Potential role of transthoracic echocardiography for screening LV systolic dysfunction in patients with a history of dengue infection. A cross-sectional and cohort study and review of the literature.

BACKGROUND: Dengue virus can affect the cardiovascular system and men may be at higher risk of severe complications than women. We hypothesized that clinical dengue virus (DENV) infection could induce myocardial alterations of the left ventricle (LV) and that these changes could be detected by transthoracic echocardiography. METHODOLOGY/PRINCIPAL FINDINGS: We examined individuals from Acre in the Amazon Basin of Brazil in 2020 as part of the Malaria Heart Study. By questionnaires we collected information on self-reported prior dengue infection. All individuals underwent transthoracic echocardiography, analysis of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). We included 521 persons (mean age 40±15 years, 39% men, 50% urban areas) of which 253 (49%) had a history of dengue infection. In multivariable models adjusted for clinical and sociodemographic data, a history of self-reported dengue was significantly associated with lower LVEF (ß = -2.37, P < 0.01) and lower GLS (ß = 1.08, P < 0.01) in men, whereas no significant associations were found in women (P > 0.05). In line with these findings, men with a history of dengue had higher rates of LV systolic dysfunction (LVEF < 50% = 20%; GLS < 16% = 17%) than those without a history of dengue (LVEF < 50% = 7%; GLS < 16% = 8%; P < 0.01 and 0.06, respectively). CONCLUSIONS/SIGNIFICANCE: The findings of this study suggest that a clinical infection by dengue virus could induce myocardial alterations, mainly in men and in the LV, which could be detected by conventional transthoracic echocardiography. Hence, these results highlight a potential role of echocardiography for screening LV dysfunction in participants with a history of dengue infection. Further larger studies are warranted to validate the findings of this study.

Prevalence and Dynamic Changes in Lung Ultrasound Findings among Adults with Uncomplicated Malaria and Controls in the Amazon Basin, Brazil.

Malaria patients are at risk of cardiopulmonary complications but diagnosis and management can be difficult in resource-limited settings. B-lines on lung ultrasound (LUS) mark changes in lung density; however, little is known about their role in malaria. We aimed to examine the prevalence of B-lines in adults with malaria at baseline and follow-up compared with controls in the Amazon Basin. We also examined the relationship between B-lines and left ventricular ejection fraction. We performed eight-zone LUS, echocardiography, and blood smears in 94 adults (mean age 40 years, 54% men) with uncomplicated malaria and 449 controls without heart failure, renal insufficiency or lung disease (mean age 41 years, 38% men). Examinations of adults with malaria were repeated after antimalarial treatment, corresponding to a median of 30 days (interquartile range [IQR] 27-39). Adults with malaria suffered from Plasmodium vivax (N = 70, median 2,823 [IQR 598-7,698] parasites/µL) or P. falciparum (N = 24, median 1,148 [IQR 480-3,128] parasites/µL). At baseline, adults with malaria more frequently had ≥ 3 B-lines (summed across eight zones) compared with controls (30% versus 2%, P value < 0.001), indicating higher lung density. When examinations were repeated, only 6% of adults with malaria had ≥ 3 B-lines at follow-up, which was significant lower compared with baseline (median reduction 3 B-line; P value < 0.001). B-lines were not significantly associated with left ventricular ejection fraction in adults with malaria. In conclusion, B-lines detected by LUS were more frequent in adults with uncomplicated malaria compared with controls and decreased after completed antimalarial treatment.

Prevalence of rheumatic heart disease in adults from the Brazilian Amazon Basin.

BACKGROUND: Rheumatic heart disease (RHD) continues to be a burden in low- and middle-income countries and prevalence estimates are lacking from South America. We aimed to determine the prevalence of RHD in the Brazilian Amazon Basin. METHODS: We examined a random sample of adults (≥18 years) from the general population, who underwent echocardiographic image acquisition by a medical doctor. All images were analyzed according to (i) the 2012 World Heart Federation criteria and (ii) a simplified algorithm for RHD from a previously validated risk score (categories: low-, medium-, high-risk) which involved assessment of the mitral valve (leaflet thickening and excessive motion, regurgitation jet length) and aortic valve (thickening and any regurgitation). RESULTS: A total of 488 adults were screened (mean age 40 ± 15 years, 38% men). The prevalence of RHD was 39/1000 adults (n = 17 definite and n = 2 borderline). Fourteen (74%) had pathological mitral regurgitation, four (21%) mitral stenosis, 0 (0%) pathological aortic regurgitation and six (32%) both mitral and aortic valve disease. None had a prior diagnosis of RHD, 10 (53%) had positive cardiac auscultation and two (11%) reported a history of rheumatic fever. The simplified algorithm identified four (21%) adults as low-risk, six (32%) as intermediate, and nine (47%) as high-risk. CONCLUSIONS: The prevalence of RHD was 39/1000 in adults from the Brazilian Amazon Basin, indicating the need for screening programs in remote areas. A simplified model was only able to categorize every second case of RHD as high-risk. External validation of simplified screening models to increase feasibility in clinical practice are encouraged.

Whole genome sequencing reveals large deletions and other loss of function mutations in Mycobacterium tuberculosis drug resistance genes.

Drug resistance in Mycobacterium tuberculosis, the causative agent of tuberculosis disease, arises from genetic mutations in genes coding for drug-targets or drug-converting enzymes. SNPs linked to drug resistance have been extensively studied and form the basis of molecular diagnostics and sequencing-based resistance profiling. However, alternative forms of functional variation such as large deletions and other loss of function (LOF) mutations have received much less attention, but if incorporated into diagnostics they are likely to improve their predictive performance. Our work aimed to characterize the contribution of LOF mutations found in 42 established drug resistance genes linked to 19 anti-tuberculous drugs across 32689 sequenced clinical isolates. The analysed LOF mutations included large deletions (n=586), frameshifts (n=4764) and premature stop codons (n=826). We found LOF mutations in genes strongly linked to pyrazinamide (pncA), isoniazid (katG), capreomycin (tlyA), streptomycin (e.g. gid) and ethionamide (ethA, mshA) (P<10-5), but also in some loci linked to drugs where relatively less phenotypic data is available [e.g. cycloserine, delaminid, bedaquiline, para-aminosalicylic acid (PAS), and clofazimine]. This study reports that large deletions (median size 1115 bp) account for a significant portion of resistance variants found for PAS (+7.1% of phenotypic resistance percentage explained), pyrazinamide (+3.5%) and streptomycin (+2.6%) drugs, and can be used to improve the prediction of cryptic resistance. Overall, our work highlights the importance of including LOF mutations (e.g. large deletions) in predicting genotypic drug resistance, thereby informing tuberculosis infection control and clinical decision-making.

Risco de Lesões Osteoporóticas - Perfil das pessoas que frequentam uma USF da Região Centro / Risk of Osteoporotic Injuries - Profile of people who attend a USF in the Central Region

Enquadramento: A osteoporose é uma doença de início silencioso e que se carateriza pela redução da densidade mineral óssea, com consequente fragilidade óssea, favorecendo um elevado risco de fraturas. São vários os fatores de risco associados, tais como, idade avançada, género feminino, raça caucasiana, história familiar de osteoporose, alterações osteoblásticas/hormonais, baixa ingestão de cálcio e vitamina D e o sedentarismo, influenciando diretamente a incidência desta patologia e, consequentemente, as lesões osteoporóticas. Objetivos: Caraterizar o perfil das pessoas que frequentam uma Unidade de Saúde Familiar (USF) da Região Centro, relativamente ao risco de lesões osteoporóticas. Como objetivos específicos, pretende-se, determinar o risco de lesão osteoporótica Major (coluna, punho, anca e ombro) e da anca a dez anos e analisar a influência das variáveis sociodemográficas, antropométricas e hábitos de vida no risco de lesões osteoporóticas. Metodologia: O domínio da investigação enquadra-se num estudo descritivo - correlacional, transversal e do tipo quantitativo. A amostra é não probabilística por conveniência, constituída por 364 pessoas com mais de 50 anos, de uma USF da Região Centro e selecionadas de forma aleatória, no período compreendido entre o mês de Abril e Julho de 2019. Aplicado um protocolo de avaliação constituído por variáveis sociodemográficas, antropométricas e hábitos de vida em associação como o uso da ferramenta Frax ® Port. O tratamento estatístico foi efetuado informaticamente, recorrendo ao programa de tratamento estatístico Statiscal Package for the Social Science (SPSS), na versão 25.0. Resultados: As pessoas mais velhas tendem a evidenciar maior probabilidade de fraturas e, consequentemente, maior risco de lesões osteoporóticas, sendo este risco superior nas mulheres; as pessoas casadas ou que vivem em união de facto evidenciam menor risco de lesões osteoporóticas; as pessoas com nível de escolaridade mais baixo apresentam um risco de lesões osteoporóticas mais elevado; as pessoas com Índice de Massa Corporal (IMC) mais elevado revelam alguma tendência para apresentarem menor risco de lesões osteoporóticas. Conclusão: No global o presente trabalho evidencia que os fatores sociodemográficos, o IMC e alguns hábitos de vida, influenciam diretamente o risco de fratura, sendo essencial uma intervenção eficaz a esse nível. No âmbito do papel e das competências do Enfermeiro Especialista em Enfermagem Comunitária destaca-se a sua intervenção no que concerne à educação das pessoas para a adoção de hábitos de vida saudáveis, integrando projetos em desenvolvimento e propondo a elaboração de outros que visem o controlo dos fatores de risco identificados e, neste sentido, a prevenção da doença e a promoção da saúde.

Background: Osteoporosis is a disease of silent onset and characterized by a reduction in bone mineral density, with consequent bone fragility, favoring a high risk of fractures. There are several associated risk factors, such as advanced age, female gender, Caucasian race, family history of osteoporosis, osteoblastic / hormonal changes, low calcium and vitamin D intake and physical inactivity, directly influencing the incidence of this pathology and, consequently, osteoporotic injuries. Objectives: To characterize the profile of people who attend a Family Health Unit (FHU) in the Centro Region, regarding the risk of osteoporotic injuries. As specific objectives, it is intended to determine the risk of major osteoporotic injury (spine, wrist, hip and shoulder) and hip for ten years and to analyze the influence of sociodemographic, anthropometric variables and life habits on the risk of osteoporotic injuries. Methodology: The field of research is part of a descriptive study - correlational, transversal and quantitative. The sample is non-probabilistic for convenience, consisting of 364 people over 50 years of age, from a FHU in the Central Region and selected at random, in the period between April and July 2019. An evaluation protocol consisting of sociodemographic, anthropometric and lifestyle habits in association with the use of the Frax ® Port tool. The statistical treatment was carried out by computer, using the statistical treatment program Statiscal Package for the Social Science (SPSS), in version 25.0. Results: Older people tend to show a higher probability of fractures and, consequently, a higher risk of osteoporotic injuries, with this risk being higher in women; people who are married or in a long time relationship have a lower risk of osteoporotic injuries; people with a lower level of education have a higher risk of osteoporotic injuries; people with a higher Body Mass Index (BMI) show some tendency to have a lower risk of osteoporotic injuries. Conclusion: Overall, this study shows that sociodemographic factors, BMI and some lifestyle habits, directly influence the risk of fracture, wath means that un efective intervention at this level is essential. Within the scope of the role and competences of the Community Nurse Specialists, his intervention stands out with regard to educating people to adopt healthy lifestyle habits, integrating projects in development and proposing the development of others aimed at controlling identified risk factors and, in this sense, disease prevention and health promotion.

Cardiopulmonary alterations by ultrasound in a patient with uncomplicated mixed malaria infection: a case report from the Amazon Basin.

BACKGROUND: Information on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described. CASE PRESENTATION: A previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized. CONCLUSIONS: This case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.

Prevalence of Cardiovascular Complications in Malaria: A Systematic Review and Meta-Analysis.

Recent studies have suggested that malaria may affect the cardiovascular system. The aim of this systematic review and meta-analysis was to determine the prevalence of cardiovascular complications in symptomatic malaria patients. We searched databases such as Pubmed, Embase, Cochrane, and Web of Science (January 1950-April 2020) for studies reporting on cardiovascular complications in adults and children with malaria. Cardiovascular complications were defined as abnormalities in electrocardiogram (ECG), cardiac biomarkers, and echocardiography on admission or during outpatient examination. Studies of patients with known heart disease or cardiovascular evaluation performed after the start of intravenous antimalarial medication were excluded. The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) (No.: CRD42020167672). The literature search yielded 1,243 studies, and a total of 43 studies with symptomatic malaria patients were included. Clinical studies (n = 12 adults; n = 5 children) comprised 3,117 patients, of which a majority had Plasmodium falciparum (n = 15) and were diagnosed with severe malaria (n = 13). In random-effects models of adults, the pooled prevalence estimate for any cardiovascular complication was 7% (95% CI: 5-9). No meta-analysis was conducted in children, but the range of abnormal ECG was 0-8%, cardiac biomarkers 0-57%, and echocardiography 4-9%. We analyzed 33 cases (n = 10 postmortem), in which the most common cardiovascular pathologies were myocarditis and acute coronary syndrome. All histopathological studies found evidence of parasitized red blood cells in the myocardium. Cardiovascular complications are not uncommon in symptomatic adults and children with malaria. Additional studies investigating malaria and cardiovascular disease are encouraged.