Síndrome pulmonar e cardiovascular por hantavírus: aspectos clínicos de uma doença emergente no sudeste brasileiro

A síndrome pulmonar e cardiovascular por hantavírus é doença causada pela aspiração de aerossóis dos dejetos de roedores silvestres contaminados por vírus da família Bunyaviridae. Estudamos manifestações clínicas e laboratoriais de 70 casos ocorridos de 1998 a 2007 na região de Ribeirão Preto, SP. A freqüência de sintomas foi dispnéia (87%), febre (81%), tosse (44%), cefaléia (34%), taquicardia (81%), hipotensão arterial (56%), hipóxia (49%), acidose metabólica (57%), linfocitopenia (51%), hematócrito >45% (70%), leucocitose com desvio à esquerda (67%), creatinina (51%) e uréia (42%) séricas elevadas. A letalidade (54,3%) ocorreu principalmente no 4o dia. Insuficiência respiratória, hipotensão arterial e choque ocorreu 24-48 horas; o hematócrito elevado e a plaquetopenia são sinais fortemente sugestivos da doença. A hipótese diagnóstica de pneumonia atípica associada a bom prognóstico (p:0,0136); a infusão hídrica >2.000ml e hipotensão arterial associadas a mau prognóstico (p:0,0286 e p:0,0453).

Serosurvey of hantavirus infection in humans in the border region between Brazil and Argentina

INTRODUCTION: According to reports by the Ministry of Health, in the far western region of the State of Santa Catarina, there have been no reports of hantavirus pulmonary syndrome, a zoonotic disease transmitted by feces of infected rodents. A seroepidemiological study of residents of this region, was conducted, with the aim of determining the presence of hantavirus infections. A total of 340 volunteers of both genus, from the towns of Belmonte and Paraíso, were studied. METHODS: The serum of these patients was collected and used to detect IgG antibodies against recombinant N protein of Araraquara hantavirus, by ELISA assay. The positive samples were then titrated and confirmed by immunofluorescence assay. RESULTS: This study demonstrated the presence of IgG antibodies against hantavirus N protein in 3.5% of the population. The most frequent occupation was farm worker, 81% had direct and indirect contact with rodents, 91.7% of positive cases were farm workers, indicating that the probable cause of infection occurred during barn cleaning. These antibodies are noteworthy, given that the levels of antibodies were verified in individuals whose contact with hantavirus may have occurred many years ago. CONCLUSIONS: This study shows the circulation of hantavirus in the region, a fact that until now, had not reported. All the serum reagents had contact with the pathogen, but did not develop pulmonary and cardiovascular syndrome. It is important to remain alert, because hantavirus is a serious and emerging disease of some relevance.

Health-related quality of life in patients with Chagas disease

INTRODUCTION: Chagas disease (ChD) is a chronic illness related to significant morbidity and mortality that can affect the quality of life (QoL) of infected patients. However, there are few studies regarding QoL in ChD. The objectives of this study are to construct a health-related QoL (HRQoL) profile of ChD patients and compare this with a non-ChD (NChD) group to identify factors associated with the worst HRQoL scores in ChD patients. METHODS: HRQoL was investigated in 125 patients with ChD and 21 NChD individuals using the Medical Outcomes Study 36-item Short-Form (SF-36) and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). Patients were submitted to a standard protocol that included clinical examination, ECG, Holter monitoring, Doppler echocardiogram and autonomic function tests. RESULTS: HRQoL scores were significantly worse among the ChD group compared to the NChD group in the SF-36 domains of physical functioning and role-emotional and in the MLWHFQ scale. For the ChD group, univariate analysis showed that HRQoL score quartiles were associated with level of education, sex, marital status, use of medication, functional classification and cardiovascular and gastrointestinal symptoms. In the multivariate analysis, female sex, fewer years of education, single status, worst functional classification, presence of cardiovascular and gastrointestinal symptoms, associated illnesses, Doppler echocardiographic abnormalities and ventricular arrhythmia detected during Holter monitoring were predictors of lower HRQoL scores. CONCLUSIONS: ChD patients showed worse HRQoL scores compared to NChD. For the ChD group, sociodemographic and clinical variables were associated with worst scores.

In-house ELISA method to analyze anti-Trypanosoma cruzi IgG reactivity for differential diagnosis and evaluation of Chagas disease morbidity

INTRODUCTION: The goal was to develop an in-house serological method with high specificity and sensitivity for diagnosis and monitoring of Chagas disease morbidity. METHODS: With this purpose, the reactivities of anti-T. cruzi IgG and subclasses were tested in successive serum dilutions of patients from Berilo municipality, Jequitinhonha Valley, Minas Gerais, Brazil. The performance of the in-house ELISA was also evaluated in samples from other relevant infectious diseases, including HIV, hepatitis C (HCV), syphilis (SYP), visceral leishmaniasis (VL), and American tegumentary leishmaniasis (ATL), and noninfected controls (NI). Further analysis was performed to evaluate the applicability of this in-house methodology for monitoring Chagas disease morbidity into three groups of patients: indeterminate (IND), cardiac (CARD), and digestive/mixed (DIG/Mix), based on their clinical status. RESULTS: The analysis of total IgG reactivity at serum dilution 1:40 was an excellent approach to Chagas disease diagnosis (100% sensitivity and specificity). The analysis of IgG subclasses showed cross-reactivity, mainly with NI, VL, and ATL, at all selected serum dilutions. Based on the data analysis, the IND group displayed higher IgG3 levels and the DIG/Mix group presented higher levels of total IgG as compared with the IND and CARD groups. CONCLUSIONS: These findings demonstrated that methodology presents promising applicability in the analysis of anti-T. cruzi IgG reactivity for the differential diagnosis and evaluation of Chagas disease morbidity.

Insights into the clinical and functional significance of cardiac autonomic dysfunction in Chagas disease

INTRODUCTION: Exclusive or associated lesions in various structures of the autonomic nervous system occur in the chronic forms of Chagas disease. In the indeterminate form, the lesions are absent or mild, whereas in the exclusive or combined heart and digestive disease forms, they are often more pronounced. Depending on their severity these lesions can result mainly in cardiac parasympathetic dysfunction but also in sympathetic dysfunction of variable degrees. Despite the key autonomic effect on cardiovascular functioning, the pathophysiological and clinical significance of the cardiac autonomic dysfunction in Chagas disease remains unknown. METHODS: Review of data on the cardiac autonomic dysfunction in Chagas disease and their potential consequences, and considerations supporting the possible relationship between this disturbance and general or cardiovascular clinical and functional adverse outcomes. RESULTS: We hypothesise that possible consequences that cardiac dysautonomia might variably occasion or predispose in Chagas disease include: transient or sustained arrhythmias, sudden cardiac death, adverse overall and cardiovascular prognosis with enhanced morbidity and mortality, an inability of the cardiovascular system to adjust to functional demands and/or respond to internal or external stimuli by adjusting heart rate and other hemodynamic variables, and immunomodulatory and cognitive disturbances. CONCLUSIONS: Impaired cardiac autonomic modulation in Chagas disease might not be a mere epiphenomenon without significance. Indirect evidences point for a likely important role of this alteration as a primary predisposing or triggering cause or mediator favouring the development of subtle or evident secondary cardiovascular functional disturbances and clinical consequences, and influencing adverse outcomes.

Immunovirological parameters and cytokines in HIV infection

Although modern combined antiretroviral therapies (cART) result in lower morbidity and mortality and a visible improvement of clinical and laboratory parameters in HIV-infected, it is known that their long-term use contributes to appearance of the many events unrelated to AIDS such as cardiovascular diseases, cancer and osteoporosis, comorbidities which have been proposed as some of the most important that deprive the majority of infected to present an even better prognosis. This is because even with a decrease in inflammation and immune activation after drug intervention to the patient, these parameters remain higher than those shown by healthy individuals and the imbalance of cytokine profiles also persists. Therefore, evaluations of other biomarkers in clinical practice are needed to complement the exams already carried out routinely and allow more effective monitoring of HIV patients. This review aims to investigate the role of cytokines as potential markers showing studies on their behavior in various stages of HIV infection, with or without cART.

Chagas disease: morbidity profile in an endemic area of Northeastern Brazil

Abstract: INTRODUCTION : This study evaluated the clinical forms and manifestation severities of Chagas disease among serologically reactive individuals from Western Rio Grande do Norte (Northeastern Brazil). METHODS : This cross-sectional study included 186 adults who were evaluated using electrocardiography, echocardiography, chest radiography, and contrast radiography of the esophagus and colon. A clinical-epidemiological questionnaire was also used. RESULTS : The indeterminate, cardiac, digestive, and cardiodigestive clinical forms of Chagas disease were diagnosed in 51.6% (96/186), 32.2% (60/186), 8.1% (15/186) and 8.1% (15/186) of the participants, respectively. Heart failure (functional classes I-IV) was detected in 7.5% (14/186) of the participants, and 36.4% (24/66), 30.3% (20/66), 15.2% (10/66), 13.6% (9/66), and 4.5% (3/66) of the patients were at stage A, B1, B2, C, and D, respectively. Dilated cardiomyopathy and electrocardiographic changes were detected in 10.2% (19/186) and 48.1% (91/186) of the participants, respectively. Apical aneurysm was diagnosed in 10.8% (20/186) of the participants, and other changes in the segmental myocardial contractility of the left ventricle were diagnosed in 33.9% (63/186) of the participants. Megaesophagus (groups I-IV) was observed in 7% (13/186) of the participants, megacolon (grades 1-3) was detected in12.9% (24/186) of the participants, and both organs were affected in 29.2% (7/24) of the megacolon cases. CONCLUSIONS : We detected various clinical forms of Chagas disease (including the digestive form). Our findings indicate that clinical symptoms alone may not be sufficient to exclude or confirm cardiac and/or digestive damage, and the number of patients with symptomatic clinical forms may be underestimated.

Prognostic factors influencing morbidity and mortality in esophageal carcinoma

PURPOSE: In 1980, operative mortality for esophageal resection was 29%. Over the last 15 years, technical and critical care improvements contributed to the reduction of postoperative mortality rate to 8%. The aim of this study is to analyze retrospectively the role of different factors (surgical procedure, stage of the disease, and anesthetic risk) on the postoperative mortality of 63 patients that underwent esophagectomy with gastric interposition for cancer. METHODS: Seventy-two patients underwent esophagectomy. The stomach was the esophageal substitute in 63 cases. Surgical procedures included transthoracic esophagectomy in 49 patients and transhiatal esophagectomy in 14 cases. Among the 49 transthoracic esophagectomy patients, there were 18 patients with a high anesthetic risk (ASA III). Among the patients that underwent transhiatal esophagectomy, there were 10 patients with a high anesthetic risk (ASA III). RESULTS: The operative mortality rate was 14% (2/14) in transhiatal esophagectomy group and 22% (11/49) in transthoracic esophagectomy group (P = ns). The postoperative mortality of patients with a high anesthetic risk (ASA III) was 47% (8/17) after transthoracic esophagectomy and 10% (1/10) after transhiatal esophagectomy (P <0.05). DISCUSSION: In our experience, the operative mortality was nearly 18% (16.6% after transhiatal esophagectomy and 20.8% after transthoracic esophagectomy). Among the patients with a high anesthetic risk (ASA III) that underwent surgery, the postoperative mortality was significantly lower after transhiatal esophagectomy (10%) compared to transthoracic esophagectomy (47%) (P <0.05).

Fatores de risco cardiovascular em alcoolistas em tratamento

OBJETIVO: Avaliar a presença de fatores de risco cardiovascular, com ênfase na hipertensão e na adiposidade corporal, em alcoolistas abstinentes ou não abstinentes em tratamento. MÉTODO: Trata-se de um estudo transversal com 65 pacientes alcoolistas em tratamento no CAP-Sad. O grau de dependência do álcool foi avaliado pelo SADD (Short Alcohol Dependence Data) e o uso de outras drogas, pelo ASSIST (Alcohol Smoking and Substance Involvement Screening Test). Foram avaliados o perfil bioquímico e o antropométrico dos usuários. RESULTADOS: Participaram do estudo 42 homens e 23 mulheres. A maioria dos participantes (67,74%) apresentou dependência alcoólica grave, com uso de álcool associado principalmente a cigarro (66,15%). A média da circunferência da cintura (CC) foi significativamente maior entre os abstinentes, em comparação aos não abstinentes (AB: 88,15 ± 15,95 x NA: 81,04 ± 9,86; p = 0,03). Pacientes abstinentes há mais tempo tiveram maior sobrepeso/obesidade e adiposidade abdominal (CC) do que os não abstinentes e abstinentes recentes, com razão de chances de 5,25. Os abstinentes apresentaram razão de chances de 3,38 para %GC acima da média, independente do tempo de abstinência. CONCLUSÃO: Pacientes alcoolistas abstinentes apresentam mais sobrepeso/ obesidade, adiposidade corporal (%GC) e abdominal (CC) do que os não abstinentes. É importante o acompanhamento multiprofissional no tratamento de alcoolistas com abordagem para fatores de risco cardiovasculares, principalmente evitando o ganho de peso.

Psychiatric morbidity and quality of life of primary care attenders in two cities in Brazil

Objective: To identify the associations among quality of life (QoL), social determinants and psychological distress in primary care in two cities in Brazil. Methods: A cross-sectional study with 1,466 patients from 2009 to 2010. The statistical analysis used the t-test to compare the variables of interest to the study. Results: The prevalence of Common Mental Disorders (CMD3), severe forms of Common Mental Disorders (CMD5), anxiety and depression were 20.5%, 32%, 37% and 25.1% respectively. Thes presence of psychological distress is associated with worse QoL among the patients studied, especially those older than 40 years of age. In cases of CMD3, those with higher income and educational levels presented higher QoL in the psychical and psychological domains. For the cases of probable anxiety, those with higher educational levels presented lower scores on the physical and social relationship scores. Conclusion: Psychological distress can be associated with a worse QoL among those studied and can be influenced by socioeconomic conditions. Therefore, it is important to structure patient-centered help, which should also include patients’ social contexts.

Avaliação dos efeitos a curto prazo de programas de conscientização e de terapia com pravastatina em indivíduos de alto risco para doença cardiovascular provenientes de consultórios particulares

OBJETIVO: Avaliar a eficácia de programas de conscientização (PC) sobre o controle de fatores de risco (FR) para doença cardiovascular (DCV). MÉTODOS: Pacientes hipercolesterolêmicos de alto risco para DCV foram divididos em 2 grupos durante 16 semanas. O grupo A (n=417, 54,3±10,0 anos, 55% homens) recebeu orientação verbal e escrita sobre controle de FR, e o grupo B (n=180, 54,4±10,9 anos, 45% homens) apenas orientação verbal. Todos os participantes receberam 10mg/dia de pravastatina por 12 semanas. Avaliaram-se o peso, pressão arterial, o colesterol total (CT) e frações, triglicérides, índices I e II de Castelli (CT/HDL-C e LDL-C/HDL-C) e escores de Framingham. RESULTADOS: No basal, A diferiu de B no HDL-C (40,0±11,0 vs 43,0±11,0mg/dl, p=0,013) e no índice I (8,2±3,0 vs 7,6±2,3, p=0,008). Após 16 semanas as variações % foram maiores em A do que B no CT (-28,0 vs -25,0, p<0,05), LDL-C (-29,0 vs -27,6, p<0,05), HDL-C (+13,7 vs. + 10,8, p<0,05) e índice I (-39,0 vs -33,0; p<0,05). A pravastatina potencializou os efeitos da dieta sobre os lípides. CONCLUSÃO: O PC parece ser mais eficaz a curto prazo, em reduzir os FR para DCV do que a orientação apenas verbal.