU for at least 48 hours. The association of patient variables with candidemia was analyzed. There were 18 (15.8%) proven cases of candidemia and 96 (84.2%) cases without candidemia. Univariate analysis revealed the following risk factors: parenteral nutrition, severe sepsis, surgical procedure, dialysis, pancreatitis, acute renal failure, and an APACHE II score higher than 20. For the Candida score index, the odds ratio was 8.50 (95% CI, 2.57 to 28.09); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.78, 0.71, 0.33, and 0.94, respectively. With respect to the clinical predictor index, the odds ratio was 9.45 (95%CI, 2.06 to 43.39); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.89, 0.54, 0.27, and 0.96, respectively. The proposed candidemia index cutoff was 8.5; the sensitivity, specificity, positive predictive value, and negative predictive value were 0.77, 0.70, 0.33, and 0.94, respectively. The Candida score and clinical predictor index excluded candidemia satisfactorily. The effectiveness of the candidemia index was comparable to that of the Candida score.
    Full-text · Article · Apr 2015 · Revista da Sociedade Brasileira de Medicina Tropical
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate musculoskeletal involvement in paracoccidioidomycosis at computed tomography. Development of a retrospective study based on a review of radiologic and pathologic reports in the institution database. Patients with histopathologically confirmed musculoskeletal paracoccidioidomycosis and submitted to computed tomography were included in the present study. The imaging findings were consensually described by two radiologists. In order to avoid bias in the analysis, one patient with uncountable bone lesions was excluded from the study. A total of seven patients were included in the present study. A total of 18 bone lesions were counted. The study group consisted of 7 patients. A total number of 18 bone lesions were counted. Osteoarticular lesions were the first manifestation of the disease in four patients (57.14%). Bone lesions were multiple in 42.85% of patients. Appendicular and axial skeleton were affected in 85.71% and 42.85% of cases, respectively. Bone involvement was characterized by well-demarcated osteolytic lesions. Marginal osteosclerosis was identified in 72.22% of the lesions, while lamellar periosteal reaction and soft tissue component were present in 5.55% of them. One patient showed multiple small lesions with bone sequestra. Paracoccidioidomycosis can be included in the differential diagnosis of either single or multiple osteolytic lesions in young patients even in the absence of a previous diagnosis of pulmonary or visceral paracoccidioidomycosis.
    Full-text · Article · Mar 2015 · Radiologia Brasileira
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective. To evaluate whether dental treatment may enhance oral antisepsis, thus preventing more effectively lower respiratory tract infections (LRTIs) among critically ill patients. Design. Observer-blind randomized clinical trial. Setting. General intensive care unit (ICU) for adult patients. Patients. We analyzed data from 254 adult patients who stayed for at least 48 hours in the ICU. Intervention. Patients were randomized by means of rolling dice. The experimental group (n = 127) had access to dental care provided by a dental surgeon, 4-5 times a week. Besides routine oral hygiene, care also included teeth brushing, tongue scraping, removal of calculus, atraumatic restorative treatment of caries, and tooth extraction. The control group (n = 127) had access to routine oral hygiene only, which included the use of chlorhexidine as a mouth rinse, which was performed by the ICU nurse staff. Results. The primary study outcome was the LRTI incidence, which was 8.7% in the experimental group and 18.1% in the control group (adjusted relative risk [RR], 0.44 [95% confidence interval (CI), 0.20-0.96]; P = .04). Ventilator-associated pneumonia rates per 1,000 ventilator-days were 16.5 (95% CI, 9.8-29.5) in the control group and 7.6 (95% CI, 3.3-15.0) in the experimental group (P < .05). Mortality rates were similar between both study groups: 31.5% in the control group versus 29.1% in the experimental group (adjusted RR, 0.93 [95% CI, 0.52-1.65]; P = .796). No severe adverse events related to oral care were observed during the study. Conclusion. Dental treatment was safe and effective in the prevention of LRTI among critically ill patients who were expected to stay at least 48 hours in the ICU. Trial registration. Brazilian Clinical Trials Registry, affiliated with the World Health Organization's International Clinical Trial Registry Platform: U1111-1152-2671.
    No preview · Article · Nov 2014 · Infection Control and Hospital Epidemiology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study was designed to characterize a collection of 60 enteropathogenic Escherichia coli (EPEC) isolates from diarrheic feces of patients in the Ribeirão Preto metropolitan area regarding different phenotypic and molecular features. We examined antibiotic resistance profiles, occurrence of virulence factors-encoding genes, intimin subtypes and the correlation of serotypes among typical (tEPEC) and atypical (aEPEC) EPEC isolates. The results demonstrated that atypical EPEC was more heterogeneous than typical EPEC concerning the characteristics investigated and 45.2% do not belong to classical EPEC serogroups. Intimin subtype β was the most frequent among the EPEC isolates (46.7%), being detected in both tEPEC and aEPEC. The majority of aEPEC isolates presented localized adherence-like (LAL) pattern to HEp-2 cells, although aEPEC isolates displaying diffuse adherence (DA) or non-adherent were also detected. High prevalence of antimicrobial resistance was found for ampicillin, cephalothin, sulfonamide and tetracycline. In general, tEPEC isolates were more resistant to the antimicrobials tested than aEPEC isolates.
    Full-text · Article · Sep 2014 · Apmis
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In this study, we report the early expansion, evolution and characterization of a multiresistant Klebsiella pneumoniae clone that was isolated with increasing frequency from inpatients in a tertiary-care university hospital in Brazil. Seven carbapenem- and quinolone-resistant and polymyxin B-susceptible or -resistant K. pneumoniae isolated between December 2012 and February 2013 were investigated. Beta-lactamase and PMQR-encoding genes and the genetic environment were investigated using PCR, sequencing and RFLP. Clonal relatedness was established using XbaI-PFGE, MLST and phylogenetic group characterization. Plasmid analyses included PBRT and hybridization of the S1-PFGE product, pMLST typing and conjugation experiments. Virulence potential was assessed by PCR by searching for ten virulence factor-encoding genes (ureA, fimH, kfuBC, uge, wabG, magA, mrkD, allS, rmpA and cf29a) and by phenotypic tests to analyze the hypermucoviscous phenotype. The genetic context of a multidrug-resistant and extensively drug-resistant K. pneumoniae ST11-KpI clone harboring IncFIIk-Tn4401a-blaKPC-2 and qnrS1, blaCTX-M-2 was found. Moreover, three isolates displayed high resistance to polymyxin B (MICs=32, 32 and 128 mg/L) as well as mucous and hypermucoviscous phenotypes. These bacteria also harbored ureA, fimH, uge, wabG and mrkD, which code for virulence factors associated with binding, biofilm formation and the ability to colonize and escape from phagocytosis. Our study describes the association of important co-resistance and virulence factors in the K. pneumoniae ST11 international high-risk clone, which makes this pathogen successful at infections and points to the quick expansion and evolution of this multiresistant and virulent clone, leading to a pandrug-resistant phenotype and persistent bacteria in a Brazilian hospital.
    Full-text · Article · May 2014 · Journal of clinical microbiology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: The distribution of infection by Histoplasma capsulatum in Brazil is heterogeneous, and the number of cases affecting immunocompetent individuals is relatively small. This study reports the epidemiological and clinical data regarding histoplasmosis in non-immunosuppressed individuals. Methods: The study included only the immunocompetent patients with histoplasmosis who were diagnosed between 1970 and 2012 at a university hospital located in Ribeirão Preto, State of São Paulo, Brazil. Clinical and epidemiological data were collected retrospectively from the patient records. Results: Of the 123 patients analyzed, 95 had an active disease that manifested in the different clinical forms of histoplasmosis. Men were the predominant gender, and most patients resided in the Northeast of the State of São Paulo and in the nearby municipalities of the State of Minas Gerais. The risk factors for acquiring histoplasmosis and prolonged contact in a rural environment were recorded in 43.9% and 82.9% of cases, respectively. Smoking, alcoholism, and comorbidity rates were high among the patients with the chronic pulmonary and subacute/chronic disseminated forms of histoplasmosis. Many patients achieved clinical cure spontaneously, but 58.9% required antifungals; the disease lethality rate was 5.3%. Conclusions: Immunocompetent individuals manifested the diverse clinical forms of histoplasmosis over a period of 4 decades, revealing an additional endemic area of this fungal disease in the Brazilian Southeast.
    No preview · Article · Jul 2013 · Revista da Sociedade Brasileira de Medicina Tropical
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Pseudomonas aeruginosa isolates related to nosocomial infections are often resistant to multiple antibacterial agents. In this study, antimicrobial combinations were evaluated to detect in vitro synergy against clinical isolates of P. aeruginosa. Methods: Four clinical P. aeruginosa isolates were selected at random among other isolates from inpatients treated at the public University hospital in Ribeirão Preto, SP, Brazil. Two isolates were susceptible to imipenem (IPM-S) and several other antimicrobials, while the other two isolates were imipenem and multidrug resistant (IPM-R). The checkerboard method was used to assess the interactions between antimicrobials. Results: Combinations of imipenem or other anti-Pseudomonas drugs with complementary antibiotics, such as aminoglycosides, fosfomycin and rifampin, reached synergy rates of 20.8%, 50%, 62.5% and 50% for the two IPM-S and two IPM-R Pseudomonas isolates, respectively. Imipenem, piperacillin-tazobactam and ceftazidime yielded a greater synergy rate than cefepime or ciprofloxacin. Synergist combinations were more commonly observed when the complementary drug was tobramycin (65%) or fosfomycin (57%). Conclusions: Some antibacterial combinations led to significant reductions of the minimum inhibitory concentrations of both drugs, suggesting that they could be clinically applied to control infections caused by multidrug-resistant P. aeruginosa.
    No preview · Article · May 2013 · Revista da Sociedade Brasileira de Medicina Tropical
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Amphotericin B, azole or sulfamide drugs are used for treatment of patients with paracoccidioidomycosis. Among the azole drugs, voriconazole was active in vitro against Paracoccidioides brasiliensis and showed efficacy in the treatment of patients infected with this fungus.In the present study the antifungal activity of voriconazole and of other drugs was compared in a rat model of paracoccidioidomycosis. Wistar rats were inoculated intravenously with the BOAS strain of P. brasiliensis and antifungal drugs were administered to the animals by gavage at the following doses (mg/kg weight/day): voriconazole (5 to 20), ketoconazole (12 to 15), fluconazole (6), itraconazole (4), and sulfamethoxazole-trimethoprim (120 to 150). The antifungal activity of the drugs was assessed by determining the P. brasiliensis colony forming units in the lungs and spleen of the animals at the end of treatment and by a survival study. Voriconazole reduced the total tissue fungal burden of P. brasiliensis, particularly at doses of ≥10mg/kg weight/day but its antifungal activity was less intense than that of fluconazole, itraconazole and sulfamethoxazole-trimethoprim. The mean survival of animals treated with the last three drugs, 29.1±10.7, 26.1± 10.1 and 28.4±9.6 days, respectively, was higher than that achieved with voriconazole 10mg/kg weight/day (18.5±8.3 days) and that observed in untreated animals (15.7±3.6 days). At doses similar to those used for clinical treatment, voriconazole showed lower antifungal activity in experimental rat paracoccidioidomycosis than that obtained with itraconazole and sulfamethoxazole-trimethoprim.
    Preview · Article · Apr 2013 · Revista da Sociedade Brasileira de Medicina Tropical
  • Source
    Dataset: Figure S2
    [Show abstract] [Hide abstract]
    ABSTRACT: PbPga1 orthologs in several fungi. The CLUSTALW2 protein phylogenetic tree was generated based on fungal PbPga1 predicted sequences obtained from the Broad Institute database. The scale bar corresponds to 0.1 amino acid changes per site. (TIF)
    Preview · Dataset · Sep 2012
  • Source
    Dataset: Figure S3
    [Show abstract] [Hide abstract]
    ABSTRACT: Mapping of tryptic peptides obtained from rPbPga1. The gel band was trypsin digested and analyzed by nanoelectrospray using MS scanning from 600 to 4000 amu in the positive ion mode for protonated peptide detection. Each ion present in the spectrum above was subjected to collision-induced dissociation to produce a fragment ion pattern. (TIF)
    Preview · Dataset · Sep 2012
  • Source
    Dataset: Figure S1
    [Show abstract] [Hide abstract]
    ABSTRACT: DNA sequences of PbPga1, PADG_02460 (Pb18), PABG_00068 (Pb03) and PAAG_04708 (Pb01). Predicted start codons and stop codons are represented by grey boxes and red boxes, respectively. Introns are limited by canonical GT/AG represented by black boxes. (TIF)
    Preview · Dataset · Sep 2012
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Paracoccidioides brasiliensis is the etiologic agent of paracoccidioidomycosis (PCM), one of the most prevalent mycosis in Latin America. P. brasiliensis cell wall components interact with host cells and influence the pathogenesis of PCM. Cell wall components, such as glycosylphosphatidylinositol (GPI)-proteins play a critical role in cell adhesion and host tissue invasion. Although the importance of GPI-proteins in the pathogenesis of other medically important fungi is recognized, little is known about their function in P. brasiliensis cells and PCM pathogenesis. We cloned the PbPga1 gene that codifies for a predicted GPI-anchored glycoprotein from the dimorphic pathogenic fungus P. brasiliensis. PbPga1 is conserved in Eurotiomycetes fungi and encodes for a protein with potential glycosylation sites in a serine/threonine-rich region, a signal peptide and a putative glycosylphosphatidylinositol attachment signal sequence. Specific chicken anti-rPbPga1 antibody localized PbPga1 on the yeast cell surface at the septum between the mother cell and the bud with stronger staining of the bud. The exposure of murine peritoneal macrophages to rPbPga1 induces TNF-α release and nitric oxide (NO) production by macrophages. Furthermore, the presence of O-glycosylation sites was demonstrated by β-elimination under ammonium hydroxide treatment of rPbPga1. Finally, sera from PCM patients recognized rPbPga1 by Western blotting indicating the presence of specific antibodies against rPbPga1. In conclusion, our findings suggest that the PbPga1gene codifies for a cell surface glycoprotein, probably attached to a GPI-anchor, which may play a role in P. brasiliensis cell wall morphogenesis and infection. The induction of inflammatory mediators released by rPbPga1 and the reactivity of PCM patient sera toward rPbPga1 imply that the protein favors the innate mechanisms of defense and induces humoral immunity during P. brasiliensis infection.
    Full-text · Article · Sep 2012 · PLoS ONE
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The global emergence of vancomycin-resistant Enterococcus faecium (VREfm) has been characterized by a clonal spread of strains belonging to clonal complex 17 (CC17). Genetic features and clonal relationships of 53 VREfm isolated from patients in 2 hospitals in Ribeirao Preto, São Paulo, Brazil, during 2005-2010 were determined as a contribution to the Brazilian evolutionary history of these nosocomial pathogens. All isolates were daptomycin susceptible, vancomycin-resistant, and had the vanA gene. The predominant virulence genes were acm and esp. Only 5 VREfm isolated in 2005-2006 had intact Tn1546, while 81% showed Tn1546 with deleted left extremity and insertion of IS1251 between the vanS and vanH genes. Multilocus sequence typing analysis permitted the identification of 9 different sequence types (STs), with 5 being new ones (656, 657, 658, 659, and 660). Predominant STs were ST412 and ST478, all belonging to CC17, except ST658. This is the first report of the ST78 in Brazil.
    Full-text · Article · Sep 2012 · Diagnostic microbiology and infectious disease
  • [Show abstract] [Hide abstract]
    ABSTRACT: Paracoccidioidomycosis (PCM) is a systemic fungal disease endemic to Latin America and characterized by two clinical presentations, i.e., patients develop either acute/ subacute or chronic clinical manifestations. The differences in clinical presentations are mainly dependent on the host immune response, but may also be related to demographic characteristics of some patients. In this retrospective study, 1,219 PCM cases treated between 1970 and 2009 in a university medical center, located in southeastern Brazil, were analyzed according to their clinical and demographic features. The most affected anatomical sites were lungs (63.8%) and oral mucosa (50.0%), with increasing involvement of these sites in accord with the age of the patients. Generalized lymphadenopathy (28.1%) and skin lesions (29.6%) were more frequent on the first decades of life. Involvement of the larynx (16.1%), gut (7.5%), spleen (4.7%), central nervous system (3.4%), bones and joints (2.2%), and adrenal (2.1%) were also variable according to the age of the host. The acute/subacute form of the disease accounted for 26.4% of PCM cases and, on a multivariate analysis, was inversely associated with aging (OR = 0.8 per year, P < 0.001), and directly associated with female sex (OR = 7.2, P < 0.001), mixed black and white racial background (OR = 2.3, P < 0.001) or black skin color (OR = 4.6, P < 0.001). Based on these findings, we have shown that host immune response, as well as age, gender and ethnicity may influence the clinical presentation of PCM.
    No preview · Article · Aug 2012 · Medical mycology: official publication of the International Society for Human and Animal Mycology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although many proteins have been described involved in Escherichia coli colonization and infection, only few reports have shown lectins as important components in these processes. Because the mechanisms underlying E. coli colonization process involving lectins are not fully understood, we sought to identify the presence of other non-described lectins in E. coli. Here, we isolated a 75-kDa protein from E. coli on Sepharose column and identified it as ferric aerobactin receptor (IutA). Since IutA is controversially associated with virulence of some E. coli strains, mainly in uropathogenic E. coli (UPEC), we evaluated the presence of iutA gene in UPEC isolated from patients with urinary infection. This gene was present in only 38% of the isolates, suggesting a weak association with virulence. Because there is a redundancy in the siderophore-mediated uptake systems, we suggest that IutA can be advantageous but not essential for UPEC.
    Preview · Article · Apr 2012 · Revista Latino-Americana de Enfermagem
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Occupational HIV infection among healthcare workers is an important issue in exposures involving blood and body fluids. There are few data in the literature regarding the potential and the duration of infectivity of HIV type 1 (HIV-1) in contaminated material under adverse conditions. We quantified HIV-1 viral RNA in 25×8mm calibre hollow-bore needles, after punctures, in 25 HIV-1-infected patients selected during the sample collection. All of the patients selected were between the ages of 18 and 55. Five samples were collected from 16 patients: one sample for the immediate quantification of HIV-1 RNA in the plasma and blood samples from the interior of 4 needles to be analyzed at 0 h, 6 h, 24 h, and 72 h after collection. In nine patients, another test was carried out in the blood from one additional needle, in which HIV-1 RNA was assessed 168 h after blood collection. The method used to assess HIV-1 RNA was nucleic acid sequence-based amplification. Up to 7 days after collection, HIV-1 RNA was detected in all of the needles. The viral RNA remained stable up to 168 h, and there were no statistically significant differences among the needle samples. Although the infectivity of the viral material in the needles is unknown, the data indicate the need to re-evaluate the practices in cases of occupational accidents in which the source is not identified.
    Full-text · Article · Nov 2011 · Revista da Sociedade Brasileira de Medicina Tropical
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Paracoccidioidomycosis has been known for over 100 years, and until now, there were only few estimates of the disease's incidence. We aim to analyze 1,000 cases treated between 1960 and 1999 at Ribeirão Preto city, São Paulo, Brazil, where the disease's incidence range detected was 1.6 to 3.7 cases per 100,000 habitants per year (mean = 2.7 cases/year). We observed a male to female ratio of 6:1 and an age distribution from 3 to 85 years. The acute/subacute form of the disease accounted for 25.4% of cases. Most of the patients (93.5%) had lived or worked in rural areas before the disease development. Smoking and alcoholism were reported by 64.7% and 37.2% of patients, respectively. Comorbidities identified included tuberculosis (8.3%), Chagas' disease (8.6%), and human immunodeficiency virus/acquired immunodeficiency syndrome (4.2%). The present study revealed an area in Brazil where paracoccidioidomycosis is hyperendemic (has the highest reported incidence of this disease); this endemic area is probably caused by geological and climatic conditions as well as intensive agriculture.
    Preview · Article · Sep 2011 · The American journal of tropical medicine and hygiene

Publication Stats

836 Citations
194.95 Total Impact Points

Institutions

  • 2002-2015
    • Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo
      San Paulo, São Paulo, Brazil
  • 1991-2015
    • University of São Paulo
      • • Departamento de Medicina Interna
      • • Ribeirão Preto School of Medicine (FMRP)
      • • Hospital das Clínicas (FMUSP)
      • • Department of Clinical Medicine (VCM)
      San Paulo, São Paulo, Brazil
  • 2009
    • Universidade Estácio de Sá
      Rio de Janeiro, Rio de Janeiro, Brazil
  • 1997-2006
    • Universidade de Ribeirão Preto
      Entre Rios, São Paulo, Brazil