Cost-effectiveness of continuous glucose monitoring with FreeStyle Libre® in Brazilian insulin-treated patients with types 1 and 2 diabetes mellitus.

BACKGROUND: Hypoglycemia is a barrier to optimal glucose control in the treatment of both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). Blood glucose monitoring is essential in diabetes management. Inappropriate glucose management is associated with high mortality and morbidity. FreeStyle Libre® (FSL) is a continuous glucose monitoring (CGM) system that provides effective, safe, and convenient glucose monitoring, without routine finger pricking. This study aims to estimate the incremental cost-effectiveness ratio (ICER) of the FSL system in comparison to conventional Self-monitoring of blood glucose (SMBG) in T1DM and T2DM patients that require intensive insulin therapy. METHODS: A decision-tree model was developed to compare the cost-effectiveness ratio between FSL and conventional SMBG from the perspective of the Brazilian Public Healthcare System (SUS). The model captures the cumulative rates of acute complications such as severe hypoglicemia and diabetic ketoacidosis, per-event costs, and quality-adjusted life-years (QALYs) gained over a 1-year time horizon in adult and pediatric patients (≥ 4 years old) with T1DM or T2DM. Inputs from the Brazilian health databases, clinical trials, and real-world data were used in the study. RESULTS: The results demonstrated that, regarding solely severe hypoglicemia and diabetic ketoacidosis events, T1DM have a QALY difference of 0.276, a cost difference of R$ 7.255, and an ICER of R$ 26,267.69 per QALY gained for CGM with FSL, when compared to conventional SMBG. T2DM results demonstrated equally a QALY difference of 0.184, a cost difference of R$ 7290, and an ICER of R$ 39,692.67 per QALY gained, in favour of CGM with FSL. CONCLUSION: Our findings demonstrated that FSL is cost-effective in T1DM and T2DM for acute diabetic complications, from a SUS perspective. CGM with FSL can promote safe, convenient, and cost-effective glucose monitoring, therefore contributing to the improvement of the incidence of complications and quality of life.

Reduction of Mosquito Survival in Mice Vaccinated with Anopheles stephensi Glucose Transporter.

Despite the fact that recent efforts to control/eradicate malaria have contributed to a significant decrease in the number of cases and deaths, the disease remains a global health challenge. Vaccines based on mosquito salivary gland antigens are a potential approach for reducing vector populations and malaria parasites. The Anopheles AGAP007752 gene encodes for a glucose transporter that is upregulated during Plasmodium infection, and its knockdown decreases the number of sporozoites in mosquito salivary glands. These results together with the fact that glucose is a vital source of energy suggested that a glucose transporter is a candidate protective antigen for the control of mosquito infestations and Plasmodium infection. To address this hypothesis, herein we investigate the effect of mice vaccination with an immunogenic peptide from mosquito glucose transporter on Anopheles stephensi fitness and Plasmodium berghei infection. We showed that vaccination with a peptide of glucose transporter reduced mosquito survival by 5% when compared to controls. However, the reduction in Plasmodium infection was not significant in mosquitoes fed on vaccinated mice. The effect of the peptide vaccination on mosquito survival is important to reduce infestation by malaria vectors. These results support further research on developing glucose transporter-based vaccines to reduce mosquito fitness.

Solute carriers affect Anopheles stephensi survival and Plasmodium berghei infection in the salivary glands.

Malaria is caused by mosquito-borne Plasmodium spp. parasites that must infect and survive within mosquito salivary glands (SGs) prior to host transmission. Recent advances in transcriptomics and the complete genome sequencing of mosquito vectors have increased our knowledge of the SG genes and proteins involved in pathogen infection and transmission. Membrane solute carriers are key proteins involved in drug transport and are useful in the development of new interventions for transmission blocking. Herein, we applied transcriptomics analysis to compare SGs mRNA levels in Anopheles stephensi fed on non-infected and P. berghei-infected mice. The A. stephensi solute carriers prestinA and NDAE1 were up-regulated in response to infection. These molecules are predicted to interact with each other, and are reportedly involved in the maintenance of cell homeostasis. To further evaluate their functions in mosquito survival and parasite infection, these genes were knocked down by RNA interference. Knockdown of prestinA and NDAE1 resulted in reduction of the number of sporozoites in mosquito SGs. Moreover, NDAE1 knockdown strongly impacted mosquito survival, resulting in the death of half of the treated mosquitoes. Overall, our findings indicate the importance of prestinA and NDAE1 in interactions between mosquito SGs and Plasmodium, and suggest the need for further research.

Spatial and temporal distribution of gerrid (Heteroptera) and predation on microcrustaceans from a tropical shallow lake / Distribuição espacial e temporal de gerrídeo (Heteroptera) e a predação sobre microcrustáceos de um lago tropical raso

Abstract Predator-prey interactions involving an aquatic insect and zooplanktonic prey of different sizes were investigated to quantify prey mortality exposed to predators. Laboratory experiments were undertaken with the young and adult gerrid Rheumatobates crassifemur to test predation and size selectivity on the cladocerans Daphnia gessneri, Ceriodaphnia richardi, and Bosmina tubicen. Population fluctuations and spatial distribution of the gerrid were also evaluated in a small and shallow Brazilian lake throughout 12 months in fortnightly samples. The insects were more abundant in the littoral (mean density 7.0 ± 1.2 ind.m-2) compared to the limnetic zone. The period with the highest densities was late January to June, in both zones. Predation by young instars on Daphnia and Ceriodaphnia was significant (mean ingestion rate of 1.3 ± 0.1 D. gessneri and 0.7 ± 0.1 C. richardi per predator per hour). Adult insect fed only the large-sized prey (mean ingestion rate of 1.0 ± 0.1 D. gessneri per predator per hour). Young gerrids have greater potential to prey on cladocerans than adults, and size selectivity occurred for both predators. Preference of adults by the larger prey is probably related to difficulties in manipulating smaller planktonic prey, such as Ceriodaphnia. Due to higher densities of insects in the littoral, higher predation on zooplankton in this zone is expected. This study does contribute to a better understanding of trophic interactions in tropical shallow lakes and is the first to investigate predation of a gerrid on cladocerans in laboratory experiments.

Resumo Foram investigadas as interações predador-presa, envolvendo inseto aquático e presas zooplanctônicas de diferentes tamanhos para quantificar a mortalidade das presas expostas a predadores. Experimentos de laboratório foram realizados com jovens e adultos do gerrídeo Rheumatobates crassifemur para testar a predação e a seletividade por tamanho das espécies de cladóceros Daphnia gessneri, Ceriodaphnia richardi e Bosmina tubicen. Flutuações populacionais e a distribuição espacial do gerrídeo também foram avaliadas em um lago brasileiro pequeno e raso durante 12 meses em amostras quinzenais. Os insetos foram mais abundantes no litoral (densidade média 7,0 ± 1,2 ind.m-2) em comparação com a zona limnética. Maiores densidades ocorreram de fim de janeiro a junho, em ambas as zonas. A predação dos jovens foi significativa sobre Daphnia e Ceriodaphnia (taxa de ingestão média 1,3 ± 0,1 D. gessneri and 0,7 ± 0,1 C. richardi por predador por hora). Adultos predaram somente a presa maior (taxa de ingestão média 1,0 ± 0,1 D. gessneri por predador por hora). Gerrídeos jovens têm um maior potencial para predar cladóceros que os adultos, e seletividade por tamanho ocorreu para ambos. A preferência dos adultos somente pela presa maior provavelmente está relacionada à dificuldade em manipular pequenas presas planctônicas como Ceriodaphnia. Devido às maiores densidades de insetos no litoral, é esperada maior predação sobre o zooplâncton nesta zona. Este estudo contribui para uma melhor compreensão sobre interações tróficas em lagos tropicais rasos e é o primeiro a investigar a predação de um gerrídeo sobre cladóceros em experimentos de laboratório.

Prion protein 2 (dublet) gene (PRND): role in ovine semen capacitation, cryopreservation and fertility.

The aim of the present study was to examine the role of Doppel protein in the capacitation process and fertilising ability of both fresh and frozen-thawed (FT) spermatozoa from rams carrying different prion protein 2 (dublet) (PRND) gene polymorphisms. The detection efficacy of new anti-Doppel monoclonal antibodies and PRND mRNA quantification were also explored in ovine spermatozoa. Three different genotypes (AA, GA, GG) were identified for codon 26 of ovine PRND-c.78G>A. Using flow cytometry, a higher fluorescence was detected in fresh compared with FT sperm samples incubated with anti-Doppel primary and fluorescein isothiocyanate-conjugated secondary antibodies (P<0.05). Capacitation was affected by semen treatment (fresh and FT) and male PRND genotype (P<0.05). After IVF, the use of fresh semen resulted in a higher cleavage rate than the use of FT spermatozoa (P=0.004). IVF using spermatozoa from individuals classified as carriers of the AA or GA PRND genotypes resulted in higher cleavage rates than seen using spermatozoa from GG carriers (P≤0.0006). Finally, using semen from rams with the AA PRND genotype resulted in the highest Day 6 and Day 8 embryo rates (P≤0.04). In conclusion, the results of the present study confirm that the identification of different PRND genotypes is important for studying the sperm capacitation process and for improving sperm cryoresistance and embryo production. Furthermore, the detection of Doppel in ejaculated ovine spermatozoa, along with its low expression after cryopreservation, strongly suggests an important physiological function of this protein in male fertility.

Distribution and fluctuations of backswimmers (Notonectidae) in a tropical shallow lake and predation on microcrustaceans / Distribuição e flutuação de notonectídeos (Notonectidae) em um lago tropical raso e a predação sobre microcrustáceos

Abstract Notonectids are widely distributed in freshwaters and can prey on zooplankton in temperate lakes. However, its role in structuring the zooplankton community is unknown in tropical lakes. Thus, our objective was to study the notonectid Martarega uruguayensis in a Brazilian tropical shallow lake to evaluate its potential as a zooplankton predator. Its horizontal distribution was analized in the lake throughout one year in fortnightly samplings. Backswimmers were more abundant (mean density 162.9 ± 25.8 ind.m–2) in the cool-dry season, with a strong preference by the littoral zone (mean density 139.9 ± 17.5 ind.m–2). Laboratory experiments were undertaken with young and adult notonectid and the two most abundant cladocerans, Daphnia gessneri and Ceriodaphnia richardi, as prey. Predation by backswimmers in the laboratory showed that only juveniles fed on microcrustaceans (mean ingestion rate of 1.2 ± 0.2 Daphnia and 1.0 ± 0.2 Ceriodaphnia per predator per hour), without size selectivity. Adult insects probably have difficulties in detecting and manipulating small planktonic organisms. On the other hand, young instars might influence zooplankton community, especially in the littoral zone of the lake. This study does contribute to a better understanding of trophic interactions in tropical shallow lakes and is the first to investigate the predation of a notonectid on microcrustaceans from Lake Monte Alegre.

Resumo Notonectídeos são amplamente distribuídos em águas continentais e podem predar zooplâncton em lagos temperados. Porém, seu papel na estruturação de comunidades zooplanctônicas é desconhecido em lagos tropicais. Então, nosso objetivo foi estudar o notonectídeo Martarega uruguayensis em um lago tropical raso brasileiro para avaliar seu potencial como predador do zooplâncton. Sua distribuição horizontal foi analisada no lago durante um ano em coletas quinzenais. Os notonectídeos foram mais abundantes (densidade média 162,9 ± 25,8 ind.m–2) na estação fria-seca, com nítida preferência pela zona litorânea (densidade média 139,9 ± 17,5 ind.m–2). Foram feitos experimentos de laboratório com jovens e adultos de notonectídeo e as duas espécies de cladóceros mais abundantes, Daphnia gessneri and Ceriodaphnia richardi, como presas. No laboratório, somente os jovens predaram os microcrustáceos (taxa média de ingestão 1,2 ± 0,2 Daphnia e 1,0 ± 0,2 Ceriodaphnia por predador por hora), sem haver seletividade. Os insetos adultos provavelmente têm dificuldade em detectar e manipular pequenos organismos planctônicos. Por outro lado, os estádios jovens podem influenciar a comunidade zooplanctônica, especialmente na zona litorânea do lago. Esse estudo contribui para uma melhor compreensão sobre interações tróficas em lagos tropicais rasos e é o primeiro a investigar a predação de um notonectídeo sobre microcrustáceos do Lago Monte Alegre.

The Anopheles gambiae transcriptome - a turning point for malaria control.

Mosquitoes are important vectors of several pathogens and thereby contribute to the spread of diseases, with social, economic and public health impacts. Amongst the approximately 450 species of Anopheles, about 60 are recognized as vectors of human malaria, the most important parasitic disease. In Africa, Anopheles gambiae is the main malaria vector mosquito. Current malaria control strategies are largely focused on drugs and vector control measures such as insecticides and bed-nets. Improvement of current, and the development of new, mosquito-targeted malaria control methods rely on a better understanding of mosquito vector biology. An organism's transcriptome is a reflection of its physiological state and transcriptomic analyses of different conditions that are relevant to mosquito vector competence can therefore yield important information. Transcriptomic analyses have contributed significant information on processes such as blood-feeding parasite-vector interaction, insecticide resistance, and tissue- and stage-specific gene regulation, thereby facilitating the path towards the development of new malaria control methods. Here, we discuss the main applications of transcriptomic analyses in An. gambiae that have led to a better understanding of mosquito vector competence.

Spatial and temporal distribution of gerrid (Heteroptera) and predation on microcrustaceans from a tropical shallow lake.

Predator-prey interactions involving an aquatic insect and zooplanktonic prey of different sizes were investigated to quantify prey mortality exposed to predators. Laboratory experiments were undertaken with the young and adult gerrid Rheumatobates crassifemur to test predation and size selectivity on the cladocerans Daphnia gessneri, Ceriodaphnia richardi, and Bosmina tubicen. Population fluctuations and spatial distribution of the gerrid were also evaluated in a small and shallow Brazilian lake throughout 12 months in fortnightly samples. The insects were more abundant in the littoral (mean density 7.0 ± 1.2 ind.m-2) compared to the limnetic zone. The period with the highest densities was late January to June, in both zones. Predation by young instars on Daphnia and Ceriodaphnia was significant (mean ingestion rate of 1.3 ± 0.1 D. gessneri and 0.7 ± 0.1 C. richardi per predator per hour). Adult insect fed only the large-sized prey (mean ingestion rate of 1.0 ± 0.1 D. gessneri per predator per hour). Young gerrids have greater potential to prey on cladocerans than adults, and size selectivity occurred for both predators. Preference of adults by the larger prey is probably related to difficulties in manipulating smaller planktonic prey, such as Ceriodaphnia. Due to higher densities of insects in the littoral, higher predation on zooplankton in this zone is expected. This study does contribute to a better understanding of trophic interactions in tropical shallow lakes and is the first to investigate predation of a gerrid on cladocerans in laboratory experiments.

Distribution and fluctuations of backswimmers (Notonectidae) in a tropical shallow lake and predation on microcrustaceans.

Notonectids are widely distributed in freshwaters and can prey on zooplankton in temperate lakes. However, its role in structuring the zooplankton community is unknown in tropical lakes. Thus, our objective was to study the notonectid Martarega uruguayensis in a Brazilian tropical shallow lake to evaluate its potential as a zooplankton predator. Its horizontal distribution was analized in the lake throughout one year in fortnightly samplings. Backswimmers were more abundant (mean density 162.9 ± 25.8 ind.m-2) in the cool-dry season, with a strong preference by the littoral zone (mean density 139.9 ± 17.5 ind.m-2). Laboratory experiments were undertaken with young and adult notonectid and the two most abundant cladocerans, Daphnia gessneri and Ceriodaphnia richardi, as prey. Predation by backswimmers in the laboratory showed that only juveniles fed on microcrustaceans (mean ingestion rate of 1.2 ± 0.2 Daphnia and 1.0 ± 0.2 Ceriodaphnia per predator per hour), without size selectivity. Adult insects probably have difficulties in detecting and manipulating small planktonic organisms. On the other hand, young instars might influence zooplankton community, especially in the littoral zone of the lake. This study does contribute to a better understanding of trophic interactions in tropical shallow lakes and is the first to investigate the predation of a notonectid on microcrustaceans from Lake Monte Alegre.

Anaplasma marginale and Theileria annulata in questing ticks from Portugal.

Ticks are ubiquitous arthropods and vectors of several pathogenic agents in animals and humans. Monitoring questing ticks is of great importance to ascertain the occurrence of pathogens and the potential vector species, offering an insight into the risk of disease transmission in a given area. In this study 428 host-seeking ticks, belonging to nine species of Ixodidae and collected from 17 of the 23 Portuguese mainland subregions, were screened for several tick-borne agents with veterinary relevance: Anaplasma marginale, Anaplasma ovis, Anaplasma centrale, Babesia spp., Coxiella burnetii and Theileria spp. Prevalence was assessed by PCR and amplified amplicons sequenced for validation of results. Twenty ticks, in a total of 428, were found positive: one Ixodes ventalloi for Theileria annulata and four Dermacentor marginatus, one Haemaphysalis punctata, five Ixodes ricinus, five I. ventalloi, and four Rhipicephalus sanguineus sensu lato for A. marginale. According to the reviewed literature, this is the first report of A. marginale and T. annulata detection in I. ventalloi. Furthermore, the amplification of A. marginale DNA in several tick species suggests a broad range for this agent in Portugal that might include other uncommon species as R. sanguineus s.l. This work provides new data towards a better understanding of tick-pathogen associations and also contributes to the surveillance of tick-borne agents in geographic areas with limited information.

Generation and characterization of monoclonal antibodies against Rift Valley fever virus nucleoprotein.

Due to the unpredictable and explosive nature of Rift Valley fever (RVF) outbreaks, rapid and accurate diagnostic assays for low-resource settings are urgently needed. To improve existing diagnostic assays, monoclonal antibodies (MAbs) specific for the nucleocapsid protein of RVF virus (RVFV) were produced and characterized. Four IgG2a MAbs showed specific binding to denatured nucleocapsid protein, both from a recombinant source and from inactivated RVFV, in Western blot analysis and in an enzyme-linked immunosorbent assay (ELISA). Cross-reactivity with genetically related and non-related arboviruses including Bunyamwera and Calovo viruses (Bunyaviridae family), West Nile and Dengue-2 viruses (Flaviviridae family), and Sindbis and Chikungunya viruses (Togaviridae family) was not detected. These MAbs represent a useful tool for the development of rapid diagnostic assays for early recognition of RVF.

HLA class II alleles as markers of tuberculosis susceptibility and resistance.

BACKGROUND: Not every individual exposed to Mycobacterium tuberculosis becomes infected. One host genetic factor, involved in modulating the immune response that has been studied in many ethnic groups is the association of human leukocyte antigens (HLA) with susceptibility to tuberculosis (TB). OBJECTIVE: To investigate the association between TB, HLA-DRB1 and HLA-DQB1 alleles in a Portuguese population. METHODS: HLA-DRB1 and HLA-DQB1 gene polymorphisms were analyzed by PCR-SSP in 92 TB patients, and 82 healthcare professionals without TB but exposed on a daily basis to infectious patients for more than two years (healthy exposed - HE). Tuberculin skin test reaction (TST), was positive in 69 individuals (all over 15 mm) in the HE group (HE+) and negative in thirteen (HE-). RESULTS: HLA-DRB1*14 frequency is higher in the TB patients group (7 % vs. 0; p = 0.038) than in HE+. CONCLUSIONS: No genetic marker clearly indicative of disease susceptibility or resistance was identified in this study. However, HLA-DRB1*14 was more frequent in TB patients suggesting that it may be involved in the evolution infection towards active TB in our population.

Effect of synthesized inhibitors on babesipain-1, a new cysteine protease from the bovine piroplasm Babesia bigemina.

Papain-like cysteine proteases (CP) have been shown to have essential roles in parasitic protozoa and are under study as promising drug targets. One gene was identified by sequence similarity search to be homologous to the CP family in the ongoing Babesia bigemina genome sequencing project database. The newly identified CP gene, called babesipain-1, was cloned and expressed as a fusion protein, and the effect of different inhibitors on proteolytic activity was tested. A series of new artemisinin-vinyl sulfone hybrid molecules were tested as inhibitors being effective on the range of 0.3-30 microm, depending on the core-containing molecule.

Bone marrow necrosis related to paracoccidioidomycosis: the first eight cases identified at autopsy.

AIMS: To report the first eight bone marrow necrosis (BMN) cases related to paracoccidioidomycosis (PCM) from patient autopsies with well-documented bone marrow (BM) histology and cytology. METHODS AND RESULTS: A retrospective evaluation was performed on BM specimens from eight autopsied patients from Botucatu University Hospital with PCM-related BMN. Relevant BMN literature was searched and analysed. CONCLUSIONS: All eight patients had acute PCM. Six had histological only (biopsies) and two cytological only (smears) specimens. Five biopsy specimens revealed severe and one mild coagulation patterned necrotic areas. Five had osteonecrosis. The cytological specimens also showed typical BMN patterns. Paracoccidioides brasiliensis yeast forms were visible within necrotic areas in all cases.

Protective efficacy of different strategies employing Mycobacterium leprae heat-shock protein 65 against tuberculosis.

BACKGROUND: Tuberculosis is a major threat to human health. The high disease burden remains unaffected and the appearance of extremely drug-resistant strains in different parts of the world argues in favor of the urgent need for a new effective vaccine. One of the promising candidates is heat-shock protein 65 when used as a genetic vaccine (DNAhsp65). Nonetheless, there are substantial data indicating that BCG, the only available anti-TB vaccine for clinical use, provides other important beneficial effects in immunized infants. METHODS: We compared the protective efficacy of BCG and Hsp65 antigens in mice using different strategies: i) BCG, single dose subcutaneously; ii) naked DNAhsp65, four doses, intramuscularly; iii) liposomes containing DNAhsp65, single dose, intranasally; iv) microspheres containing DNAhsp65 or rHsp65, single dose, intramuscularly; and v) prime-boost with subcutaneous BCG and intramuscular DNAhsp65. RESULTS: All the immunization protocols were able to protect mice against infection, with special benefits provided by DNAhsp65 in liposomes and prime-boost strategies. CONCLUSION: Among the immunization protocols tested, liposomes containing DNAhsp65 represent the most promising strategy for the development of a new anti-TB vaccine.

Dysautonomia and ventricular dysfunction in the indeterminate form of Chagas disease.

BACKGROUND: The associations between autonomic function and biventricular function in patients with the indeterminate form of Chagas disease remains to be elucidated. METHODS: In 42 asymptomatic patients and 19 healthy volunteers, the autonomic function was assessed by time domain indices of heart rate variability (HRV), analyzed for 24 h; the right ventricular function was assessed by fraction area change, right ventricle shortening, and systolic excursion of the tricuspid valve; and the left ventricular function was assessed by ejection fraction and transmitral flow velocities. Data were expressed as mean+/-SD or medians (including the lower quartile and upper quartile). Groups were compared by Student's t or Mann-Whitney U test. Autonomic and ventricular function were correlated by Pearson's or Spearman's correlation coefficient. The level of significance was 5%. RESULTS: Right and left ventricular systolic function indexes were comparable between groups. Transmitral flow velocities were decreased in the Chagas disease group (p<0.05). The patients presented impaired HRV as indicated by the values of SDNN-day (80 (64-99) ms vs. 98 (78-127) ms; p=0.045), SDNNI-24 h (54 (43-71) vs. 65 (54-105) ms; p=0.027), SDNNI-day (49 (42-64) vs. 67 (48-76) ms; p=0.045), pNN50-day (2.2 (0.7-5)% vs. 10 (3-11)%; p=0.033); and pNN50-24 h (3 (1-7)% vs. 12 (8-19)%; p=0.013). There were no correlations between the left ventricular diastolic indices and autonomic dysfunctional indices (p>0.05). CONCLUSION: Patients with the indeterminate form of Chagas disease have both dysautonomia and left ventricular diastolic dysfunction. However, the right ventricular function is preserved. Importantly, ventricular diastolic dysfunction and dysautonomia are independent phenomena.

Angina-like chest pain and syncope as the clinical presentation of left ventricular endomyocardial fibrosis: a case report.

A 47-year-old woman complained of angina-like chest pain, near-syncope, and syncopal episodes of 17 years' duration. Physical examination was unremarkable. A 12-lead resting ECG showed symmetrically inverted T waves in the inferior and anterolateral leads. A graded treadmill exercise stress test precipitated angina-like chest pain accompanied by a near-syncopal episode associated with a systemic arterial pressure of 60/40 mm Hg. Echocardiography disclosed left ventricular apical obliteration. Left ventriculogram showed a typical "ace of heart'' shadow as well as filling defects and apical obliteration. Endomyocardial biopsy of the left ventricle diagnosed left ventricular endomyocardial fibrosis. Thus, angina-like chest pain and near-syncopal episodes should be added to the list of clinical manifestations of pure left ventricular endomyocardial fibrosis.