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2/5/2020
Well being

Time to think about fighting skin cancer

Guess what type of cancer is most frequently diagnosed in Brazil? If you thought about breast, prostate, intestine or lung cancer you did not get it right. The most common malignant tumor in these sunny lands is the non-melanoma skin cancer, especially the types basal cell carcinoma and squamous cell carcinoma, which accounts for one third of all cases of cancer diagnosed in Brazil. According to the National Cancer Institute, last year alone, 165,500 cases were recoded, 85,100 of which having developed in men and 80,100 in women. According to experts, several factors explain the large number of people affected by this disease. With a tropical climate, Brazil is subject to high solar irradiance all year round, which naturally makes the population more vulnerable to this type of tumor. Add to that the fact that many Brazilians have the habit of only using sunscreen when they go to the beach or the pool, and fail to protect themselves on a daily basis, which increases the level of exposure to radiation. Other risk factors include family history - relatives who have had this cancer - and very fair skin. Finally, excessive exposure to sun throughout life also increases the possibility of acquiring this malignant lesion, since the harmful effects of ultraviolet rays A and B (UVA and UVB) to the skin cells are cumulative. Not so long ago, people would use tanning oil at the beach, field workers, construction workers and urban cleaners did not protect themselves with adequate clothes, and even water and outdoor sports practitioners only applied, at most, a layer of cream against rashes on the nose and cheeks. The fact is that culture of photoprotection is rather recent in Brazil because, for a long time, the idea that a tanned skin was  healthy prevailed. For instance, suntan lotion was available in Brazil in the 1960s while products with a sun protection factor (SPF), only became available in the 1980s, initially with protection factors 4, 8 and 15.  Fortunately, the skin tumor is much less lethal than other cancers - except for the melanoma, which, although rarer, has a high mortality rate because it spreads quickly to other organs (link to melanoma article). Even so, both the basal cell and the spinocellular type need to be treated as quickly as possible because they can cause injuries that mutilate or disfigure the skin in exposed areas of the body, which has a major emotional impact on patients. How to recognize the tumor It is evident that protecting yourself from the sun is essential in this context (link to box Prevention against breast cancer ...), but photoprotection is not enough, precisely because of these risk factors. In practice, people should be well aware of their body and the location of spots, patches and other injuries and, above all, pay particular attention to those that appear in areas that are most exposed to the sun, such as face, arms, ears, neck, lips, shoulders, back and the scalp, for those who have little hair.  According to the Brazilian Society of Dermatology (SBD), suspected non-melanoma skin cancer lesions appear as a shiny lump, which can be red, brown and pink, and bleed easily. Patches or wounds that do not heal should also raise the alert, especially if they grow, become itchy, bleed and become crusty. Such signs are sufficient to seek a dermatologist as soon as possible for a detailed evaluation. The diagnosis depends on clinical examination, dermoscopic examination (performed during the consultation) and biopsy of the lesions, that is, removal of tiny fragments for micro and macroscopic examination of the nature of their changes. Treatment options There are several different types of treatment for non-melanoma skin cancer, such as: conventional and laser surgical removal, scraping the lesion and destroying malignant cells by means of curettage and electrocauteryan , freezing the tumor with liquid nitrogen and Mohs micrographic surgery, a technique based on the removal of the compromised tissues and analyzing them under the microscope, several times, until there are no more tumor cells - the healthy tissues are preserved.   Photodynamic therapy is another possibility; it combines the application of a photosensitizing substance (sensitive to light) on the lesion and exposing it to a light source that activates this agent and destroys the malignant cells, with minimal impact on the intact skin. In addition, classical therapies are also used, especially if the tumor is prone to spreading, including chemotherapy and radiotherapy, among others. The best option is chosen on a case-by-case basis, by the dermatologist who takes into account the type and size of the lesion, as well as the location. Like any other type of cancer, the earlier the diagnosis, the greater the chances of cure, without major repercussions on the patient's appearance or even quality of life. Protect your skin all year round and go to a dermatologist regularly. Skin cancer prevention is at your fingertips - Avoid exposure to the sun during the period of high irradiation of ultraviolet (UV) rays, that is, from 10 am to 4 pm, even on overcast days. If you are outdoors, on the beach or by the pool, take shelter in the shade. It should be noted that parasols and nylon tents help very little, since most of the solar radiation passes through this material. If you choose tents, the ideal one is made of canvas or cotton, which absorb at least half of the UV rays. Nonetheless, even in the shade, you can't give up sunscreen on the beach, by the pool, in the countryside or on the street. - Use a product that protects against UVA and UVB rays and with SPF 30, at least. For Afro-descendants, however, the SPF may even be lower, from 15 to 20, since black skin has natural protection, that is, a greater amount of melanin, which acts as a shield against the sun's rays. However, the choice of the ideal SPF should also take into account the skin tone in this group, which varies widely.  - Use sunscreen filter on exposed areas not only on the beach or by the pool, but also on a daily basis and in any outdoor activity, leisure or not, in the four seasons of the year. Those who stay indoors should apply sunscreen before leaving home and repeat application before going out into the street during the day. For those who remain outdoors, application must be repeated every two hours or less, especially in the case of sports, as excessive sweating removes protection. - Learn how to use the sunscreen correctly: apply the product about 30 minutes before sun exposure, so that the skin can absorb it, distributing it evenly on all exposed parts of the body. The ideal amount, according to the Brazilian Dermatology Society, is one teaspoon for each part of the body, on average. Do not forget ears, neck, hands and feet, which are almost always neglected. Reapply the protector every two hours or after excessive sweating and/or entering the water. Such care applies to any skin tone. It is worth noting that the natural barrier of black skin ceases to function if reapplication is not adequate .  - Keep babies protected from the sun, since SPF products can only be applied to children after 6 months of age. The daily sunbath, recommended by pediatricians for the production of vitamin D by the body, should be done without sunscreen, exposing  arms and legs, for at least ten minutes, but always before 9 am. - When outdoors, resort to other types of protection in addition to sunscreen, such as t-shirts, sunglasses, wide-brimmed caps and hats, long-sleeved shirts with sun protection factor and the like. Those who work outdoors, for example, need to be fully covered. - Do a self-examination of your skin, following the ABCDE rule (link to box How to follow the ABCDE rule ). Regardless of the findings, see a dermatologist at least once a year for a general evaluation.  How to apply the ABCDE rule for self-examination of skin In order to make it easier for patients to identify suspicious lesions by themselves, the SBD suggests following the ABCDE rule. Check it out: Letter / What to watch  Characteristic of malignant tumor Characteristic of benign tumor A for asymmetry Asymmetric Symmetrical B for border Irregular Regular C for color Two or more Only one D of diameter Above 6 mm (probably malignant) Below 6 mm (probably benign) E for evolution Grows and changes color (probably malignant) Does not grow or change color (probably benign)   Basal cell or squamous cell carcinoma? Learn the differenceThe classification of the type of non-melanoma skin cancer has to do with the type of cell involved in the lesion. Basal cell, the most common, originates from so-called basal cells, found in the deepest layer of the skin. It usually appears in areas exposed to the sun, such as face, ears, neck, scalp, back and shoulders. Whereas squamous cell carcinoma is formed from squamous cells, which make up most of the upper layers of the skin. This is also more common in exposed regions, but it can appear anywhere on the body. In addition to the sun, it is worth remembering that this type of  tumor is associated with chronic wounds and scars, use of drugs to prevent rejection of transplanted organs and exposure to certain chemicals and other types of radiation.

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2/5/2020
Prevention

Number of dengue virus infections skyrockets and calls for union of strategies

At the end of the year, before the summer rainy season, the Ministry of Health repeatedly seeks to mobilize the population in order to reduce the proliferation of Aedes aegypti, the mosquito that carries the dengue virus and other diseases caused by arboviruses, that is, arboviral disease- such as chikungunya fever and Zika virus infection. (link to box Learn the difference ...) Particularly this year, the scenario is startling, so much so that the Ministry of Health anticipated to September their advertising campaign to encourage the fight against A. aegypti. According to the latest Epidemiological Bulletin published by the Health Surveillance Department, in the first nine months of 2019, Brazil recorded 1,469,605 cases of dengue virus infections, while 207,400 cases were recorded in the same period of 2018. This is equivalent to an increase of nearly 610%, with 646 deaths caused by the disease already confirmed and 414 other fatalities still under investigation. The fact is that, at this rate, given that cases recorded in the last quarter, which is usually rainiest of all, are yet to be computed, 2019 may break the historical record of 2015, when 1.68 million cases were recorded. The Southeast concentrated most of the occurrences until September, and the state of Minas Gerais ranked first, having recorded most cases, 477.5 thousand, followed very closely by São Paulo, which recorded 440.2 thousand cases, and then the state of Espírito Santo, with 60.6 thousand cases, the fourth Brazilian state with the most people infected. The state of Goiás, in the mid-west region, came third, with 110,800 cases, and Bahia fifth, with 62,100 cases recorded. What explains such boost of dengue virus infections? The Ministry of Health states the great increase in the number of cases is due to a set of factors, which includes the spread of dengue fever throughout Latin America - in September, the Pan American Health Organization activated the epidemiological alert after the region exceeded 2 million individuals infected - the high rainfall volume and the high temperatures recoded this year, the higher number of people susceptible to the disease, since the number of cases had dropped in the two previous years, and, in particular, the change of the virus serotype that is now causing the epidemic. We should remember that the dengue virus has four serotypes (1, 2, 3 and 4), which means that an individual can be infected up to four times, and only then does the body acquire immunity to all of them. Serotype 2 was not recorded in the past decade, when types 1 and 4 prevailed. However, in 2019, until April only, it accounted for 84% of infections, according to the Ministry of Health. In other words, since many people were not immune to serotype 2, the problem  increased substantially. Tropical climate and disorderly growth But this is far from justifying the new dengue fever epidemic. Although the population has the crucial obligation of removing materials that could accumulate water and therefore create breeding grounds (link to What you can do ...), there is, in our country, a combination of aspects that favor the proliferation of mosquitoes. According to experts, added up, the tropical climate (20-40 degrees centigrade), rainfall favoring the reproductive cycle of the A. aegypti, the rather disorganized growth of cities, the accumulation of garbage and the still poor basic sanitation are increasingly distancing health authorities from their goal of eradicating the disease virus vector. The solution definitely requires educating the population on health, this is true, but it equally requires investment in technology, firstly and foremost, for the development of a vaccine that is safe enough for the entire vulnerable population. The immunization currently available covers only two serotypes of the virus and is recommended only for the age group of 9 to 45 years old, provided that the person has already been infected before, otherwise this individual would be susceptible to developing the serious form of disease. This already happens to some people who has been infected by dengue more than once. With this vaccine that protects against two strains only, in the event of another exposure to the virus, the body understands that it was previously infected. At the moment, Instituto Butantan is working on a potentially effective formula against the four serotypes, which has already been tested on 17,000 volunteers and is in the final phase of pharmacological studies. After the tests, this clinical trial will be sent for evaluation by the National Health Surveillance Agency (Anvisa), which, based on evidences of efficacy and safety of the vaccine, will allow its registration, or not. Until then, however, we will have to face the mosquito for a few summer seasons. Self-sustainable strategy against A. aegypti Fortunately, there are other fronts, such as the World Mosquito Program (WMP), that operates in 12 countries and receives investment from local governments and also from the Bill & Melinda Gates Foundation. Coordinated by the Oswaldo Cruz Foundation (Fiocruz) in Brazil, the project consists of introducing the Wolbachia bacterium, already present in 60% of insects, in the mosquito, as this would inhibit the transmission of the virus by A. aegypti. When it came up in Australia, each larva received a micro injection with the bacteria. Today, however, researchers maintain colonies of mosquitoes that carry this agent, which multiply and are used in each region where the WMP is implemented. However, in order to reduce the females’ ability to transmit diseases, Wolbachia mosquitoes of both genders have to be released in nature, so that, little by little, they can predominate in the environment and decrease the number of cases of arboviruses. This is because the crossbreeding of carriers of the bacterium results in offsprings bearing the same characteristic, which also occurs if only the female is a carrier of the Wolbachia. Nonetheless, if the female that does not carry the agent crosses with a male that does, these mosquitoes will cease to breed. It is a self-sustainable strategy that does not require genetic engineering. In Brazil, between August 2015 and January 2016, mosquitoes carrying Wolbachia began to be released in two municipalities in the state of Rio de Janeiro. Today, these mosquitoes are already found in 62 neighborhoods in the capital of Rio de Janeiro and Niterói, the  females continue to bite normally, it is worth noting - in any case, the community of each location involved receives explanations from WMP multipliers. In April, according to Fiocruz, the WMP reached its final stage in Brazil, with the announcement by the Ministry of Health that starting next year, Campo Grande (MS), Belo Horizonte (MG) and Petrolina (PE) will also receive mosquitoes carrying Wolbachia. According to the researchers involved, preliminary data indicates that the initiative has been successful, but the organization has already promised to deliver a first complete study on the project in Rio de Janeiro by 2022. Although these and other actions have been successfully applied across the country, this does not eliminate the need for each citizen to do whatever is within their reach, at least ten minutes every day, according to this year's campaign against dengue, since, in 80% of cases, the mosquito is found in homes, very close to all of us - at least 50 to 100 meters away. Check the tips from the Ministry of Health and get down to work. What can you personally do against the A. aegypti? Get rid of any possible breeding site Cover water tanks and other water reservoirs. Keep bins tightly covered. Clean gutters. Store tires in covered storage areas. Keep empty bottles upside down. Periodically clean drains, ditches and other drainage systems. Cover with screens any drain that has no opening and closing system Thoroughly wash pet drinking bowls with a brush. Remove accumulated water from air conditioning and refrigerator trays, and sanitize them whenever possible, as well as laundry areas - for instance, behind the washing machine, where standing water usually collects. Fill plant pot dishes with sand or clean these items every week. Remove water from plants and trees that collect water, such as bamboo and bromeliads, and also clean them periodically. Keep buckets upside down. Stretch well tarps used to cover objects. Keep pools clean. Store safely or discard any object that collect water: bottle caps, dry leaves, toys, etc.   Eliminate mosquito breeding sites    Wash the edges of containers that collect water with soap and a brush or sponge. Discard larvae found on earth or on dry ground - never on water. For large tanks and other reservoirs of water for human consumption, call a health worker for larvicide application. For containers where larvae were found for which waste or proper disposal is not possible, use products such as washing powder, liquid detergent, disinfectant and swimming pool chlorine, provided such water is not intended for human or animal consumption. Check these parts every week and contact a health worker. Protect yourself from bites Use Anvisa approved insect repellents, following the instructions and precautions featured on the product packaging. Use environmentally friendly insecticides and repellents, provided they are also approved by Anvisa, and also following instructions and recommendations. Learn the difference between dengue, chikungunya and Zika infectionThe viruses from these three infections are transmitted by A. aegypti and cause very similar symptoms, though different in frequency and intensity. For this reason, in the face of any symptoms, it is important to seek a doctor for a clinical evaluation and, if possible, have exams requested to identify the condition. This piece of information is always useful. Anyone who was previously infected by a dengue virus, confirmed by a laboratory, for example, is already aware that they may be infected three more times, and, in such case, the infection could be more severe, and therefore would require greater medical care. Although dengue fever is the infection to cause the highest number of fatalities among these three arboviruses, chikungunya can also have a bad outcome - 72 deaths have already been recorded in Brazil this year - and the main complication resulting from Zika infection is the possibility of microcephaly of fetuses if the mother is infected during pregnancy. Signs and Symptoms  Dengue Zika Chikungunya High fever for 4 to 7 days Absent or low-grade fever, for 1 to 2 days High fever for 2 to 3 days Skin rash In 30-50% of cases In most cases In 50% of cases Muscle pain Intense light/moderate Light  joint pain Light light/moderate moderate/intense Swollen joints Rare  Light moderate/intense Conjunctivitis  Rare  In 50-90% of cases In 30% of cases Itchy skin Light moderate/intense Light Headache Intense light/moderate light/moderate pain behind the eyes  Intense Absent  light/moderate Increased ganglia Light Intense moderate Hemorrhagic disorders Moderate  Absent Light 

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2/5/2020
Prevention

The victory of life over the virus: it is possible to go through pregnancy despite being HIV positive

Few are the ways through which one can be infected by HIV virus and develop AIDS, which emerged as a lethal threat in the 1980s and today, thanks to advances in science, has gained the status of chronic disease. That is, it can be treated, but there is no cure for that, as is the case of diabetes, for instance. Transmission can occur through unprotected sex, perforation of skin or mucous membranes with sharp materials contaminated by virus, such as needles, blood transfusions and also contaminated blood products and by means of the so-called vertical transmission, from mother to baby, during pregnancy, through the placenta, during childbirth and breastfeeding.  The first two forms of transmission have well-known prevention strategies and rely heavily on self-care. In the other cases, however, those who are vulnerable have no choice, even though blood transfusions are currently much safer than in the 1980s and 1990s. In pregnancy, in turn, the baby depends exclusively on the mother's responsibility not to be infected, since a medical protocol now in place can minimize the risk of vertical transmission. The fact is that for HIV/AIDS treatment, already so successful, can also be done during pregnancy and, together with other preventive measures, reduces the possibility the child being infected to less than 1%. According to the Joint United Nations Program on HIV and AIDS (Unaids), 82% of pregnant women infected by the virus around the world had access, last year, to antiretroviral drugs, which suppress the amount of virus, or viral load, in the organism, to the point of making it undetectable in the blood.  In Latin America and the Caribbean alone, as a result of this protocol, between 2010 and 2017, nearly 31,000 babies were born without being infected by HIV. In Brazil, between 2007 and 2017, the number of cases of vertical HIV transmission was reduced by 42%, despite the fact that the number of infected pregnant women increased by 21.7% in that same period. How vertical transmission can be avoided There is no big secret. A HIV-positive pregnant woman needs to unrestrictedly adhere to antiretroviral therapy throughout her pregnancy, in order to make HIV undetectable in the circulation. This strategy prevents transmission during pregnancy and may even allow normal labor, although this option also depends on other clinical factors. It all depends on when the woman finds out she is HIV positive. Therefore, the sooner prenatal care begins, the higher the chances of decreasing the amount of virus circulating in the maternal body. At the time of labor or just before C-section, in any case, antiretroviral zidovudine (AZT) is intravenously administered to the mother and, shortly after birth, the same medication is also orally administered to the child - all that aiming at minimizing the possibility of contaminating the baby, who, after all, always ends up exposed to maternal blood at birth, even in the case of a C-section. If the woman did not receive HIV treatment during the prenatal care period, or if her viral load is equal to or greater than 1,000 copies/mL in the last gestational trimester, the preventive scheme for the newborn also includes another antiretroviral, neviparin. Regardless of the drugs used, this therapy will last between four and six weeks.  As the baby carries the mother's anti-HIV antibodies in the first months after birth, tests to indicate a possible contamination in the first months can only be on the viral load, and not the usual serological test, which will be positive at this moment. The determination of the amount of virus should be done two to three times between the first and the second month, or according to pediatric instructions. In case two results present detectable viruses, the child is considered infected and, until the age of 12 months, treatment begins, regardless of the virus load value and CD4 count. After 12 months, the decision to start antiretroviral therapy will depend on the clinical condition and on the result of these tests. The fact is that the postpartum period is equally decisive to complete the scheme aimed at combating vertical transmission. But not all families continue to be monitored. According to Unaids data, of the 1.1 million babies exposed to HIV last year in the 23 countries most affected by HIV/AIDS, only 63% were tested up to 2 months of age.  Regardless of an undetectable viral load, pediatric follow-up must continue because the definitive answer that the baby really has not been infected by the virus comes only after 18 months. If serology is positive after this period, the diagnosis HIV/AIDS is confirmed and antiretroviral therapy is also performed according to the patient's condition and the results of viral load and CD4 count, the defense cell that is the main target of HIV - the greater the amount, the less the immune system is compromise, thus reducing vulnerability to HIV/AIDS complications.   It is worth noting that, since HIV can also be transmitted through breastfeeding, breastfeeding is absolutely contraindicated for HIV positive mothers, even if the virus cannot be detected in the blood. In Brazil, since 1999, children born to HIV-positive mothers are entitled to receive sufficient milk formula to be fed at least up to 6 months of age. The woman, in turn, receives medication to inhibit lactation. Prenatal is everything in the fight against HIV in children To prevent vertical transmission, therefore, it is clear that the pregnant woman needs to be very well monitored throughout the nine months of pregnancy and, evidently, needs support and a lot of information when the baby is born, so she needs to keep going to the doctor’s.  To begin with, ideally, an HIV test should be done still during family planning, together with her partner. This way, if woman is HIV positive, she may try to get pregnant while her viral load is undetectable, and therefore, with the lowest possible risk for the baby.  As this does not frequently happen in reality, it is essential to start prenatal care as soon as possible. The HIV test is requested right at the first consultation and, if it is negative, it is repeated also in the last gestational trimester, so that the medical team can make sure they won’t need to provide special attention during delivery and after birth. If the test is positive at the beginning, the pregnant woman must receive the antiretroviral drugs indicated by the doctor and perform the quantification of viral load, given that the purpose of the treatment is to make the amount of virus undetectable in the blood, and the CD4 count. Tests to measure the functioning of the kidneys and liver, which need to be monitored, are also performed due to the use of these drugs. For all the rest, prenatal care is carried out exactly in the same way as for any pregnant woman. Becoming aware that you are HIV positive right at the beginning of pregnancy can, of course, be difficult news for any woman, but it is the most effective way to protect the baby from this virus, that is so devastating in childhood, and from other sexually transmitted agents, such as Treponema pallidum, which causes congenital syphilis, a very serious disease due to the sequelae that it can cause to the baby born to untreated mothers.  Give your baby your greatest proof of love before it's even conceived. Ask your gynecologist to plan your pregnancy and, above all, go through prenatal care, strictly following your obstetrician's instructions. Seeking to put an end on vertical transmission From 2008 to 2017, 1.6 million children stopped being infected globally thanks to antiretroviral therapy during pregnancy, childbirth and shortly after birth, according to Unaids. But there is a lot to be done. Last year alone, 160,000 children worldwide were diagnosed with HIV/AIDS. Ending the possibility of contamination by those who have no choice to defend themselves is the goal of the World Health Organization (WHO), which has been acknowledging the countries that eliminate this form of transmission. In practice, WHO grants a certification to nations that reduce rates of mother-to-child transmission to levels below 2% - or two cases of HIV in children per every 100 pregnant women infected. Cuba was the first country to receive the document, followed by Thailand, Armenia and Moldova. In Brazil, with its continental dimensions, for the time being only two municipalities with more than 100 thousand inhabitants - a condition for receiving such acknowledgment - have managed to achieve this objective: Curitiba and Umuarama, both in Paraná. It is a beginning. 

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