Clinical predictors of non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus

BACKGROUND: Several studies had suggested that non-diabetic renal disease (NDRD) was common among non-insulin dependent diabetes mellitus (NIDDM) patients with renal involvement. METHODS: We prospectively studied the prevalence of NDRD among a Chinese NIDDM population. Renal biopsy specimens were evaluated with light-, immunohistological and electron-microscopy. The cohort consisted of 51 patients who had NIDDM and proteinuria > 1 g/24 h. RESULTS: Patients with both isolated diabetic nephropathy (DN, n = 34) and NDRD (n = 17) had comparable duration of DM, creatinine clearance, serum creatinine, albumin and glycosylated haemoglobin levels, as well as incidences of retinopathy, neuropathy and hypertension. Significantly more patients with NDRD had microscopic haematuria (P = 0.043) or non-nephrotic proteinuria (P = 0.004). IgA nephropathy accounted for 59% of the NDRD identified. CONCLUSIONS: In this study, microscopic haematuria and non-nephrotic proteinuria predicted the presence of NDRD among NIDDM patients presenting with renal disease.     

Thin glomerular membrane nephropathy. Clinico-pathological observations

In two nephrology centres between 1983 and 1993 among 1545 kidney biopsies 34 cases of thin basement membrane nephropathy have been diagnosed. All patients had a varying degree of microscopic dysmorph haematuria, occasional slight proteinuria--except two nephrotic children; and normal blood pressure with one exception. 5 children and 7 adults experienced repeated bouts of macroscopic haematuria mainly after exercise or upper respiratory tract infection, one child after tonsillectomy. All patients had normal renal function and retained it during the follow-up period (mean 61 months, 3 months to 22 years), except a 46 year old patient, who was found to have the joint occurrence of light chain gammopathy and hypertension. Seven patients had positive family history for microscopic haematuria, in four family members of three patients renal biopsy disclosed mesangioproliferative glomerulonephritis with thin GBM segments. As a cut off value for thin basement membrane nephropathy we considered 264 nm. The morphometric analysis of the electron micrographs revealed a mean thickness of 210 nm. No differences in basement membrane thickness were measured regarding gender, age or the presence of macroscopic haematuria. The thin basement membrane is considered to be the pathological basis and predisposing alteration leading to haematuria.     

Permanent endoprostatic prostheses in patient with obstruction caused by benign hyperplasia of the prostate

Presentation of the results obtained using the intraprostatic prosthesis UroLume in 78 patients wit BPH obstruction, 69 of which presented high surgical risk (ASA IV). Mean age was 79.8 years (r: 62-93). All patients carried urethral catheters, except 4 (5.1%) who had a provisional metal coil that required replacement. Prosthesis were implanted successfully in 72 cases (93.3%). The most significant exclusion criterion was an excessive length of prostate urethra. Mean follow-up was 15.3 months (r: 3-38). Mean maximum flow at 1 year after implant was 12.7 mL/sec; mean symptoms score (I-PSS score) was 6.2 points and in most prosthesis, epithelization had taken place. Three patients required implant of another prosthesis, either during the same surgical procedure (1 case) or later due to retention or dysuria (2 cases). Due to acute urine retention (AUR) during the immediate postoperative, resection of the middle lobe was performed in one case while a second case required late resection of intraluminal hyperplastic tissue. Three patients (4.1%) had haematuria that forced hospital admission some months after the implant, and three cases (4.1%) required removal of the prosthesis; at patient's request (1 case), due to calcification (1 case) and for stress incontinence (1 case). After a follow-up of over three years, it can be concluded that the UroLume prosthesis is an effective alternative to TUR in patients at high surgical risk.     

Maximum flow rate--the single uroflowmetric parameter in clinical trials for benign prostatic hyperplasia?

BACKGROUND: Uroflowmetry parameters should be examined for both reliability and optimal test conditions in patients with benign prostatic hyperplasia (BPH), since the difference between one pre- and one post-intervention uroflow rate is usually evaluated in clinical trials of BPH. PATIENTS AND METHODS: Reproducibility of maximum flow rate (Qmax) or its modified forms, and the effects of urinary volume on the reproducibility were examined in terms of Spearman's correlation coefficient (r) in 67 BPH patients. RESULTS: Qmax had a higher r (0.672) as compared to other uroflow rates, such as mathematically modified forms of Qmax and adjusted values of Qmax on nomograms. Reliability was improved by bladder instillation (r = 0.811) or when voided volume was > or = 150 ml or the ratio of volumes was < 2.0 (r = 0.690-0.736). CONCLUSION(S): Qmax, preferably performed with urinary volumes of more than 150 ml or the ratio of volumes less than 2.0, is the most practical single parameter at present in the comparison of two uroflowmetric tests in BPH treatment.     

Paraganglioma of the prostatic urethra. A report of three cases and a review of the literature

OBJECTIVE: To determine the incidence and clinical presentation of prostatic urethral paragangliomas and to compare these findings with paragangliomas occurring in the other sites of the lower urinary tract. PATIENTS AND METHODS: The clinical records of three patients with prostatic urethral paragangliomas were reviewed, as was the histology of each specimen. The tumours were stained immunocytochemically with neuron-specific enolase, chromogranin, S100 protein, protein gene product 9.5, prostate-specific acid phosphatase and prostate-specific antigen. RESULTS: The three tumours occurred in elderly men, two of whom presented with haematuria, one of whom also had a vesical transitional cell carcinoma, and the third patient had obstructive symptoms due to co-existent prostatic hyperplasia. The histological appearances and immunocytochemical findings were consistent with paraganglioma. Treatment consisted of local excision and there were no recurrences or metastases at 5 and 6 years in two patients for whom follow-up was available. CONCLUSION: Urethral paragangliomas are rare tumours arising in elderly men and are hormonally inactive. Although haematuria may be the presenting symptom, it is important to exclude additional more common and possibly more sinister lesions such as transitional cell carcinoma. Local excision appears to be curative.     

Epidermoid carcinoma of the larynx. VI. Histologic grading in the clinical evaluation

A multifactorial microscopic grading of malignancy was performed on a clinically well examined series of 129 patients with laryngeal carcinoma. The microscopic score was statistically significantly correlated to the frequency or regional lymph-node metastases and to the death rate. It afforded important supplementary information for the T-classification and for the prognosis. Microscopic grading is an essential supplement to the clinical evaluation of risk groups.     

Normal communication changes in older adults

A case of arterial hypertension following an adder bite (Vipera Berus) in a six year-old boy is presented. Initially he had gross local symptoms and mild systemic symptoms, but was not treated with viper venom antiserum. Ten days after the initial admittance he developed symptoms of high blood pressure. Microscopic haematuria was found, and renal function was mildly impaired. It was concluded that the adder bite had caused the temporary rise in arterial blood pressure and renal dysfunction. Treatment with viper venom antiserum is recommended if local symptoms progress to involve the trunk or if systemic symptoms evolve.     

A nationwide survey of practicing urologists: current management of benign prostatic hyperplasia and clinically localized prostate cancer

PURPOSE: Our aim was to define the spectrum of urological care for benign prostatic hyperplasia (BPH) and clinically localized prostate cancer. MATERIALS AND METHODS: In 1995 a random sample of 394 American urologists was surveyed with a response rate of 67%. RESULTS: Respondents reported seeing a median of 240 BPH patients during the preceding 12 months, and they had prescribed alpha-blockers for 70 and finasteride for 15. They had performed a median of 25 transurethral prostatectomies but few other operations for BPH. Almost all urologists routinely used digital rectal examinations and prostate specific antigen tests for BPH diagnosis. The next most common studies were American Urological Association symptom scores and uroflowmetry. Pressure-flow studies were rarely done. Respondents reported seeing a median of 35 new patients with prostate cancer during the last year, and performing a median of 90 prostate biopsies and 13 radical prostatectomies. Respondents had referred a median of 10 patients for external beam radiotherapy but few patients received brachytherapy or cryotherapy. Urologist staging practices varied considerably. CONCLUSIONS: These data provide a picture of current practice regarding the management of BPH and prostate cancer.     

Tobacco smoking and testicular cancer

A 12 year old male immigrant from Somalia was admitted to hospital after several years of haematuria and dysuria. Microscopic examination of the urine revealed eggs of the Schistosoma haematobium. Urine culture was negative. Cystoscopy showed a characteristic bilharzial tubercle, and numerous sandy patches were also seen. Mucosal biopsy showed schistosoma eggs, some with calcification. There was squamous cell metaplasia and infiltration of plasma cells and eosinofilic granulocytes. The patient was treated with praziquantel 600 mg x 4 for two days. Three months later no schistosoma eggs were seen in his urine and cystoscopy was negative. In immigrants from countries where bilharzia is endemic, it should be considered a differential diagnosis in patients with haematuria.     

Ratio of free-to-total prostate specific antigen in serum cannot distinguish patients with prostate cancer from those with chronic inflammation of the prostate

PURPOSE: We demonstrate the effect of chronic inflammation of the prostate on the ratio of free-to-total prostate specific antigen (PSA) in serum calculated as a percentage of free PSA and, therefore, that percentage of free PSA is an unspecific means to distinguish among prostate cancer, chronic prostatitis and benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Total, free and percentage of free PSA was measured in 66 men with prostate cancer, 119 with BPH and 17 with asymptomatic chronic prostatitis. In all patients the diagnosis was histopathologically confirmed by microscopic examination of prostatic specimens after sextant biopsy, transurethral prostatic resection or prostatectomy. RESULTS: The median values of total, free and percentage of free PSA were 4.11 microg./l., 0.75 microg./l. and 20.4% in patients with BPH, 10.0 microg./l., 0.84 microg./l. and 8.5% in those with prostate cancer, and 7.60 microg./l., 1.23 microg./l. and 10.6% in those with chronic prostatitis. Patients with prostate cancer and chronic prostatitis had a significantly lower percentage of free PSA than those with BPH. Receiver operating characteristics curve analysis showed that percentage of free PSA as a discriminator between prostate cancer and BPH was not suitable for differentiating between prostate cancer and chronic prostatitis. CONCLUSIONS: Chronic prostatitis is not characterized by elevated total PSA concentrations alone but also by a decreased percentage of free PSA, a tendency similar to that in prostate cancer. This unspecific change in percentage of free PSA must be considered to interpret the percentage of free PSA correctly.     

Clinical value of studying hematuria using phase-contrast microscopy

To evaluate the examination of urine erythrocytes with a contrast phase microscope for the etiological diagnosis of haematuria (erythrocytes > 10/mm3 of non centrifuged urine) the charts of 84 patients with haematuria were reviewed. A nephrological origin had been established with certainty in 56 cases with a renal biopsy and an urological origin was also established with certainty in 28 cases thanks to appropriate radiological, endoscopical and pathological examinations. The morphological criteria of the erythrocytes deformation were those of Birch and Fairley but the quantitative criteria of these authors (either 80 or 100%) were found to be of no value. By successive approaches the threshold of 20% of deformed erythrocytes was selected and found to be the best criterion for diagnosing glomerular hematuria: the sensitivity of the test is then 73% and its specificity 60%. As these results were relatively modest, conditions which decrease the percentage of deformed erythrocytes were excluded to improve the sensitivity, such as macroscopic haematuria and also examinations made during the 6 hours following furosemide administration whereas conditions which increase the percentage of deformed erythrocytes and which are easily diagnosed such as urinary infections, lithiasis and renal insufficiency associated with an uropathy were excluded in order to improve the specificity. Then the examination has a sensitivity and a specificity of 90% which makes it clinically relevant, authorizing a wait and see attitude in case there is an isolated microscopic haematuria of glomerular type.     

The importance of human glandular kallikrein and its correlation with different prostate specific antigen serum forms in the detection of prostate carcinoma

BACKGROUND: Human glandular kallikrein (hK2), the prostate specific antigen (PSA) close homologue, possesses approximately 80% structure identity with PSA. The identification of PSA was an important step in the detection of prostate carcinoma (PCa). Thus, hK2 measurement in the serum has the potential to become another important diagnostic test for PCa. In the current study, the authors measured the serum concentrations of the hK2 with "in-house" immunofluorometric assays in different patient groups. The correlation between serum hK2 and different PSA forms was investigated. METHODS: The prospectively collected serum samples were obtained preoperatively on admission from 311 consecutive male patients. Sixteen patients did not fulfill inclusion criteria; the remaining patients were divided into four groups (Groups I-III confirmed histologically): Group I: patients with PCa (n = 56); Group II: patients with benign prostatic hyperplasia (BPH) (n = 163); Group III: patients with BPH with a chronic in-dwelling catheter (BPH cat) (n = 44); and Group IV-control group (n = 32). The patients in Group IV had urolithiasis, varicocele, or kidney or bladder tumors). An experimental immunofluorometric assay with an analytic sensitivity of 0.01 ng/mL and a functional sensitivity of 0.05 ng/mL was used to determine serum hK2 concentrations. Total PSA, free PSA, and PSA complexed to alpha-1-antichymotrypsin (PSA-ACT) also were measured. hK2 concentrations equal to or above the functional sensitivity limit were correlated with each of these PSA serum forms. Free to total PSA, hK2 to total PSA, and hK2 to free PSA ratios were calculated and compared in different patient groups. RESULTS: The hK2 concentrations were equal to or above the functional sensitivity limit in 179 of 311 samples (57.6%). In these samples, hK2 correlated best with free PSA (correlation coefficient [r] = 0.79) and correlated well with total PSA (r = 0.72) and PSA-ACT (r = 0.74). Similar correlations also could be observed when each clinical group was analyzed separately. The median proportion of hK2 in relation to total PSA was 2.1%, 1.8%, and 1.4%, respectively, for PCa, BPH, and BPH cat patients. Both the free to total PSA ratio and the hK2 to free PSA ratio discriminated well between PCa and BPH patients. Within the range of total PSA of 4-10 ng/mL (PCa [n = 11] and BPH [n = 41]) the hK2 to free PSA ratio had a specificity of 63.4% and 90.9% sensitivity (area under the receiver operating characteristic [ROC] curve = 0.85) whereas the free to total PSA ratio had a 34.1% specificity at the same sensitivity level (area under ROC curve = 0.74). CONCLUSIONS: The hK2 serum level correlates well with all PSA serum forms in all clearly defined clinical groups. The preliminary finding that the hK2 to free PSA ratio appeared to improve the detection of PCa compared with the free to total PSA ratio in patients with total PSA within a 4-10 ng/mL range is of clinical interest. Combining human serine proteases in the multivariate regression analysis will be a tool to improve cancer detection. Further investigations with more sensitive hK2 assays and in larger patient populations are needed to confirm this finding.     

Increased incidence of depressive symptoms in men with erectile dysfunction

OBJECTIVES: To investigate the hypothesis that men with erectile dysfunction (ED) have a higher incidence of depressive symptoms compared with age-matched control subjects. We also hypothesized that depressive symptoms impact on the level of libido and on the success of treatment of ED. METHODS: One hundred twenty men with ED or benign prostatic hyperplasia (BPH) were divided into three groups. Group 1 had ED only, group 2 had BPH only, and group 3 had both ED and BPH. Patients were screened for depressive symptoms using the Primary Care Evaluation of Mental Disorders and the Beck Depression Inventory. They were also surveyed for comorbidity, marital status, severity of ED, level of libido, prior ED treatment choice (if any), success of treatment, and others. RESULTS: One hundred patients completed the questionnaires. Depressive symptoms were reported by 26 (54%) of 48 men with ED alone, 10 (56%) of 18 men with ED and BPH, and 7 (21 %) of 34 men with BPH alone. Patients with ED were 2.6 times more likely to report depressive symptoms than men with BPH alone (P < 0.005). Patients with depressive symptoms reported lower libido than other patients (P < 0.0001). Severity of comorbidities did not differ among the three groups. A total of 33 patients with ED had prior treatment for ED using penile injections or vacuum devices. All 15 (100%) patients with ED only continued treatment and were satisfied with its outcome, whereas only 7 (38.9%) of 18 patients with ED and depressive symptoms continued treatment (P < 0.00021). CONCLUSIONS: ED is associated with high incidence of depressive symptoms, regardless of age, marital status, or comorbidities. Patients with ED have a decreased libido compared with control subjects. In addition, patients with depressive symptoms have a lower libido than patients without depressive symptoms. Patients with ED and depressive symptoms are more likely to discontinue treatment for ED than other patients with ED. These data emphasize the importance of a multidisciplinary approach to the treatment of erectile dysfunction.     

Epidemiological study on diet, smoking and alcohol drinking in the relationship to prostatic weight

BACKGROUND: There have been no epidemiological studies on the relationship between the prostatic weight and blood examination data. This study was carried out to evaluate this relationship. SUBJECTS AND METHODS: Blood examination (beta-carotene, GOT, GPT, total cholesterol, etc.) and measurement of the prostatic weight were performed in 432 subjects aged 50 years or more of a town in Japan, and the possible relationship between blood analysis data and the prostatic weight was evaluated. The prostates were examined by transrectal ultrasonography (TRUS) and classified into the normal prostate and benign prostatic hypertrophy (BPH). The prostatic weight was measured by Watanabe's method based on TRUS images. In addition, the possible association between the prostatic weight and smoking, drinking, height, body weight, or age was evaluated. RESULTS: Analysis by the logistic procedure and the general linear models procedure showed a significant positive correlation between the normal prostatic weight and beta-carotene, height, as well as body weight and a significant negative correlation between the normal prostatic weight and smoking. Comparison between subjects with the normal prostate and those with BPH suggested that serum beta-carotene is a significant positive risk for BPH, and HDL-cholesterol, drinking, and smoking are negative risks by logistic procedure analysis. CONCLUSION: It was thought that serum beta-carotene and smoking are associated with the development of BPH.     

The influence of prostate volume on the ratio of free to total prostate specific antigen in serum of patients with prostate carcinoma and benign prostate hyperplasia

BACKGROUND: Determining the ratio of free to total prostate specific antigen (f-PSA to t-PSA, calculated as the percentage of f-PSA [f-PSA%]) in serum allow for a clearer distinction between patients with prostate carcinoma (PCa) and patients with benign prostate hyperplasia (BPH) than determining the level of t-PSA alone. To find influencing factors on f-PSA%, the authors investigated prostate volume, TNM classification, and tumor stage. METHODS: The authors measured f-PSA and t-PSA in 36 men with untreated PCa (tumor classification: T1, 2, 3pNO, MO), 44 patients with BPH, and 54 healthy controls. Prostate volume was determined by transrectal ultrasound. RESULTS: The median values of t-PSA and f-PSA% were 7.8 micrograms/L and 10.5% in PCa patients, 4.3 micrograms/L and 20.8% in patients with BPH, and 1.4 micrograms/L and 23.6% in the control group. Patients with PCa had a significantly lower proportion of f-PSA than BPH patients and healthy men. There was no correlation of f-PSA% to TNM stage or tumor grade. In PCa patients a significant positive correlation (correlation coefficient [r] = 0.51, P < 0.001) was found between f-PSA% and prostate volume, whereas there was no significant correlation in BPH patients (r = -0.27, P > 0.05). There was a significant difference in f-PSA% between PCa and BPH patients with prostate volumes smaller than 40 cm3 (9.0% vs. 21.6%, P < 0.01) but not between patients in these 2 groups with prostate volumes exceeding 40 cm3 (15.1% vs. 18.2%, P = 0.11). CONCLUSIONS: Determining the ratio of f-PSA to t-PSA to discriminate between PCa and BPH patients yields significant results only in men with a prostate volume of less than 40 cm3.     

A serial section study of visually normal posterior pelvic peritoneum from baboons (Papio cynocephalus, Papio anubis) with and without spontaneous minimal endometriosis

OBJECTIVES: To determine if microscopic endometriosis exists in visually normal pelvic peritoneum from baboons with and without endometriosis. DESIGN: Observational histologic study at Institute of Primate Research, Nairobi, Kenya. SUBJECTS: Seventeen baboons including 13 adult females (5 with histologically proven endometriosis, 8 with a normal pelvis) and 4 juveniles (1 female and 3 males). INTERVENTIONS: Diagnostic laparoscopy with identification of visually normal pelvic peritoneum before euthanasia, followed by laparotomy with excision of a large area (at least 4 x 6 cm or 24 cm2 per animal, 408 cm2 surface in all baboons) of this visually normal-appearing peritoneum. MAIN OUTCOME MEASURE: Presence of microscopic endometriosis (endometrial glands and stroma) in serial sections of visually normal pelvic peritoneum. RESULTS: Two adjacent glandular structures compatible with endometriosis were found in normal peritoneum obtained during menses from one female baboon without macroscopic disease. Microscopic endometriosis was not detected in the other female primates with or without macroscopic disease or in male animals. CONCLUSION: Microscopic endometriosis was found in only 1 of 14 female baboons (prevalence 7%; 95% confidence interval 0% to 33%) with visually normal pelvic peritoneum. These findings suggest that, with the paucity of human data available, more studies are needed before concluding that massive microscopic disease exists in visually normal-appearing peritoneum of women.     

The clinical utility of measuring free-to-total prostate-specific antigen (PSA) ratio and PSA density in differentiating between benign prostatic hyperplasia and prostate cancer

OBJECTIVE: To evaluate the role of free-to-total prostate-specific antigen ratio (f/tPSA), prostate volume and PSA density in differentiating between men with prostate cancer and benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: The study comprised 51 patients who were assessed after transurethral electroresection of the prostate (16 with prostate cancer and 35 with BPH). Patients with a tPSA of < or = 4.0 ng/mL and > or = 30.0 ng/mL were excluded from the analysis. Total and fPSA were measured using an immunoradiometric assay and prostate volume was determined by transrectal ultrasonography. The incidence of prostate cancer and BPH was then compared with the PSA variables to determine specificity and predictive value. RESULTS: Most patients with BPH had a tPSA of 4.0-6.0 ng/mL; no patients with BPH had a tPSA of > 20.0 ng/mL. Most patients with prostate cancer had a f/tPSA of 6-10%. The area under the receiver operating characteristic curve for f/tPSA was significantly greater than that for tPSA (P < 0.003). CONCLUSIONS: The measurement of f/tPSA and PSA density increase the specificity of the differential diagnosis between BPH and prostate cancer.     

Central venous access: low internal jugular vein approach using imaging guidance

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniae and Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.     

Proteinuria, other selected urinary abnormalities and hypertension among teenage secondary school students in Nairobi, Kenya

Four hundred and three teenage secondary school students (50.6% males) from two girls' and two boys' Nairobi City Schools, selected by stratified sampling, were screened to determine the prevalence of proteinuria, haematuria, nitrituria and hypertension. Nine students (2.2%) had significant proteinuria while 14 (3.5%) had microscopic haematuria. Two students had combined proteinuria and haematuria. There was no statistically significant difference in the prevalence of proteinuria and/or haematuria between the sexes. Other urinary abnormalities detected were leucocyturia in 14(3.5%) and nitrites in four (1%). Leucocyturia was commonner in females (p = 0.001). Cloudy urinary appearance was significantly associated with the presence of leucocyturia (p = 0.0028) and proteinuria (p = 0.0276). Neither personal history of recurrent sore throat and skin infections nor family history of hypertension, diabetes mellitus or kidney disease was significantly associated with proteinuria or haematuria. Blood pressure tended to increase with age. Mean systolic and diastolic blood pressures were significantly higher in boys than girls in the age group 15-18 years (P < 0.001). Of the 397 students whose blood pressures were measured, four (1%) were found to be hypertensive. Weight and body mass index were strong positive correlates of blood pressure. The prevalence of proteinuria, haematuria, other urinary abnormalities and hypertension ranges between 1% and 3.5% among teenage secondary school children. The majority are asymptomatic and have no significant associations. It is recommended that routine urinalysis and blood pressure measurements should be part of the school health service so as to identify asymptomatic students who require close monitoring and/or intervention.     

Reactivation of Chagas' disease in a human immunodeficiency virus-infected patient leading to severe heart disease with a late positive direct microscopic examination of the blood

We report a human immunodeficiency virus (HIV)-infected man with chronic Chagas' disease who developed a congestive heart failure that could not be clinically controlled. Endomyocardial biopsy revealed severe myocarditis and the xenodiagnosis result was positive, but Trypanosoma cruzi by direct microscopic examination of the blood was found only four months after the symptoms had started. Treatment with benznidazole was effective in reducing parasitemia, stabilizing the clinical status, and controlling tissue damage related to the parasite. Although the finding of T. cruzi trypomastigotes by direct microscopic examination of the blood has been considered the mark of Chagas' reactivation in immunocompromised patients with chronic disease, in this case it was a late finding.