Conhecimentos sobre a doença de Chagas entre escolares de dois municípios de Minas Gerais, Brasil / Knowledge about Chagas disease among schoolchildren from two municipalities of Minas Gerais, Brazil

Resumo Introdução: No Brasil, a vigilância entomológica da doença de Chagas (DCh) é respaldada na participação comunitária, que notifica a presença dos vetores nas habitações. Assim, a sustentabilidade desta medida de controle depende do conhecimento da população sobre os vetores. Objetivo: Avaliar o conhecimento de escolares sobre a doença de Chagas nos municípios mineiros de Itatiaiuçu (vigilância ativa) e Sabará (vigilância inativa). Método: Questionário semiestruturado foi aplicado para alunos matriculados no ensino médio em duas escolas de Sabará (rural e urbana) e uma em Itatiaiuçu (urbana). Resultados: Em geral, os alunos residentes em Sabará demonstraram conhecimento limitado acerca dos vetores, patógeno, transmissão e doença (sem diferenças relevantes quanto à localização entre área urbana e rural), quando comparados aos residentes em Itatiaiuçu, que apesar de ter uma vigilância mais atuante, também não apresentaram conhecimento totalmente satisfatório. Conclusões: Os resultados enfatizam a carência de informações sobre a DCh tanto em relação ao conhecimento acadêmico quanto às campanhas de educação firmadas pelo programa. Ações educativas para sensibilizar a comunidade e promover o conhecimento sobre esta doença mostram-se necessárias e fundamentais para a manutenção da vigilância ao longo do tempo e espaço.

Abstract Background: In Brazil, entomological surveillance of Chagas disease (ChD) is based on community participation, which notifies the presence of vectors inside their homes. Thus, the sustainability of this control measure depends on the knowledge of the population about the vectors. Objective: To evaluate the knowledge of schoolchildren about ChD in the municipalities of Itatiaiuçu (active surveillance) and Sabará (inactive surveillance). Method: A semi-structured questionnaire was given to students enrolled in two high schools in Sabará (rural and urban) and one in Itatiaiuçu (urban). Results: In general, students living in Sabará demonstrated only limited knowledge about vectors, pathogens, transmission, and disease (with no significant differences between the schools in urban and rural areas). Similarly, the schoolchildren in Itatiaiuçu, despite living in an area of active surveillance, also did not have a fully satisfactory knowledge of ChD. Conclusions: The results emphasize the lack of information about ChD, both in relation to academic knowledge and the education campaigns established by the program. Improvements in educational interventions to raise community awareness and promote knowledge about ChD are necessary and vital for maintaining vigilance against ChD over space and time.

Prognosis of chronic Chagas heart disease and other pending clinical challenges

In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.

Exercise intensity during official soccer matches / Intensidade de exercício durante partidas oficiais de futebol

Abstract The aims of the study were: 1) to analyze the exercise intensity in several phases (six phases of 15 min) of soccer matches; 2) to compare the match time spent above anaerobic threshold (AT) between different age groups (U-17 and U-20); and 3) to compare the match time spent above AT between players’ positions (backs, midfielders, forwards and wingabcks). Forty-four male soccer players were analyzed. To express players’ effort, the heart rate (HR) was continuously monitored in 29 official matches. Further, HR corresponding to the intensity at the onset of blood lactate accumulation (OBLA) was obtained in a field test. The highest exercise intensity during match was observed in the 15-30 min period of the first half (p< 0.05). Match time spent above AT was not different between players from U-17 and U-20. In the comparison among players’ positions, wingbacks showed lower time above AT (p< 0.05) than players of other positions. The intensity of effort is higher in the 15 to 30 minutes of play (intermediate phase), probably because the players are more rested in the beginning and wearing out is progressive throughout the game. It is also noteworthy that the intensity of exercise (HR and time above AT) of wingbacks was lower, probably because they usually are required to run a larger number of sprints and need more time below the AT to recover.

Resumo Os principais objetivos do presente estudo foram: 1) comparar a intensidade de exercício em diversas fases (seis fases de 15 min) de partidas de futebol; 2) comparar o tempo de partida acima do limiar anaeróbio (LAN) entre diferentes categorias (sub-17 e sub-20); e 3) comparar o tempo de partida acima do LAN entre jogadores de diferentes posições (zagueiros, meio campistas, atacantes e laterais). Quarenta e quatro jogadores foram analisados. A intensidade de esforço como frequência cardíaca (FC) foi monitorada em 29 jogos oficiais. A FC correspondente à intensidade do OBLA (onset of blood lactate accumulation) foi obtida em um teste de campo. A maior intensidade de exercício foi observada no período 15-30 min do primeiro tempo (p< 0,05). O tempo de partida gasto acima do LAN não foi diferente entre jogadores das categorias sub-17 e sub-20. Os laterais apresentaram menor tempo acima do LAN (p< 0,05). Pode concluir-se que a intensidade do esforço foi maior em 15 a 30 min (fase intermediária), provavelmente porque os jogadores estão mais descansados no início e o desgaste é progressivo ao longo do jogo. A intensidade de exercício (FC e tempo acima LAN) dos laterais foi menor, provavelmente porque eles executam um maior número de sprints e necessitam de mais tempo abaixo do LAN para se recuperar.

II Consenso Brasileiro em Doença de Chagas, 2015 / Brazilian Consensus on Chagas Disease, 2015

A doença de Chagas é uma condição crônica negligenciada com elevada carga de morbimortalidade e impacto dos pontos de vista psicológico, social e econômico. Representa um importante problema de saúde pública no Brasil, com diferentes cenários regionais. Este documento traduz a sistematização das evidências que compõe o Consenso Brasileiro de Doença de Chagas. O objetivo foi sistematizar estratégias de diagnóstico, tratamento, prevenção e controle da doença de Chagas no país, de modo a refletir as evidências científicas disponíveis. Sua construção fundamentou-se na articulação e contribuição estratégica de especialistas brasileiros com conhecimento, experiência e atualização sobre diferentes aspectos da doença. Representa o resultado da estreita colaboração entre a Sociedade Brasileira de Medicina Tropical e o Ministério da Saúde. Espera-se com este documento fortalecer o desenvolvimento de ações integradas para enfrentamento da doença no país com foco em epidemiologia, gestão, atenção integral (incluindo famílias e comunidades), comunicação, informação, educação e pesquisas.

Chagas disease is a neglected chronic condition that presents high morbidity and mortality burden, with considerable psychological, social, and economic impact. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on collaboration and contribution of renowned Brazilian experts with vast knowledge and experience on various aspects of the disease. It is the result of close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. This document shall strengthen the development of integrated control measures against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research.

Long-term follow-up of a patient since the acute phase of Chagas disease (South American trypanosomiasis): further treatment and cure of the infection

ABSTRACTA woman had been followed since 1957 for acute phase Chagas disease. Parasitological and serological tests were positive, and treatment included benznidazole in 1974. Following treatment, parasitological test results were negative and conventional serology remained positive until 1994, with subsequent discordant results (1995-1997). The results became consistently negative since 1999. She had an indeterminate chronic form until 1974. Only two minor and transitory nonspecific alterations on electrocardiogram were noted, with the last nine records normal until June 2014. This case confirms the possibility of curing chronic disease and suggests the benefit of specific treatments for preventing long-term morbidity.

Predictive factrrs for the progression of chronc chagas cardiomyopathy in patiients without left ventricular dysfunction / Preditores da evolução da cardiopatia chagásica crônica em pacientes sem disfunção ventricular esquerda

The identification of predictors for the progression of chronic Chagas cardiomyopathy (CCC) is essential to ensure adequate patient management. This study looked into a non-concurrent cohort of 165 CCC patients between 1985 and 2010 for independent predictors for CCC progression. The outcomes were worsening of the CCC scores and the onset of left ventricular dysfunction assessed by means of echo-Doppler cardiography. Patients were analyzed for social, demographic, epidemiologic, clinical and workup-related variables. A descriptive analysis was conducted, followed by survival curves based on univariate (Kaplan-Meier and Cox’s univariate model) and multivariate (Cox regression model) analysis. Patients were followed from two to 20 years (mean: 8.2). Their mean age was 44.8 years (20-77). Comparing both iterations of the study, in the second there was a statistically significant increase in the PR interval and in the QRS duration, despite a reduction in heart rates (Wilcoxon < 0.01). The predictors for CCC progression in the final regression model were male gender (HR = 2.81), Holter monitoring showing pauses equal to or greater than two seconds (HR = 3.02) increased cardiothoracic ratio (HR = 7.87) and time of use of digitalis (HR = 1.41). Patients with multiple predictive factors require stricter follow-up and treatment.

A identificação de preditores da progressão da cardiopatia chagásica crônica (CCC) é essencial ao manejo adequado do paciente. Estudo coorte não concorrente de 165 pacientes portadores de CCC entre 1985-2010 quanto a preditores independentes da evolução da CCC. Os desfechos foram piora da classificação da CCC e surgimento de disfunção ventricular esquerda ao ecoDopplercardiograma. Variáveis sócio-demográficas, epidemiológicas, clínicas e propedêuticas foram estudadas e realizadas análise descritiva, análise de sobrevida com análise univariada (Kaplan-Meier e modelo univariado de Cox) e multivariada (modelo de regressão de Cox). O seguimento foi de dois a 20 anos, com média de 8,2 anos. A média de idade dos pacientes foi de 44,8 anos (20- 77 anos). Comparando ambos os tempos do estudo, no tempo 2 houve significância estatística do aumento do intervalo PR e da duração do QRS, além da redução da frequência cardíaca (Wilcoxon < 0,01). Os preditores da evolução da CCC no modelo final de regressão foram sexo masculino (HR = 2,81), pausas iguais ou maiores que dois segundos ao Holter (HR = 3,02), aumento do índice cardiotorácico (HR = 7,87) e tempo de uso de digital (HR = 1,41), destacando-se necessidade de seguimento e tratamento mais rigoroso para os chagásicos que cumulam estes fatores.

A serological, parasitological and clinical evaluation of untreated Chagas disease patients and those treated with benznidazole before and thirteen years after intervention

The etiological treatment of Chagas disease is recommended for all patients with acute or recent chronic infection, but controversies remain regarding the benefit of chemotherapy and interpretations of the parasitological cure after etiological treatment. This study compares the laboratory and clinical evaluations of Chagas disease patients who were diagnosed 13 years earlier. Fifty-eight Chagas disease patients (29 treated with benznidazole and 29 untreated) were matched at the time of treatment based on several variables. Conventional serology revealed the absence of seroconversion in all patients. However, lower serological titres were verified in the treated group, primarily among patients who had the indeterminate form of the disease. Haemoculture performed 13 years after the intervention was positive for 6.9% and 27.6% of the treated and untreated patients, respectively. Polymerase chain reaction tests were positive for 44.8% and 13.8% of the treated and untreated patients, respectively. Patients who presented with the indeterminate form of the disease at the beginning of the study exhibited less clinical progression (17.4%) compared with the untreated group (56.5%). Therefore, this global analysis revealed that etiological treatment with benznidazole may benefit patients with respect to the clinical progression of Chagas disease and the prognosis, particularly when administered to patients with the indeterminate form of the disease.

Tendencias sociales de la enfermedad de Chagas para las próximas décadas / Social tendencies of Chagas disease in the next decades

La existencia de la enfermedad de Chagas humana se considera el resultado de un conjunto complejo de determinantes bioecológicos y sociales. Su cumbre de incidencia se produjo entre los años 1950 y 1970, observándose una tendencia a la disminución en las décadas siguientes. Innumerables elementos socioculturales y políticos están presentes también en la expansión geográfica de la enfermedad, en su prevención y en la atención médica a los infectados. Para las próximas décadas se espera una mayor reducción de la transmisión, especialmente vectorial y transfusional, como producto de las acciones de control y de los cambios en el sistema de producción, en paralelo con la urbanización y con las acciones antrópicas extensivas en las áreas endémicas. Se espera también una reducción en la morbilidad, dependiente de un mejor acceso a los sistemas de salud y de los constantes avances en la medicina. Sin embargo, la enfermedad seguirá siendo muy importante por dos o tres décadas más, dejando como principales desafíos la vigilancia sobre su transmisión y la atención a los individuos ya infectados. Está prevista una disminución en la visibilidad de la enfermedad, con reflejos negativos en la prioridad política de las acciones sobre su atención y control.

Chagas disease is known to be the result of a complex set of bio-ecological and social determinants. The maximum incidence of the disease occurred between 1950 and 1970, with a downward tendency observed in the following decades. Innumerable socio-cultural and political elements take part in the geographic expansion of the disease, the prevention of the disease and in the medical attention given those infected. Over the next decades a major reduction in transmission is expected, especially in the vector and transfusion routes, as a consequence of control-oriented programs and changes in the production system, in conjunction with urbanization processes and extensive anthropic actions in endemic areas. A reduction in morbidity is also expected, owing to better access to the health system and to medical advances. Nevertheless, Chagas disease will continue to have great importance in the next two to three decades, the main challenges being surveillance of disease transmission and the medical attention provided to infected individuals. A reduction in the visibility of the disease, with negative repercussions in the political priority given to medical attention and disease control, is also anticipated.

Relação da prevalência de atividade física com variáveis psicológicas e componentes da síndrome metabólica em agentes penitenciários de Belo Horizonte-MG / Relation of prevalence of physical activity with psychological variables and factors of metabolic syndrome in prison agents in Belo Horizonte, MG, Brazil

É crescente a população carcerária no país. O agente penitenciário (ASP) é o profissional que presta serviço junto ao setor de segurança, tendo como funções o acompanhamento e vigilância dos presos nas dependências das unidades prisionais e realizando também escolta de presos. Os ASP têm uma vida atribulada e estressante e não possuem tempo e nem instalações para a prática de exercícios físicos. Assim o objetivo do estudo foi relacionar a prevalência da prática regular de exercícios físicos com a síndrome metabólica, com a ansiedade de traço e de estado, e com distúrbios psíquicos menores em ASP de Belo Horizonte, MG. Também foram caracterizados os hábitos de vida, frequência de exercício físico e parâmetros clínicos dos ASP. Participaram do estudo 101 ASP de três unidades Prisionais de Belo Horizonte. A média e desvio-padrão de idade da amostra masculina (n=76) foi de 33,1±5,7 anos e com 4,8±3,4 anos de trabalho. Verificou-se que a maioria da amostra faz o uso de bebidas alcoólicas (63%) e que 97,3% consideram seu trabalho muito perigoso. Ainda com relação ao sexo masculino, onde ocorreram as maiores alterações de componentes da SM, os agentes fumantes representam 26,3%. Foram encontrados valores menores (p<0,05): na glicemia de jejum de praticantes (101,0±14,9 mg?dl-1), comparados com não praticantes (111,9±21,5 mg?dl-1) e de pressão arterial sistólica (122,3±8,0 e 131,3±11,5 mmHg, respectivamente). O índice de massa corporal (IMC) de praticantes e não praticantes foi 26,4±3,8 e 29,6±6,1 kg?m-2 e a circunferência da cintura 91,2±8,7 e 100,1±13,9 cm, respectivamente, também foram menores (p<0,05). .

The prison population in Brazil has been growing. The prison agent (PA) is the professional who works in the security sector, having the tasks of conducting prisoners and vigilance inside the facilities, and escorting the prisoners to outside, as well. The agents have a busy and stressing life and they do not have time and facilities to physical exercise practice. Therefore, the objective was to relate the prevalence of physical exercise with metabolic syndrome, with trace and state anxiety, and with minor psychological disturbs in agents in Belo Horizonte, MG, Brazil. Also habits of life, physical exercise and clinical parameters were characterized. One hundred and one agents took part in this study, as volunteers, from 3 different prison units. The male average (n=76) age and standard deviation of the sample was 33.1±5.7 years old and 4.8±3.4 years working as PA. It was evident that the majority uses alcoholic beverages (63%) and 97.3% classified their job as very dangerous. Considering males, where the greater alterations in MS factors were found, smokers represented 26.3% and altered glucose concentration was present in 27.6% of the sample. Smaller values were found (p<0.05) for: glucose in agents who practice (101.0±14.9 mg?dl-1) compared with non practitioners (111.9±21.5mg?dl-1) and arterial pressure (122.3±8.0 and 131.3±11,5 mmHg, respectively). Body mass index (BMI) in practitioners and non practitioners were 26.4±3.8 and 29.6±6.1 kg?m-2, and waist circumference 91.6±9.7 and 99.7±16.7 cm, respectively, were also smaller (p<0,05). It was concluded that there were greater alterations in the metabolic profile in males non practitioners of physical exercise in the three prisons institutions studied, because it was found systolic arterial pressure, BMI, waist circumference and blood glucose with statistically significant different values (p<0.05) compared with practitioners of physical activity.

Acesso pela artéria subclávia para implante por cateter da bioprótese valvar aórtica CoreValve®: dados do registro brasileiro / Subclavian access for transcatheter CoreValve® aortic prosthesis implantation: data from the brazilian registry

INTRODUÇÃO: A via de acesso transfemoral é preferencial para o implante por cateter de bioprótese valvar aórtica. Entretanto, algumas situações, como a presença de doença vascular periférica, impossibilitam a utilização desse acesso. Nesses casos, o acesso por dissecção da artéria subclávia é uma alternativa para a realização do procedimento. Nosso objetivo foi avaliar a experiência brasileira com a utilização da artéria subclávia como via de acesso para o implante por cateter da bioprótese CoreValve®. MÉTODOS: Foram requisitos para o procedimento área valvar aórtica < 1 cm², ânulo valvar aórtico ≥ 20 mm e ≤ 27 mm (CoreValve® de 26 mm e 29 mm), aorta ascendente ≤ 43 mm e artéria subclávia com diâmetro ≥ 6 mm, isenta de lesões obstrutivas significativas, tortuosidade acentuada e calcificação excessiva. O acesso pela artéria subclávia foi obtido por dissecção cirúrgica e, sob visão direta, punção da artéria subclávia. Obtido o acesso arterial, empregou-se a técnica padrão. RESULTADOS: Entre janeiro de 2008 e abril de 2012, 8 pacientes com doença vascular periférica foram submetidos a implante de prótese CoreValve® pela artéria subclávia em 4 instituições. O procedimento foi realizado com sucesso em todos os casos, com redução do gradiente transvalvar aórtico médio de 46,4 ± 17,5 mmHg para 9,3 ± 3,6 mmHg (P = 0,0018) e melhora dos sintomas. Aos 30 dias e no seguimento de 275 ± 231 dias, 87,5% e 62,5% dos pacientes, respectivamente, apresentavam-se livres de complicações maiores (óbito, infarto do miocárdio, acidente vascular cerebral e cirurgia cardíaca de urgência). CONCLUSÕES: Na experiência brasileira, o acesso pela artéria subclávia mostrou-se seguro e eficaz como via alternativa para o implante por cateter da bioprótese CoreValve®.

BACKGROUND: Transfemoral access is the preferred approach for transcatheter aortic valve implantation. However, some situations, such as the presence of peripheral vascular disease, preclude the use of such access. In these cases, subclavian access is an alternative approach for this procedure. This study aimed at evaluating the Brazilian experience using the subclavian approach for transcatheter CoreValve® prosthesis implantation. METHODS: Aortic valve area < 1 cm², aortic valve ring ≥ 20 mm and ≤ 27 mm (26 mm and 29 mm CoreValve®), ascending aorta ≤ 43 mm and subclavian artery with a diameter ≥ 6 mm, without significant obstructive lesions, marked tortuosity and excess calcification were requisites for the procedure. The access through the subclavian artery was obtained by surgical dissection and, under direct vision, a subclavian artery puncture was performed. Once artery access was obtained, the standard technique was used. RESULTS: Between January 2008 and April 2012, 8 patients with peripheral vascular disease underwent CoreValve® prosthesis implantation through the subclavian artery in 4 institutions. The procedure was successful in all cases with reduction of the mean transvalvular pressure gradient from 46.4 ± 17.5 mmHg to 9.3 ± 3.6 mmHg (P = 0.0018) and improvement of symptoms. At 30 days and after 275 ± 231 days of follow-up, 87.5% and 62.5% of the patients, respectively, were free from major adverse events (death, myocardial infarction, stroke and urgent cardiac surgery). CONCLUSIONS: In the Brazilian experience, the subclavian access was a safe and effective alternative for transcatheter CoreValve® implantation.

First report of Panstrongylus megistus sylvatic focus in municipality of Bambuí, state of Minas Gerais, Brazil

In 1943, the Center for the Study and Prophylaxis of Chagas Disease, Oswaldo Cruz Foundation, state of Minas Gerais (MG), was created in the municipality of Bambuí to carry out studies related to Chagas disease in the mid-western region of MG. Since that time, several investigations have been conducted to determine the natural habitat of triatomines, but Panstrongylus megistus colonies have never been found in this region. This paper records the first finding of a P. megistus sylvatic colony in 69 years of research. The characteristics of this ecotope and its implications for the epidemiology of Chagas disease are discussed.

Mecanismos alternativos de transmissão do Trypanosoma cruzi no Brasil e sugestões para sua prevenção / Alternative transmission mechanisms of Trypanosoma cruzi in Brazil and proposals for their prevention

INTRODUÇÃO: Com o avanço no controle da transmissão vetorial e por transfusão sanguínea da doença de Chagas, as formas alternativas de transmissão ganharam relevância. Este artigo de opinião discute a importância de cada uma dessas modalidades e as medidas para sua prevenção. MÉTODOS: Foi realizada uma revisão bibliográfica sobre os mecanismos de transmissão do Trypanosoma cruzi através de modalidades alternativas, vigentes no Brasil, e as possibilidades de sua prevenção. Foram consultadas as bases de dados PubMed e BVS. RESULTADOS: Foram identificadas 25 publicações que discutiam as modalidades alternativas de transmissão da doença de Chagas. CONCLUSÕES: A transmissão oral, pela ingestão de alimentos contaminados, tem sido o modo de transmissão predominante no Brasil nos últimos anos. Os demais modos alternativos de transmissão são de ocorrência menos frequente. É importante conhecer essas ocorrências, sobretudo agora que a veiculação vetorial do parasita está controlada. Conforme os conhecimentos atuais foram apresentadas medidas preventivas, de acordo com cada uma das situações consideradas.

INTRODUCTION: Following advances in the control of vector and blood transfusion transmission of Chagas disease, alternative mechanisms of transmission have become more relevant. This article discusses the importance of each one of these alternative mechanisms and the measures to prevent them. METHODS: A review was conducted of the scientific literature concerning alternative transmission mechanisms of Trypanosoma cruzi occurring in Brazil and the measures to prevent them. PubMed and BVS databases were consulted. RESULTS: Twenty-five publications describing alternative mechanisms of transmission of Chagas disease were identified. CONCLUSIONS: Oral transmission, through ingestion of contaminated food items has been the most frequent mode of transmission in Brazil in recent years. Other alternative mechanisms of transmission occur less frequently. It is important to understand these occurrences, especially now that vector transmission of the parasite is under control. Preventive measures have been presented, according to each of the situations considered, in line with current knowledge.