Inspiratory Muscle Strength in Chagas Cardiomyopathy: A Systematic Scoping Review

ABSTRACT The increase in inflammatory markers associated with persistent chronic fibrosing myocarditis, a characteristic of chronic Chagas disease, can result in a reduction in inspiratory muscle strength (IMS) in Chagas cardiomyopathy (CC). However, literature in this field is still scarce. This review aimed to map and summarize the evidence regarding IMS in patients with CC. The inclusion criteria included reports with adult participants with a CC diagnosis, with or without heart failure (HF). The core concept examined was the maximum inspiratory pressure evaluated in the untrained and trained groups in the pre-training period. The context was open, including but not limited to hospitals and health centers. Two authors independently identified eligible studies and extracted the data. Descriptive synthesis was used as the primary strategy for analyzing the results. Nine studies (five clinical trials, three cross-sectional, and one cohort) were included. The CC classification differed among the studies, with no mention of HF in five and no CC staging specification in six. IMS was assessed using a manovacuometer, and only six studies analyzed and interpreted the data concerning the predicted values. The CC population with HF appeared to have impaired IMS. All studies involved only Brazilian volunteers. In conclusion, randomized clinical trials evaluating IMS and the effects of inspiratory muscle training need to be conducted to better understand the prevalence and risk of inspiratory muscle weakness in the CC population, as well as the effects of training. Such studies should be conducted at different stages of CC in different populations and countries.

Chagas disease mortality during the coronavirus disease 2019 pandemic: A Brazilian referral center experience

ABSTRACT Background We investigated the mortality rates of patients with Chagas disease (CD) during the coronavirus disease 2019 (COVID-19) pandemic and assessed the association between this mortality and CD clinical presentation and comorbidities. Methods: This was an observational retrospective study with clinical data retrieved from medical records. Results: Comorbidities were more prevalent among patients who died from COVID-19 than those who died from other causes. The proportion of patients according to CD clinical presentation was similar between the two groups. Conclusions: The prevalence of comorbidities seems to be related to a poorer prognosis in CD and COVID-19.

Epidemiological-clinical profile and mortality in patients coinfected with Trypanosoma cruzi/HIV: experience from a Brazilian reference center

ABSTRACT Background: The recent urbanization of Chagas disease (CD) has contributed to a greater risk of coexistence with human immunodeficiency virus (HIV) and AIDS. Methods: This retrospective observational study included patients who were followed at INI-Fiocruz between July 1986 and October 2021. All patients underwent an assessment protocol that included sociodemographic profile, epidemiological history, and clinical evaluation. Descriptive data analyses included reports of the medians and frequencies of variables of interest. Differences in medians between groups were tested using the Mann-Whitney U test. Differences in frequency were tested using Fisher's exact test. Results: Among 2201 patients, 11 (0.5%) were identified with Trypanosoma cruzi/HIV coinfection. Of these, 63.6% were women with a median age of 51.0 years old. Two patients had the indeterminate form of CD, six had the cardiac form, two had the digestive form and one had the cardio-digestive form. Half of the patients were undergoing antiretroviral treatment at the time of coinfection diagnosis with a median CD4+ count of 350 cells/μL and a viral load of 1500 copies/μL. Four patients underwent a xenodiagnosis test at coinfection diagnosis, which all yielded positive results; two of them presented high parasitemia under the risk of reactivation. Prophylaxis for CD reactivation was administered to four patients; two with ketoconazole and two with benznidazole. Six patients died after a median follow-up of 22.5 months, with AIDS being the most common cause of death. Only one case of reactivation was observed. Conclusions: Early diagnosis and prompt treatment of CD reactivation dramatically reduced mortality. Identification of Trypanosoma cruzi/HIV co-infection is crucial to planning a close follow-up of coinfected patients.

The CUIDA Chagas Project: towards the elimination of congenital transmission of Chagas disease in Bolivia, Brazil, Colombia, and Paraguay

ABSTRACT Background: Mother-to-child transmission of Chagas disease (CD) has become a relevant problem in both endemic and non-endemic areas. Methods: Description of the CUIDA Chagas Project - Communities United for Innovation, Development and Attention for Chagas disease'. Results: Through innovative and strategic research, this project will provide improved diagnostic and treatment options as well as replicable implementation models that are adaptable to different contexts. Conclusions: By integrating test, treat and care actions for CD into primary health care practices, the burden of CD on people and health systems may be significantly reduced.

Critical analysis of Chagas disease treatment in different countries

As a result of globalization and constant migratory flows, Chagas disease is now present in almost all continents. The management and treatment of the disease is often influenced by the economic and social context of the societies that host patients. In this manuscript, we aim to provide a comparative review of approaches to patients with Chagas disease in the Americas and Europe.

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.

Temporal changes in the clinical-epidemiological profile of patients with Chagas disease at a referral center in Brazil

Abstract INTRODUCTION We aimed to describe the sociodemographic, epidemiological, and clinical characteristics of patients with chronic Chagas disease (CD) at an infectious disease referral center. Changes in patient profiles over time were also evaluated. METHODS This retrospective study included patients with CD from November 1986-December 2019. All patients underwent an evaluation protocol that included sociodemographic profile; epidemiological history; anamnesis; and physical, cardiologic, and digestive examinations. Trend differences for each 5-year period from 1986 to 2019 were tested using a nonparametric trend test for continuous and generalized linear models with binomial distribution for categorical variables. RESULTS A total of 2,168 patients (52.2% women) were included, with a mean age of 47.8 years old. White patients with low levels of education predominated. The reported transmission mode was vectorial in 90.2% of cases. The majority came from areas with a high prevalence (52.2%) and morbidity (67.8%) of CD. The most common clinical presentation was the indeterminate form (44.9%). The number of patients referred gradually decreased and the age at admission increased during the study period, as did the patients' levels of education. CONCLUSIONS The clinical profile of CD is characterized by a predominance of the indeterminate form of the disease. Regarding the patients who were followed up at the referral center, there was a progressive increase in the mean age and a concomitant decrease in the number of new patients. This reflects the successful control of vector and transfusion transmission in Brazil as well as the aging population of patients with CD.

Study of Arboviruses in Philander opossum, Didelphis marsupialis and Nectomys rattus captured from forest fragments in the municipality of Belém, Pará, Brazil / Estudo de Arbovírus em Philander opossum, Didelphis marsupialis e Nectomys rattus capturados em fragmentos florestais no município de Belém, Pará

ABSTRACT: Arboviruses are viruses that maintain their life cycle in the wild and are transmitted to vertebrate hosts by hematophagous diptera. They are zoonotic and can establish an enzootic cycle in the urban areas; in humans, the infection can manifest from being encephalitogenic to hemorrhagic. This study aimed to report the occurrence of arboviruses in mammals of the order Didelphimorphia and Rodentia, captured from the Amazon. Serum samples were subjected to hemagglutination inhibition test using a viral panel of 19 species of arboviruses that are known to occur in the Amazon. Altogether, 14 wild mammals, 12 of Philander opossum, 1 of Didelphis marsupialis, and 1 of Nectomys rattus were captured. Eight of these were reported to be seropositive for arboviruses (57.14%) with monotypic seroprevalence for the Eastern Equine Encephalitis Virus (n=1), the Ilheus Virus (n=2), and the Catu virus (n=4); 4 heterotypic responses were observed for Flavivirus and Orthobunyavirus. In conclusion, several arbovirus species are in active circulation and maintenance, exhibiting enzootic characteristics in the wild mammals of the Amazon region; these animals prove to be potential hosts in the transmission of diseases to humans.

RESUMO: Os arbovírus são vírus que mantêm o seu ciclo de vida em ambiente silvestre. Eles são transmitidos aos hospedeiros vertebrados por dípteros hematófagos, tem caráter zoonótico podendo estabelecer um ciclo enzoótico no meio urbano, sendo que em humanos a infecção pode ter caráter encefalomiogênico a hemorrágico. Este estudo teve como objetivo relatar a ocorrência de arbovírus em mamíferos da ordem Didelphimorphia e Rodentia capturados na Amazônia. Os soros dos animais foram submetidos a testes de Inibição da Hemaglutinação utilizando um painel viral com as 19 principais espécies de arbovírus que ocorrem na Amazônia. Foram capturados 14 espécimes de mamíferos silvestres, 12 Philander opossum, 1 Didelphis marsupialis e 1 Nectomys rattus. A soropositividade para arbovírus foi observada em 57,14% (8/14) dos espécimes estudados, com soroprevalência monotípica para o vírus da Encefalite Equina do Leste (n = 1), o vírus Ilheus (n = 2) e o vírus Catu (n = 4) e quatro reações heterotípicos para Flavivírus e Orthobyavírus. Conclui-se que há manutenção e circulação de espécies de arbovírus com características enzoóticas em mamíferos silvestres da região amazônica, podendo ser hospedeiros em potenciais na transmissão da doença para humanos.

Functional capacity and rehabilitation strategies in Covid-19 patients: current knowledge and challenges

Abstract Covid-19 is a novel infectious disease whose spectrum of presentation ranges from absence of symptoms to widespread interstitial pneumonia associated with severe acute respiratory syndrome (SARS), leading to significant mortality. Given the systemic pattern of Covid-19, there are many factors that can influence patient's functional capacity after acute infection and the identification of such factors can contribute to the development of specific rehabilitation strategies. Pulmonary impairment is the primary cause of hospitalization due to Covid-19, and can progress to SARS as well as increase length of hospitalization. Moreover, cardiac involvement is observed in approximately 30% of hospitalized patients, with an increased risk of acute myocarditis, myocardial injury, and heart failure, which may compromise functional capacity in the long-term. Thromboembolic complications have also been reported in some patients with Covid-19 and are associated with a poor prognosis. Musculoskeletal complications may result from long periods of hospitalization and immobility, and can include fatigue, muscle weakness and polyneuropathy. Studies that address the functional capacity of patients after Covid-19 infection are still scarce. However, based on knowledge from the multiple systemic complications associated with Covid-19, it is reasonable to suggest that most patients, especially those who underwent prolonged hospitalization, will need a multiprofessional rehabilitation program. Further studies are needed to evaluate the functional impact and the rehabilitation strategies for patients affected by Covid-19.

Characterization of ruminal acidosis and initial phase of laminitis inducted by oligofructose in crossbred calves / Caracterização da acidose ruminal e da fase inicial da laminite induzidas por oligofrutose em bezerros mestiços

One of the ways to study cattle laminitis is its experimental induction by supplying a large amount of high fermentation carbohydrate. The most effective protocol until now has been the use of oligofructose. The objective of this study was to evaluate clinical and histological aspects of the hoof in experimental induction of ruminal acidosis and laminitis in calves using oligofructose. Six crossbred (Bos taurus x Bos indicus) yearling calves divided into Group I (GI) and Group II (GII) were used. Animals in GI and GII received intraruminal oligofructose in doses of 13 and 17g/kg, respectively. During 28 hours the calves were clinically evaluated and 30 hours after induction, samples were taken from coronary and abaxial wall of the hoof for histologic evaluation. Were noticed signs of ruminal and metabolic acidosis like rumen distension with fluid, diarrhea, ruminal pH reduction and, at blood gas analysis, pH and bicarbonate below reference range. Lameness was not observed however, some animals had a slower gait and apathy, possibly due to metabolic acidosis, though. Histologically, typical lesions of laminitis like circulatory changes and inflammatory infiltrate in the dermis, irregularities and areas of detachment at basement membrane and morphologic changes in cells from basal epidermis were found. The protocol induced, in the first 30 hours, clinical signs of ruminal and metabolic acidosis and low grade histologic lesions in the digits. Lameness and digit pain were not observed, characterizing the prodromic phase of the disease.(AU)

Uma das formas de se estudar a laminite bovina é sua indução experimental por meio do fornecimento de grande quantidade de carboidrato de alta fermentação. O protocolo mais eficaz até o momento foi o uso de oligofrutose. Objetivou-se avaliar aspectos clínicos e histológicos dos dígitos de bovinos na indução experimental de acidose ruminal e laminite usando oligofrutose. Utilizaram-se seis bezerros mestiços (Bos taurus x Bos indicus) de um ano, divididos em Grupo I (GI) e Grupo II (GII). Os animais em GI e GII receberam oligofrutose por via intrarruminal nas doses de 13 e 17g/kg respectivamente. Os bovinos foram avaliados clinicamente por 28 horas e fragmentos de coroa e muralha abaxial dos dígitos foram colhidos para histologia 30 horas após a indução. Foram identificados sinais de acidose ruminal e metabólica como distensão ruminal com líquido, diarreia e baixo pH ruminal. Os resultados de hemogasometria indicaram baixos pH e nível plasmático de bicarbonato. Os animais não apresentaram claudicação, entretanto, observaram-se apatia e marcha mais lenta, atribuídas à acidose metabólica. Histologicamente foram observadas lesões indicativas de laminite como alterações circulatórias e infiltrado inflamatório na derme, irregularidades e áreas de destacamento da membrana basal e alterações morfológicas de células da epiderme basal. O protocolo induziu, nas primeiras 30 horas, sinais de acidose ruminal e metabólica e lesões histológicas de baixa intensidade nos dígitos. Não foi observada claudicação ou sensibilidade nos dígitos, caracterizando a fase prodrômica da enfermidade.(AU)

Avaliação das lesões pigmentadas e isoladas da face por microscopia confocal: desenvolvimento de um nomograma preditivo de melanoma / Reflectance confocal microscopy of pigmented and isolated face lesions: a predictive nomogram for melanoma

INTRODUÇÃO: O lentigo maligno (LM) é o subtipo do melanoma mais comum da face. O LM apresenta-se clinicamente como uma mácula acastanhada na sua fase inicial, sendo difícil sua diferenciação com lesões pigmentadas benignas da face ao exame clínico. A face, por apresentar particularidades anatômicas e histológicas, pode dificultar o diagnóstico do LM ao diferenciá-lo dos seus simuladores (ceratose actínica pigmentada, ceratose líquen plano-like, lentigo solar, ceratose seborreica). A microscopia confocal in vivo (MC) auxilia no diagnóstico das lesões dermatológicas em que a dermatoscopia possui limitação, permitindo assim, aumentar a acurácia diagnóstica e evitar procedimentos invasivos em lesões benignas, de maneira desnecessária. OBJETIVOS: Descrever as alterações celulares e arquiteturais significativas no exame de MC nas lesões isoladas da face para o diagnóstico de melanoma. Elaborar um método diagnóstico acurado utilizando os critérios da microscopia confocal. MÉTODOS: Estudo prospectivo e retrospectivo com amostragem não aleatória consecutiva no qual foram incluídos 105 pacientes com lesões pigmentadas solitárias da face provenientes do Núcleo de Câncer de Pele A.C.Camargo Cancer Center. Critérios avaliados na MC: padrão em "favo de mel" típico ou atípico; células dendríticas; células nucleadas redondas; disseminação pagetóide, Sheets of cells; ninhos celulares densos e homogêneos (típico) ou denso e esparsos, com atipias (atípico); célula nucleada redonda ou dendrítica na junção dermo-epidérmica; células dendríticas foliculares (célula dendrítica no epitélio folicular) e cords ou projeções bulbosas; ilhas tumorais e fendas. O teste Exato de Qui Quadrado foi aplicado aos critérios da MC. Regressão Logística Univariada foi realizada através de estimativas de risco pelo Odds Ratio. Foi realizado a Regressão Logística Múltipla, resultando em um Nomograma para quantificar, em porcentagem, a chance de ter o diagnóstico de melanoma de acordo com a presença, singular ou concomitante, dos critérios da microscopia confocal supracitados. RESULTADOS: Os critérios da MC célula redonda atípica nucleada na epiderme, célula dendrítica nucleada na epiderme, disseminação pagetóide, célula atípica na JDE, ninhos juncionais atípicos, célula dendrítica folicular, sheets of cells e ilhas tumorais ou silhuetas escuras apresentaram significância estatística (p<0,05). Enquanto que os critérios cords ou projeções bulbosas e padrão em favo de mel atípico não tiveram significância. O único critério que apresentou-se como fator protetor pelo odds ratio foi a presença de ilhas tumorais ou silhuetas escuras. A Regressão Logística Múltiplo resultou em 3 critérios: célula redonda nucleada na epiderme, disseminação pagetóide e célula dendrítica folicular. A partir destes dados, foi realizado o nomograma para definir a chance, em percentual, de ter o diagnóstico de melanoma de acordo com a presença ou ausência das alterações celulares encontradas na microscopia confocal. A presença destes 3 critérios concomitantes expressa 98% de probabilidade da lesão ser melanoma. CONCLUSÃO: Este estudo viabilizou uma estimativa de probabilidade por intermédio de um percentual executável para o referido diagnóstico de melanoma da face, de acordo com a presença, ausência e concomitância destes critérios, de maneira prática e factível à aplicação no cotidiano do consultório

INTRODUCTION: Lentigo maligna (LM) is the most common subtype of facial melanoma. LM presents clinically as a brownish macule in its initial phase, and it is a challenge to differentiate from others facial benign pigmented lesions. Anatomical and histological face's features may make difficult to diagnose LM and to distinguish it from its simulators (actinic keratosis, lichen planus-like queratosis, solar lentigo, seborrheic keratosis). In vivo reflectance confocal microscopy (RCM) assists in the diagnosis of dermatological lesions in which dermatoscopy is limited, allowing to increase diagnostic accuracy and avoid invasive procedures in benign lesions, unnecessarily. OBJECTIVES: Describe cellular and architectural characteristics that were significant in the RCM examination in lesions face for the diagnosis of melanoma. Also elaborate an accurate diagnostic method using the criterias of RCM. METHODS: A prospective and retrospective study with consecutive non-random sampling with 105 patients presenting solitary pigmented facial lesions from the A.C.Camargo Cancer Center Skin Center. RCM criteria: typical or atypical honeycomb; dendritic cells; round nucleated cells; pagethoid spread, Sheets of cells; nests dense and homogeneous (typical) or dense and sparse (atypical); round or dendritic nucleated cell at the dermo-epidermal junction; follicular dendritic cells (dendritic cell in the follicular epithelium) and bulbous cords or projections; tumor islands and dark silluets. The exact test of Chi Square was applied to the criteria of RCM. Univariate Logistic Regression was performed through risk estimates by the Odds Ratio. Multiple Logistic Regression model was performed, resulting in a Nomogram to quantify, in percentage, the chance of having the diagnosis of melanoma according to the singular or concomitant presence of the above mentioned RCM criteria. RESULTS: RCM criteria atypical round cell nucleated in the epidermis, nucleated dendritic cell in the epidermis, pagethoid spread, atypical cell in the JDE, atypical junctional nodes, follicular dendritic cell, sheets of cells and tumor islands or dark silhouettes presented statistical significance (p <0.05). While the criteria cords or projections bulbous and standard in atypical honeycomb had no significance. The only criterion that presented itself as a protective factor by odds ratio was tumor islands or dark silhouettes. The Multiple Logistic Regression resulted in 3 criteria: nucleated round cell in the epidermis, pagetoid spread and follicular dendritic cell. From these data, the nomogram was used to define the percentage chance of having the diagnosis of melanoma according to the presence or absence of cellular alterations found in RCM. The presence of these 3 concomitant criteria expresses 98% probability of the lesion being a melanoma. CONCLUSION: This study enabled estimate probability for the diagnosis of facial melanoma, according to the presence, absence and concomitance of RCM criteria, in a practical and feasible way to the daily medical practice

Ética e cuidado humanizado em Saúde Mental: percepções dos profissionais de enfermagem / Ethics and humanizing health care in mental health: from nursing professionals' perspective

Estudo exploratório, descritivo de abordagem qualitativa, que teve por objetivo compreender como os profissionais que atuam no campo da saúde mental percebem a ética e o cuidado humanizado na sua prática profissional, a partir do referencial da Ética das Virtudes (EV), conforme a proposta de Pellegrino e Thomasma (1993). Foram entrevistados 21 profissionais da equipe de enfermagem, entre eles auxiliares e técnicos de enfermagem e enfermeiros de um hospital psiquiátrico situado no interior do estado de São Paulo. As entrevistas foram gravadas em mídia digital, com o consentimento dos participantes e posteriormente transcritas, os dados foram analisados através do método de Análise de Conteúdo de Bardin (2016) emergiram as categorias 8.2.1 Significados atribuídos a ética; 8.2.2 Percepções sobre situações que envolvam ética na oferta do cuidado; 8.2.3 Significados atribuídos a cuidado humanizado; 8.2.4 Percepções sobre situações que envolvam cuidado humanizado. Dessas categorias despontaram 10 subcategorias, dentre essas destacaram-se 8.2.1.1 Sigilo Profissional, que para o grupo pesquisado é associado ao termo " ética" e associado ao respeito e a confiança na relação profissional-paciente; 8.2.1.3 Hábitos e virtudes e 8.2.2.2 Virtudes subcategorias estas onde os profissionais trouxeram práticas éticas alicerçadas em virtudes; 8.2.2.1 Violência, onde foram expressadas situações que caracterizam o cuidado como não ético; 8.2.3.2 Empatia entendida pelos entrevistados como um fator afetivo essencial na prática do cuidado humanizado e a subcategoria 8.2.4.1 Vínculo que também está relacionado com a empatia, a percepção dos profissionais é que este laço deve ser construído com base na confiança. Foi evidenciado que o termo " ética" foi eminentemente associado a situações negativas enquanto o termo "cuidado humanizado", está relacionado majoritariamente a situações positivas

Exploratory research, employing qualitative descriptive approach, aimed to understand how mental health professionals perceive ethics and humanizing health care in their practice, based on The Virtues in Medical Practice proposed by Pellegrino and Thomasma (1993). 21 nursing professionals (including nurses and nursing assistants) from a psychiatric hospital in the state of São Paulo were interviewed. The interviews were consentingly recorded in electronic devices and transcribed. The Bardin's Content Analysis method (2016) were applied to the data and the following categories emerged 8.2.1 Meanings attributed to ethics; 8.2.2 Perceptions of situations involving ethics in the provision of care; 8.2.3 Meanings attributed to humanizing health care, and 8.2.4 Perceptions of situations involving humanizing health care. 10 subcategories came out from these categories, bringing attention to 8.2.1.1 Professional Secrecy, which is associated with ethics, respect and trust in the professional-patient relationship, according to the group studied; 8.2.1.3 Habits and virtues; 8.2.2.2 Subcategories of virtues where the professionals mentioned ethical practices based on virtues; 8.2.2.1 Violence, where situations were characterized as unethical care; 8.2.3.2 Empathy as an essential affective factor to humanizing health care, according to the interviewees, and 8.2.4.1 Connection also associated with empathy, which from the professionals' perspective, must be based on trust. It was found that the term "ethics" is usually associated with negative situations while the term "humanizing health care" is mostly associated with positive ones

Reassessment of quality of life domains in patients with compensated Chagas heart failure after participating in a cardiac rehabilitation program

Abstract INTRODUCTION: We evaluated the effects of a cardiac rehabilitation program on quality of life. METHODS This secondary analysis of a single-arm study included 12 patients with Chagas heart failure. The cardiac rehabilitation program comprised exercise training and nutritional and pharmaceutical counseling. Quality of life was assessed using the SF-36 questionnaire. RESULTS: The program promoted improved physical functioning (β= +5.7; p=0.003), role-physical (β= +1.9; p=0.03), and bodily pain (β= +3.5; p=0.02) scores. Moreover, the summary physical health score (β= +1.4; p=0.001) improved. CONCLUSION: The cardiac rehabilitation program significantly improved the physical quality of life of patients with Chagas heart failure.

Cardiac rehabilitation program in patients with Chagas heart failure: a single-arm pilot study

Abstract: INTRODUCTION: The benefit of a cardiac rehabilitation (CR) program for patients with Chagas heart failure (CHF) remains unclear. Therefore, we aimed to investigate the effects of CR for CHF patients. METHODS: A single-arm pilot study, including 12 patients with CHF, was performed. Patients participated in an 8-month physical exercise intervention, comprising aerobic, strength, and stretching exercises (3 times per week, 60 minutes per session). Nutritional and pharmaceutical counseling were also performed. Functional capacity (cardiopulmonary exercise test), muscle respiratory strength (manovacuometry), and body composition (anthropometry and skinfolds) were evaluated at baseline, and after 4 and 8 months of intervention. Cardiac function (echocardiography), biomarkers (lipid profile, glucose, and glycated hemoglobin) and quality of life (Minnesota Living with Heart Failure Questionnaire) were assessed at baseline and at the end of the intervention. RESULTS: Seven of 12 patients included in the study completed the 8-month follow-up period. Only 2 moderate adverse events occurred during the exercise training. Functional capacity improved after 4 months of CR, while left ventricular ejection fraction (LVEF) and respiratory strength improved after 8 months. Patients with right ventricular (RV) dysfunction at baseline exhibited an improvement in functional capacity after 4 months, and improvements in left ventricular (LV) diastolic pressure, respiratory strength, and quality of life at the end of follow-up. Conversely, those with normal baseline RV function demonstrated LVEF increases that were not observed in patients with RV dysfunction. CONCLUSIONS: CR was feasible, safe, and has important clinical benefits for patients with CHF, specifically for cardiac function and muscle respiratory strength.

Penile ulcer as a specific clinical manifestation of Waldenstrom's macroglobulinemia

Abstract Waldenstrom’s macroglobulinemia is considered a lymphoma by the World Health Organization. Cutaneous lesions, particularly of a specific type, are rare occurring in 5% of patients. What draws attention in this case is the unusual cutaneous clinical manifestation and its location on the genitals, which has not been described in researched literature, therefore imposing differential diagnosis with other etiologies of genital ulcers.

Atrial Fibrillation in Decompensated Heart Failure: Associated Factors and In-Hospital Outcome / Fibrilação Atrial em Insuficiência Cardíaca Descompensada: Fatores Associados e Evolução Hospitalar

Background: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality. .

Fundamento: Estudos sobre fibrilação atrial (FA) na insuficiência cardíaca descompensada (ICD) são muito escassos no Brasil. Objetivos: Determinar a prevalência, os tipos e os fatores associados à FA em pacientes hospitalizados por ICD; analisar perfil de risco embólico e taxa de anticoagulação; e avaliar o impacto da FA na mortalidade hospitalar e no tempo de internação. Métodos: Estudo seccional de casos incidentes, retrospectivo, observacional. Analisaram-se 659 internações consecutivas por ICD entre 01/01/2006 a 31/12/2011. Risco embólico foi avaliado pelo acrônimo CHADSVASc. Na análise univariada, foram utilizados o qui-quadrado, teste t de Student ou Mann Whitney. Na análise multivariada, utilizou-se a regressão logística. Resultados: A prevalência de FA foi de 40%, predominando o tipo permanente (73,5%). No modelo multivariado, a FA se associou à idade avançada (p < 0,0001), etiologia não isquêmica (p = 0,02), disfunção ventricular direita (VD) (p = 0,03), menor pressão arterial sistólica (PAS) (p = 0,02), maior fração de ejeção (FE) (p < 0,0001) e aumento atrial esquerdo (AE) (p < 0,0001). A mediana do CHADSVASc foi quatro e 90% tinham escore ≥ 2. A taxa de anticoagulação foi de 52,8% na admissão e 66,8% na alta, sendo menor em escores mais elevados. O grupo com FA apresentou maior mortalidade hospitalar (11,0% versus 8,1%, p = 0,21) e internação mais prolongada (20,5 ± 16 versus 16,3 ± 12, p = 0,001). Conclusões: A FA é frequente na ICD, predominando o tipo permanente. Associa-se com idade avançada, etiologia não isquêmica, disfunção de VD, menor PAS, maior FE e aumento AE. O perfil de risco embólico é elevado e a anticoagulação é subutilizada. ...

Vacina como agente de imunização contra o HPV / Vaccines as an agent for immunization against HPV

Considerada uma infecção de alta prevalência em todo o mundo, o papiloma vírus humano (HPV) é um DNA vírus que infecta a mucosa genital e possui grande potencial oncogênico, sendo relacionado ao risco aumentado de lesões do trato genital inferior, como o câncer cervical. Este câncer é responsável pela morte de cerca de 231 mil mulheres por ano no mundo, o que torna o HPV um grande problema para a saúde pública. Sabendo que a maneira mais eficaz e com melhor custo-benefício para controlar uma doença infecciosa é o desenvolvimento de vacinas, duas profiláticas foram desenvolvidas e aprovadas no Brasil, uma bivalente e outra quadrivalente. Essa revisão de literatura se propõe a apresentar as características do vírus HPV, os tipos de vacinas presentes no mercado, suas indicações e contraindicações, seus efeitos adversos, sua eficácia, seus títulos de anticorpos (GMT) e seu custo-efetividade.

Considered a highly prevalent infection throughout the world, the human papillomavirus (HPV) is a DNA virus that infects the genital mucosa and has high carcinogenic potential, being related to an increased risk of lower genital tract lesions, such as cervical cancer. This cancer is responsible for the deaths of about 231,000 women per year worldwide, which means that HPV is a major problem for public health. Knowing that the most effective and cost-effective way to control an infectious disease is the development of vaccines, two prophylactic vaccines have been developed and approved in Brazil, one of which is bivalent and the other is tetravalent. This review of the literature seeks to present the characteristics of the HPV virus, types of vaccines available on the market, their indications and contraindications, their adverse effects, their effectiveness, their geometric mean titer (GMT) and their cost-effectiveness.