Impact of chagas disease in human evolution:the challenges continue

Chagas disease affects 8 to 10 million people worldwide and, although most of them live in Latin America, there has been an increase in cases occurring in countries of Europe and North America although most of them live in Latin America. This study aims to describe the epidemiological situation in the present as well as government and research centers actions, particularly the study group of Chagas disease of the School of Medicine of Botucatu (FMB/UNESP)/Brazil.

Indeterminate form of chagas disease and metabolic syndrome: a dangerous combination

Chagas’ disease (CD) has been a major concern in public health in Latin America countries and in Brazil there are about 3 million people suffering from this disease. With the social and economic changes which have been occurring in the last 6 decades in the country, there have been a lot of changes in the population life style with severe metabolic consequences, especially for those with Chagas' disease. The objective of this study was to evaluate the prevalence of metabolic syndrome in individuals with the indeterminate form of CD. A total of 74 individuals, mean age of 55.6 years, participated in the study. Anthropometric and biochemical evaluations were performed. Overweight/obesity was found in 86.5 % of individuals, increased waist circumference in 72.5%, and 67% had more than 30% of fat mass. Hyperglycemia and dyslipidemia were observed in 24.3% and 75.7% of patients, respectively. Metabolic syndrome was diagnosed in 48.2% of patients. The family history revealed high prevalence of cardiovascular diseases (80.3%), systemic arterial hypertension (57.1%) and diabetes mellitus (42.8%). A total of 90% of patients were overweight/obese, and it is well known that increased adipose tissue, specially visceral adipose tissue is highly associated with dyslipidemia and cardiovascular diseases, as well as imbalance in production of proinflammatory and antiinflammatory cytokines produced by that tissue. Adipocytes are also known as a reservoir for Trypanosoma cruzi, favoring an increase in parasite load and a possible reacutization of the disease. Therefore, the study individuals are at high risk of developing cardiovascular diseases as well as further symptomatic form of the Chagas' disease, mainlychagastic cardiopathy.

Increased Risk of Chronic Wasting Disease in Rocky Mountain Elk Associated With Decreased Magnesium and Increased Manganese in Brain Tissue

Chronic wasting disease (CWD) is a transmissible spongiform encephalopathy (TSE) of Rocky Mountain elk in North America. Recent studies suggest that tissue and blood mineral levels may be valuable in assessing TSE infection in sheep and cattle. The objectives of this study were to examine baseline levels of copper, manganese, magnesium, zinc, selenium, and molybdenum in the brains of Rocky Mountain elk with differing prion genotypes and to assess the association of mineral levels with CWD infection. Elk with leucine at prion position 132 had significantly lower magnesium levels than elk with 2 copies of methionine. Chronic wasting disease-positive elk had significantly lower magnesium than control elk. The incorporation of manganese levels in addition to magnesium significantly refined explanatory ability, even though manganese alone was not significantly associated with CWD. This study demonstrated that mineral analysis may provide an additional disease correlate for assessing CWD risk, particularly in conjunction with genotype.

Scraping Behavior in Male White-tailed Deer as a Potential Means of Transmitting Chronic Wasting Disease

Chronic wasting disease (CWD) has become a concern for wildlife managers and hunters across the United States. High prevalence of chronic wasting disease (CWD) in older male white-tailed deer (Odocoileus virginianus) suggests that sex-specific social behavior may contribute to the spread of the disease among males. Scraping is a marking behavior performed by male white-tailed deer during the rut in which a pawed depression and associated over-hanging branch are marked with saliva, glandular secretions, urine, and feces. We placed 71 and 35 motion-activated cameras on scrapes in DeSoto National Wildlife Refuge in western Nebraska and eastern Iowa from Oct. – Nov. 2005 and Sept. – Nov. 2006, respectively. We recorded 5009 encounters and 1830 direct interactions. We developed an ethogram of behaviors of interest at scrapes. We found that males interacted with scrapes more frequently than females (P < 0.001). Male interactions were more complex, with 69% consisting of ≥2 observed behaviors versus 25% and 13% for females and fawns. We identified individual male deer ≥2.5 years old and determined the minimum number of different scrapes individuals visited and the number of individuals that visit a single scrape. Individuals that appeared on camera ≥5 times visited a mean of 3.9 scrapes (range = 1-15) and traveled a mean minimum distance of 978 m between consecutive scrapes. A mean of 5.1 individuals visited a single scrape, and up to 43% of individuals returned to a scrape previously visited at least once. We modeled Risk Values based on frequency of occurrence, duration, and Threat Values of each behavior, for contacting and transmitting CWD prions at scrapes. Adult males had the highest total Risk Values for contacting CWD prions (114.1) and shedding prions (59.4). The “grasp-lick branch” behavior had the highest Risk Value for adult males for both contacting and transmitting prions. Our study reveals a sex specific social behavior in male white-tailed deer that has the potential to spread chronic wasting disease between adult males in the population.

Does orchiectomy enhance the immune-stimulatory effects of melatonin during experimental Chagas' disease?

Melatonin has been reported to play a fundamental role in T-cell immunoregulation. Control of Trypanosome cruzi parasitism during the acute phase of infection is considered to be critically dependent on direct macrophage activation by cytokines. The aim of this work was to evaluate the influence of exogenous melatonin treatment and the influences exerted by sexual hormones during the acute phase of the experimental Chagas' disease in rats. With melatonin treatment, orchiectomized animals (CMOR and IMOR) displayed the highest concentrations of IFN-gamma and TNF-alpha. On the 7th day post-infection, untreated and treated orchiectomized animals (IOR and IMOR) showed an enhanced number of peritoneal macrophages. Nitric oxide levels were also increased in untreated and treated orchiectomized (IOR and IMOR) when compared to the other groups, with or without LPS. Our data suggest that melatonin therapy associated with orchiectomy induced a stimulating effect on the immune response to the parasite. (c) 2012 Published by Elsevier Ltd.

EFFECTS OF VITAMIN C SUPPLEMENTATION ON ACUTE PHASE CHAGAS DISEASE IN EXPERIMENTALLY INFECTED MICE WITH Trypanosoma cruzi QM1 STRAIN

The tissue changes that occur in Chagas disease are related to the degree of oxidative stress and antioxidant capacity of affected tissue. Studies with vitamin C supplementation did not develop oxidative damage caused by Chagas disease in the host, but other studies cite the use of peroxiredoxins ascorbate - dependent on T. cruzi to offer protection against immune reaction. Based on these propositions, thirty "Swiss" mice were infected with T. cruzi QM1 strain and treated with two different vitamin C doses in order to study the parasitemia evolution, histopathological changes and lipid peroxidation biomarkers during the acute phase of Chagas disease. The results showed that the parasite clearance was greater in animals fed with vitamin C overdose. There were no significant differences regarding the biomarkers of lipid peroxidation and inflammatory process or the increase of myocardium in animals treated with the recommended dosage. The largest amount of parasite growth towards the end of the acute phase suggests the benefit of high doses of vitamin C for trypomastigotes. The supplementation doesn't influence the production of free radicals or the number of amastigote nests in the acute phase of Chagas disease.

High-Performance Liquid Chromatography Under Partially Denaturing Conditions (dHPLC) is a Fast and Cost-Effective Method for Screening Molecular Defects: Four Novel Mutations Found in X-Linked Chronic Granulomatous Disease

Implementing precise techniques in routine diagnosis of chronic granulomatous disease (CGD), which expedite the screening of molecular defects, may be critical for a quick assumption of patient prognosis. This study compared the efficacy of single-strand conformation polymorphism analysis (SSCP) and high-performance liquid chromatography under partially denaturing conditions (dHPLC) for screening mutations in CGD patients. We selected 10 male CGD patients with a clinical history of severe recurrent infections and abnormal respiratory burst function. gDNA, mRNA and cDNA samples were prepared by standard methods. CYBB exons were amplified by PCR and screened by SSCP or dHPLC. Abnormal DNA fragments were sequenced to reveal the nature of the mutations. The SSCP and dHPLC methods showed DNA abnormalities, respectively, in 55% and 100% of the cases. Sequencing of the abnormal DNA samples confirmed mutations in all cases. Four novel mutations in CYBB were identified which were picked up only by the dHPLC screening (c.904 insC, c.141+5 g>t, c.553 T>C, and c.665 A>T). This work highlights the relevance of dHPLC, a sensitive, fast, reliable and cost-effective method for screening mutations in CGD, which in combination with functional assays assessing the phagocyte respiratory burst will contribute to expedite the definitive diagnosis of X-linked CGD, direct treatment, genetic counselling and to have a clear assumption of the prognosis. This strategy is especially suitable for developing countries.

High Rates of Detection of Respiratory Viruses in Tonsillar Tissues from Children with Chronic Adenotonsillar Disease

Chronic tonsillar diseases are an important health problem, leading to large numbers of surgical procedures worldwide. Little is known about pathogenesis of these diseases. In order to investigate the role of respiratory viruses in chronic adenotonsillar diseases, we developed a cross-sectional study to determine the rates of viral detections of common respiratory viruses detected by TaqMan real time PCR (qPCR) in nasopharyngeal secretions, tonsillar tissues and peripheral blood from 121 children with chronic tonsillar diseases, without symptoms of acute respiratory infections. At least one respiratory virus was detected in 97.5% of patients. The viral co-infection rate was 69.5%. The most frequently detected viruses were human adenovirus in 47.1%, human enterovirus in 40.5%, human rhinovirus in 38%, human bocavirus in 29.8%, human metapneumovirus in 17.4% and human respiratory syncytial virus in 15.7%. Results of qPCR varied widely between sample sites: human adenovirus, human bocavirus and human enterovirus were predominantly detected in tissues, while human rhinovirus was more frequently detected in secretions. Rates of virus detection were remarkably high in tonsil tissues: over 85% in adenoids and close to 70% in palatine tonsils. In addition, overall virus detection rates were higher in more hypertrophic than in smaller adenoids (p = 0.05), and in the particular case of human enteroviruses, they were detected more frequently (p = 0.05) in larger palatine tonsils than in smaller ones. While persistence/latency of DNA viruses in tonsillar tissues has been documented, such is not the case of RNA viruses. Respiratory viruses are highly prevalent in adenoids and palatine tonsils of patients with chronic tonsillar diseases, and persistence of these viruses in tonsils may stimulate chronic inflammation and play a role in the pathogenesis of these diseases.

Religious/spiritual coping in people with chronic kidney disease undergoing hemodialysis

The objective of the present study is to investigate the use of religious/spiritual coping mechanisms in patients with chronic kidney disease undergoing hemodialysis, by means of interviews using a sociodemographic questionnaire and the religious/spiritual coping scale. Data analysis was performed using descriptive statistics and multiple linear regression. A total of 123 individuals were interviewed, 79.6% of whom presented a high score for religious/spiritual coping and none of whom presented low or irrelevant scores. The variables that affected the religious/spiritual coping behavior were: gender, age group, treatment time, family income, and religious practice. In conclusion, the participants used religious/spiritual coping mechanisms as a strategy to cope with the disease, particularly women with a higher family income who attend church every week.

A General Latent Class Model for Performance Evaluation of Diagnostic Tests in the Absence of a Gold Standard: An Application to Chagas Disease

We propose a new general Bayesian latent class model for evaluation of the performance of multiple diagnostic tests in situations in which no gold standard test exists based on a computationally intensive approach. The modeling represents an interesting and suitable alternative to models with complex structures that involve the general case of several conditionally independent diagnostic tests, covariates, and strata with different disease prevalences. The technique of stratifying the population according to different disease prevalence rates does not add further marked complexity to the modeling, but it makes the model more flexible and interpretable. To illustrate the general model proposed, we evaluate the performance of six diagnostic screening tests for Chagas disease considering some epidemiological variables. Serology at the time of donation (negative, positive, inconclusive) was considered as a factor of stratification in the model. The general model with stratification of the population performed better in comparison with its concurrents without stratification. The group formed by the testing laboratory Biomanguinhos FIOCRUZ-kit (c-ELISA and rec-ELISA) is the best option in the confirmation process by presenting false-negative rate of 0.0002% from the serial scheme. We are 100% sure that the donor is healthy when these two tests have negative results and he is chagasic when they have positive results.

The role of myocardial scintigraphy in the assessment of cardiovascular risk in patients with end-stage chronic kidney disease on the waiting list for renal transplantation

The usefulness of stress myocardial perfusion scintigraphy for cardiovascular (CV) risk stratification in chronic kidney disease remains controversial. We tested the hypothesis that different clinical risk profiles influence the test. We assessed the prognostic value of myocardial scintigraphy in 892 consecutive renal transplant candidates classified into four risk groups: very high (aged epsilon 50 years, diabetes and CV disease), high (two factors), intermediate (one factor) and low (no factor). The incidence of CV events and death was 20 and 18, respectively (median follow-up 22 months). Altered stress testing was associated with an increased probability of cardiovascular events only in intermediate-risk (one risk factor) patients [30.3 versus 10, hazard ratio (HR) 2.37, confidence interval (CI) 1.693.33, P 0.0001]. Low-risk patients did well regardless of scan results. In patients with two or three risk factors, an altered stress test did not add to the already increased CV risk. Myocardial scintigraphy was related to overall mortality only in intermediate-risk patients (HR 2.8, CI 1.55.1, P 0.007). CV risk stratification based on myocardial stress testing is useful only in patients with just one risk factor. Screening may avoid unnecessary testing in 60 of patients, help stratifying for risk of events and provide an explanation for the inconsistent performance of myocardial scintigraphy.

Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors?

Introduction: While some studies show that patients submitted to radical nephrectomy have a higher risk of developing chronic kidney disease (CKD), some studies report that carefully selected living kidney donors do not present a higher risk for CKD. Here, we aim to study predictive factors of CKD after radical nephrectomy. Materials and Methods: Between January 2006 to January 2010, 107 patients submitted to radical nephrectomy for cortical renal tumors at our institution were enrolled in this study. Demographic data were recorded, modified Charlson-Romano Index was calculated, and creatinine clearance was estimated using abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Pathological characteristics, surgical access and surgical complications were also reviewed. The end-point of the current study was new onset estimated glomerular filtration rate (eGFR) less than 60 and less than 45 mL/minute/1.73 m(2). Results: Age, preoperative eGFR, Charlson-Romano Index and hypertension were predictive factors of renal function loss, when the end-point considered was eGFR lower than 60 mL/minute/1.73 m(2). Age and preoperative eGFR were predictive factors of renal function loss, when the end-point considered was eGFR lower than 45 mL/minute/1.73 m2. Moreover, each year older increased 1.1 times the risk of eGFR lower than 60 and 45 mL/minute/1.73 m(2). After multivariate logistic regression, only age remained as an independent predictive factor of eGFR loss. Conclusion: Age is an independent predictive factor of GFR loss for patients submitted to radical nephrectomy for cortical renal tumors.

Effect of Colchicine on Myocardial Injury Induced by Trypanosoma cruzi in Experimental Chagas Disease

Background: The hallmark of Chagas disease (CD) is multifocal myocarditis and extensive fibrosis. We investigated the potential effect of colchicine on myocardial remodeling in experimental CD. Methods and Results: One hundred Syrian hamsters were randomly divided into noninfected untreated control (CG), noninfected control treated with colchicine (COLG 0.4 mg kg(-1) d(-1) by gavage), infected (IG), and infected treated with colchicine (ICOLG, 0.4 mg kg(-1) d(-1)) groups. The interstitial collagen volume fraction (ICVF) was evaluated by videomorphometry with picrosirius red staining. The gelatinolytic activities of matrix metalloproteinase (MMP) 2 were examined with the use of zymography. Myocarditis was described according to the Dallas criteria. Statistical comparisons were performed with parametric analysis of variance and Tukey test. ICVF (%) accumulation was attenuated in infected colchicine-treated animals in the left (CG 0.81 +/- 0.13, COLG 0.85 +/- 0.13, IG: 1.35 +/- 0.31,* ICOLG 1.06 +/- 0.19; *P < .05 compared with ICOLG) and right ventricles (CG 1.4 +/- 0.36, COLG 1.26 +/- 0.14, IG 1.97 +/- 0.058,* ICOLG: 1.52 +/- 0.23; *P < .05 compared with ICOLG). A significant increase in MMP-2 enzymatic activity (UA) was observed in ICOLG (17,432.8*) compared with GC (3731.6), COLG (2,792.6), and IG (4,286.3; *P < .001). In IG, 66% of animals had myocarditis compared with only 49% in ICOLG. Conclusions: Colchicine had a protective effect on myocardium, indicated by decreased interstitial myocardial fibrosis, increased intensity of MMP-2, and attenuated myocardial inflammation. (J Cardiac Fail 2012;18:654-659)

Functional independence in patients with chronic kidney disease being treated with haemodialysis

Purpose: This study has described and analysed the functional independence of the patients served in the haemodialysis services of a countryside town in the State of Sao Paulo, Brazil, using the Functional Independence Measure (FIM). Method: The population considered was that of 214 patients being treated with haemodialysis, assessed in 2011, by means of a social, demographic and clinical report, a Mini-Mental State Examination (MMSE) and also the FIM. Results: The mean age of the population under study was 58.01 years, while the mean FIM point score was 118.38 points, showing a level of complete or modified independence within this population. Even though the level of dependence found has been low, this can be highlighted, within the locomotion domain, in the activity of going up and down stairs (10.28%). Age, complications arising from haemodialysis, and comorbidities show a negative correlation with FIM. Conclusion: Awareness of the level of functional independence of the patients being subjected to treatment with haemodialysis is essential in order to back up intervention for the improvement of nursing assistance provided to this population.

Congenital Chagas disease: time to screen pregnant women?

The congenital transmission of Trypanosoma cruzi has gained epidemiological importance because it is partially responsible for the spread of Chagas disease worldwide. The feasibility of a cure when infected children are treated early makes the detection of congenital infection a valuable goal toward the control of the disease. Here, the authors review and discuss the findings of Bua et al., who quantified the parasitemia of infected women and their newborns by quantitative PCR. The authors demonstrate that the maternal parasite burden is directly related to the risk of neonatal infection. This study points out the importance of a quantitative screen for T. cruzi in pregnant women who live in, or have traveled to, endemic areas for improving the diagnosis of infected newborns and providing prompt treatment.