InsCor: um método simples e acurado para avaliação do risco em cirurgia cardíaca

FUNDAMENTO: Escores de risco apresentam dificuldades para obter o mesmo desempenho em diferentes populações. OBJETIVO: Criar um modelo simples e acurado para avaliação do risco nos pacientes operados de doença coronariana e/ou valvar no Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). MÉTODOS: Entre 2007 e 2009, 3.000 pacientes foram operados consecutivamente de doença coronariana e/ou valvar no InCor-HCFMUSP. Desse registro, dados de 2/3 dos pacientes foram utilizados para desenvolvimento do modelo (técnica de bootstrap) e de 1/3 para validação interna do modelo. O desempenho do modelo (InsCor) foi comparado aos complexos 2000 Bernstein-Parsonnet (2000BP) e EuroSCORE (ES). RESULTADOS: Apenas 10 variáveis foram selecionadas: Idade > 70 anos; sexo feminino; cirurgia de revascularização coronariana + valva; infarto de miocárdio < 90 dias; reoperação; tratamento cirúrgico da valva aórtica; tratamento cirúrgico da valva tricúspide; creatinina < 2mg/dL; fração de ejeção < 30%; e eventos. O teste de Hosmer Lemeshow para o InsCor foi de 0,184, indicando uma excelente calibração. A área abaixo da curva ROC foi de 0,79 para o InsCor, 0,81 para o ES e 0,82 para o 2000BP, confirmando que os modelos são bons e similares na discriminação. CONCLUSÕES: O InsCor e o ES tiveram melhor desempenho que o 2000BP em todas as fases da validação; pórem o novo modelo, além de se identificar com os fatores de risco locais, é mais simples e objetivo para a predição de mortalidade nos pacientes operados de doença coronariana e/ou valvar no InCor-HCFMUSP.

Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System

AbstractBackground:Heart surgery has developed with increasing patient complexity.Objective:To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).Method:All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.Results:Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.Conclusion:Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

Age, Creatinine and Ejection Fraction Score in Brazil: Comparison with InsCor and the EuroSCORE

AbstractBackground:Risk scores for cardiac surgery cannot continue to be neglected.Objective:To assess the performance of “Age, Creatinine and Ejection Fraction Score” (ACEF Score) to predict mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery, and to compare it to other scores.Methods:A prospective cohort study was carried out with the database of a Brazilian tertiary care center. A total of 2,565 patients submitted to elective surgeries between May 2007 and July 2009 were assessed. For a more detailed analysis, the ACEF Score performance was compared to the InsCor’s and EuroSCORE’s performance through correlation, calibration and discrimination tests.Results:Patients were stratified into mild, moderate and severe for all models. Calibration was inadequate for ACEF Score (p = 0.046) and adequate for InsCor (p = 0.460) and EuroSCORE (p = 0.750). As for discrimination, the area under the ROC curve was questionable for the ACEF Score (0.625) and adequate for InsCor (0.744) and EuroSCORE (0.763).Conclusion:Although simple to use and practical, the ACEF Score, unlike InsCor and EuroSCORE, was not accurate for predicting mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery in a Brazilian tertiary care center. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0)

Geographic distribution and morphometric differentiation of Triatoma nitida usinger 1939 (Hemiptera: Reduviidae: Triatominae) in Guatemala

Triatoma nitida was found in 14 (0.4%) out of 3,726 houses located in six departments across Guatemala, which were surveyed from 1994 to 1998 by the man-hour collection method. Compared to previous information, the distribution of T. nitida in Guatemala has increased from five to nine departments; the species is present in mild climates at altitudes from 960 to 1,500 m. Fourteen percent of the intradomestic T. nitida were infected with Trypanosoma cruzi. The species was often found in conjunction with other triatomines (T. dimidiata and Rhodnius prolixus). The domestic and peridomestic presence of T. nitida in Guatemala was rare, but occasionally this species was colonizing human-made constructions. T. nitida appears to have a low importance as Chagas disease vector in Guatemala, as indicated by its scarce presence in the domestic habitats and defecation patterns. However, it clearly has potential to become a Chagas vector so we recommend an on-going study of the intradomestic presence of T. nitida following the control programs in Guatemala. Morphometric analysis of 47 T. nitida males from three localities showed quantitative differences between the populations, which indicates that geographic distance is an important factor in the structuring of T. nitida populations.

Epidemiology of Chagas disease in Guatemala: infection rate of Triatoma dimidiata, Triatoma nitida and Rhodnius prolixus (Hemiptera, Reduviidae) with Trypanosoma cruzi and Trypanosoma rangeli (Kinetoplastida, Trypanosomatidae)

A five-year domiciliary collection in the 22 departments of Guatemala showed that out of 4,128 triatomines collected, 1,675 were Triatoma dimidiata (Latreille, 1811), 2,344 were Rhodnius prolixus Stal 1859, and only 109 were T. nitida Usinger 1939. The Chagas disease parasite, Trypanosoma cruzi, was found in all three species. Their natural infection rates were similar in the first two species (20.6%; 19.1%) and slightly lower in T. nitida(13.8%). However there was no significant difference in the infection rates in the three species (p = 0.131). T. dimidiata males have higher infection rates than females (p = 0.030), whereas for R. prolixus there is no difference in infection rates between males and females (p = 0.114). The sex ratios for all three species were significantly skewed. More males than females were found inside houses for T. dimidiata (p < 0.0001) and T. nitida (p = 0.011); a different pattern was seen for R. prolixus (p = 0.037) where more females were found. Sex ratio is proposed as an index to show the mobility of T. dimidiata in different populations. T. dimidiata is widely distributed in the country, and is also the main vector in at least ten departments, but R. prolixus with higher vectorial capacity is an important vector in at least two departments.

Action of Trypanosoma rangeli in infections with virulent Trypanosoma cruzi populations

In experimental murine infections with Trypanosoma rangeli it has been observed development immune response to Trypanosoma cruzi. The aim of the present work was to analyze the result of antigenic stimuli and the protective effect with T. rangeli in T. cruzi infections. Mice groups immunized with metacyclic trypomastigotes of T. rangeli (Choachí-2V strain), derived from haemolymph and salivary gland and reinfected with T. cruzi virulent populations (Tulahuen strain, SA strain and Dm28c clone) from infected in vitro cells, showed decrease severity of disease outcomes, low parasitemia levels and 100% survival of all mice immunized, in comparison with groups infected only with T. cruzi populations, which demonstrated tissue affection, high parasitemia levels and the death of all animals. The above mentioned data contribute to understand the biological behaviour of T. cruzi and T. rangeli and their interaction with vertebrate host.

Blood transfusion and iatrogenic risks in Mexico city: anti-Trypanosoma cruzi seroprevalence in 43,048 blood donors, evaluation of parasitemia, and electrocardiogram findings in seropositive

Iatrogenous transmission of Trypanosoma cruziby blood transfusion was suggested as a potential risk by Pellegrino (1949). Seropositive blood donors in Mexico were first reported in 1978, however, limited information is available due to small sampling, the use of heterogeneous serologic assays, and geographically limited studies. A wide survey carried out in 18 out of the 32 states of Mexico, showed a national mean of 1.6% seropositive among 64,969 donors, ranging from 0.2 to 2.8%. In the present study, we have screened 43,048 voluntary blood donors in a period of five years at the Instituto Nacional de Cardiología I. Chávez, a concentration hospital located in Mexico city which serves mainly the metropolitan area and accepts from all over the country. Standardized ELISA and IIF were used to identify seropositive individuals in addition to hemoculture, PCR and standard 12 lead ECG tests that were applied to a group of seropositive patients (29/161). The result showed a seropositivity of 0.37% (161/43,048). From the group of seropositive individuals 40% (12/29) were potential carriers of T. cruzi at the donation time and 5/29 had subclinical ECG abnormalities. Parasitological tests performed in 70 erythrocyte and platelet fractions from seropositive units (70/161) showed negative results. Our findings strongly support T. cruzi screening in the transfusion medicine practice and identify subclinical heart disease among seropositive blood donors.

Experimental infection of Leishmania (L.) chagasi in a cell line derived from Lutzomyia longipalpis (Diptera:Psychodidae)

The present work describes the in vitro infection of a cell line Lulo, derived from Lutzomyia longipalpis embryonic tissue, by Leishmania chagasi promastigotes. This infection process is compared with a parallel one developed using the J774 cell line. The L. chagasi MH/CO/84/CI-044B strain was used for experimental infection in two cell lines. The cells were seeded on glass coverslips in 24-well plates to reach a final number of 2 x 10(5) cells/well. Parasites were added to the adhered Lulo and J774 cells in a 10:1 ratio and were incubated at 28 and 37ºC respectively. After 2, 4, 6, 8, and 10 days post-infection, the cells were extensively washed with PBS, fixed with methanol, and stained with Giemsa. The number of internalized parasites was determined by counting at least 400 cultured cells on each coverslip. The results showed continuous interaction between L. chagasi promastigotes with the cell lines. Some ultrastructural characteristics of the amastigote forms were observed using transmission electron microscopy. The highest percentage of infection in Lulo cells was registered on day 6 post-infection (29.6%) and on day 4 in the J774 cells (51%). This work shows similarities and differences in the L. chagasi experimental infection process in the two cell lines. However, Lulo cells emerge as a new model to study the life-cycle of this parasite.

Trypanosoma cruzi strains isolated from human, vector, and animal reservoir in the same endemic region in Mexico and typed as T. cruzi I, discrete typing unit 1 exhibit considerable biological diversity

In this study, three strains of Trypanosoma cruzi were isolated at the same time and in the same endemic region in Mexico from a human patient with chronic chagasic cardiomyopathy (RyC-H); vector (Triatoma barberi) (RyC-V); and rodent reservoir (Peromyscus peromyscus) (RyC-R). The three strains were characterized by multilocus enzyme electrophoresis, random amplified polymorphic DNA, and by pathological profiles in experimental animals (biodemes). Based on the analysis of genetic markers the three parasite strains were typed as belonging to T. cruzi I major group, discrete typing unit 1. The pathological profile of RyC-H and RyC-V strains indicated medium virulence and low mortality and, accordingly, the strains should be considered as belonging to biodeme Type III. On the other hand, the parasites from RyC-R strain induced more severe inflammatory processes and high mortality (> 40%) and were considered as belonging to biodeme Type II. The relationship between genotypes and biological characteristics in T. cruzi strains is still debated and not clearly understood. An expert committee recommended in 1999 that Biodeme Type III would correspond to T. cruzi I group, whereas Biodeme Type II, to T. cruzi II group. Our findings suggest that, at least for Mexican isolates, this correlation does not stand and that biological characteristics such as pathogenicity and virulence could be determined by factors different from those identified in the genotypic characterization

A four-year surveillance program for detection of Plasmodium falciparum chloroquine resistance in Honduras

Countries could use the monitoring of drug resistance in malaria parasites as an effective early warning system to develop the timely response mechanisms that are required to avert the further spread of malaria. Drug resistance surveillance is essential in areas where no drug resistance has been reported, especially if neighbouring countries have previously reported resistance. Here, we present the results of a four-year surveillance program based on the sequencing of the pfcrt gene of Plasmodium falciparum populations from endemic areas of Honduras. All isolates were susceptible to chloroquine, as revealed by the pfcrt “CVMNK” genotype in codons 72-76.

Embarazo, parto y puerperio: creencias y prácticas de parteras en San Luis Potosí, México

OBJETIVO: Documentar las creencias y las prácticas de las parteras tradicionales respecto al embarazo parto y puerperio. MÉTODOS: Aprovechando un curso de capacitación de 160 parteras tradicionales locales de las regiones Media y Huasteca del Estado de San Luis Potosí, México, dos de las enfermeras-instructoras entrevistaron a 25 de los capacitandos, apoyadas por un miembro de las comunidades náhuatl y tenek. La identidad de los participantes se mantiene anónima y se obtuvo permiso para publicar los resultados mediante consentimiento informado. RESULTADOS: Las prácticas de las parteras (os) tradicionales son comunes en los grupos sociales que carecen de servicios de salud. Sus funciones no están limitadas al parto e incluyen nutrición, cuidados prenatales, del puerperio y la lactancia, así como apoyo afectivo emocional de las madres parturientas y sus familiares. En este estudio se registraron varios mitos y terapias tradicionales. CONCLUSIÓN: Los recursos de la terapia tradicional y de la atención primaria de la salud de las parteras Náhuatl y Tenek son útiles y benéficos para los cuidados perinatales.

Digestibilidad in situ de dietas con harina de nopal deshidratado conteniendo un preparado de enzimas fibrolíticas exógenas

Se evaluó el efecto de un preparado de enzimas fibrolíticas exógenas (celulasas y xilanasas) en la degradabilidad in situ de la materia seca (DisMS), fibra detergente neutro (DFDNr) y fibra detergente ácido residual (DFDAr), en dietas altas o bajas en harina de nopal deshidratado. Se aplicaron concentraciones de 0, 1, 2 y 3 g de enzima por kilogramo de materia seca al inicio y 24 horas antes de la degradación in situ. Se determinó la concentración de ácidos grasos volátiles totales y de nitrógeno amoniacal a las 0, 3, 6, 9, 12 y 24 horas después de aplicarse la enzima. No se observaron efectos en DisMS, DFDNr y DFDAr; la aplicación al inicio de la degradación in situ mostró valores más altos que a 24 horas para DisMS y DFDNr, pero fue menor para DFDAr. No se observaron diferencias en las interacciones entre niveles de enzima, tipo de dieta y tiempo de pretratamiento. La aplicación de 1 y 3 g de enzima, en la dieta con bajo contenido de harina de nopal, tuvo efectos en el incremento de los ácidos grasos volátiles totales; para el nitrógeno amoniacal, los mejores resultados ocurrieron con 0 y 1 g de enzima.

Diversidad genética en cerdos criollos mexicanos con genes candidatos asociados a características productivas

El objetivo de este trabajo fue comparar la variabilidad, diversidad y distancias genéticas entre cerdos criollos, Pelón Mexicano (CPM) y Cuinos (CC), con Yorkshire, cuanto a los genes candidatos CAST, DECR1, HAL, HFABP4, LEP, LIPE, MCR4, MYOG, RN y CHX, a través de analysis por PCR-RFLP. Se evaluaron 180 cerdos: 59 CPM, 65 CC y 56 Yorkshire. Se analizaron las frecuencias génicas y genotípicas, heterocigosidad, distancias genéticas y árboles filogenéticos entre grupos raciales. Para CAST, DECR1, HFABP4, LEP, MCR4 y CHX las frecuencias génicas y genotípicas fueron diferentes al comparar las tres razas. En LIPE, los CC fueron iguales a los Yorkshire; en cuanto a MYOG, los CPM fueron iguales a los Yorkshire. No hubo diferencias entre poblaciones criollas y Yorkshire en las frecuencias génicas y genotípicas para HAL y RN. Los cerdos Yorkshire presentaron mayor frecuencia en alelos favorables para CAST, LIPE, MCR4 y MYOG, menor frecuencia de DECR1, HFABP4, CHX, y moderada en LEP. La heterocigosidad promedio para todos los genes fue mayor en CPM (0,42±0,05) y similar en CC (0,33±0,06) y Yorkshire (0,35±0,05). Al calcular distancias genéticas con todos los genes, los CC se encuentran más distantes de los Yorkshire.

Variables físicas que explican la variabilidad de suelo aluvial y su comportamiento espacial

El objetivo de este trabajo fue utilizar el análisis de componentes principales y de semivarianza para seleccionar variables físicas que explicaran la variabilidad de un suelo aluvial, y establecer el comportamiento espacial de las variables seleccionadas, con el fin de definir técnicamente la localización de parcelas experimentales para estudiar los efectos de la abrasividad del suelo sobre el desgaste de herramientas agrícolas. Las pruebas de campo se realizaron en 2008, en un lote plano de 6.000 m² con suelos de textura media a pesada (Vertic Haplustepts). Se hizo un muestreo intensivo en cuadrícula de 10x14 m. Las variables que mayor peso tuvieron en los tres primeros componentes principales fueron los contenidos de limo, arena fina y media, gravilla media, la humedad a capacidad de campo y el coeficiente higroscópico. A excepción de la arena media y la capacidad de campo, las demás propiedades presentaron alta dependencia espacial y su distribución mostró que en el lote experimental se encuentran tres sectores de acumulación diferencial de limo y de arena fina. La combinación de los análisis de componentes principales y geoestadística permitió definir las propiedades del suelo involucradas en el desgaste de herramientas, su patrón espacial y la manera más adecuada de distribuir parcelas experimentales, para estudiar la abrasividad del suelo.