DESCRIPTION OF ESOPHAGOSTOMY TUBE PLACEMENT IN TWO GIANT ANTEATER (MYRMECOPHAGA TRIDACTYLA) CADAVERS.

Feeding of managed populations of giant anteater (Myrmecophaga tridactyla) is challenging in injured patients that present with anorexia. This report describes an approach for esophagostomy tube placement in this species. Cadavers of two adult giant anteaters were used for technique development. The animal was positioned in dorsal recumbency, and a guide feeding tube was inserted orally into the esophagus. A ventral midline incision in the midcervical region was made to access the esophagus and to protect submandibular salivary glands. The cervical musculature was dissected and retracted laterally to the right, the vagosympathetic nerve trunk was identified and preserved, and the esophagus was incised over the guide tube. The guide tube was removed to facilitate placement of the definitive tube, which was premeasured from its insertion point in the midcervical area to the level of the seventh-ninth intercostal space. The tube was secured to the cervical skin on the left side with a finger-trap suture.

Cardiac and Liver Fibrosis Assessed by Multiparametric MRI in Patients with Fontan Circulation.

The abnormal hemodynamics in Fontan circulation due to persistently increased systemic venous pressure results in hepatic venous congestion and Fontan-associated liver disease. Combined assessment of cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in this context have not been fully explored. To evaluate cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in patients who have undergone Fontan procedures. Thirty-eight patients and 23 controls underwent cardiac and liver MRI examinations in a 3.0-T scanner. Mann-Whitney, Fisher exact test, and Spearman's correlation were applied to evaluate myocardial volumes, function, native cardiac and liver T1 mapping, ECVs and liver stiffness. The mean native cardiac T1 value (p = 0.018), cardiac ECV (p < 0.001), liver native T1 (p < 0.001), liver ECV (p < 0.001), and liver stiffness (p < 0.001) were higher in patients than controls. The indexed end-diastolic volume (EDVi) correlated with the myocardial ECV (r = 0.356; p = 0.033), native liver T1 (r = 0.571; p < 0.001), and with liver stiffness (r = 0.391; p = 0.015). In addition, liver stiffness correlated with liver ECV (r = 0.361; p = 0.031) and native liver T1 (r = 0.458; p = 0.004). An association between cardiac remodeling and cardiac and liver fibrosis were found in this population. The usefulness of MRI to follow cardiac and liver involvement in these patients is critical to improve treatment strategies and to prevent the need for combined liver and heart transplantation.

Molecular detection of Sarcocystis sp. in a kept under human care black capuchin monkey (Sapajus nigritus., Goldfuss 1809) with necrotizing encephalitis.

A senile male black capuchin monkey (Sapajus nigritus) kept under human care in a Zoo was found dead after 2 weeks presenting signals of weight loss and hyporexia. Histopathological revealed a necrotizing encephalitis. Although it was not observed microscopically, Sarcocystis sp infection was detected in brain tissue from molecular assays. These infections have been rarely described in neotropical primates, particularly associated with tissue lesions.

Radiologic and computed tomography evaluation of the beaks from three bird species.

This study aimed to evaluate the beaks of three species of birds using radiography and computed tomography (CT). The mean lengths of maxillary and mandibular rostra on radiographs were highest for toco toucan, followed by buff-necked ibis, and least for red-legged seriema birds. The height and width of maxillary and mandibular rostra measured on CT had mean values highest for toco toucans, followed by red-legged seriema, and least for buff-necked ibis. Except for the proximal region of the maxillary rostrum, the HU values were positive for other regions of the maxillary and mandibular rostra in the buff-necked ibis and red-legged seriema and negative in all for the toco toucan.

Stress Load and Ascending Aortic Aneurysms: An Observational, Longitudinal, Single-Center Study Using Computational Fluid Dynamics.

Ascending aortic aneurysm (AAoA) is a silent disease with high mortality; however, the factors associated with a worse prognosis are not completely understood. The objective of this observational, longitudinal, single-center study was to identify the hemodynamic patterns and their influence on AAoA growth using computational fluid dynamics (CFD), focusing on the effects of geometrical variations on aortic hemodynamics. Personalized anatomic models were obtained from angiotomography scans of 30 patients in two different years (with intervals of one to three years between them), of which 16 (53%) showed aneurysm growth (defined as an increase in the ascending aorta volume by 5% or more). Numerically determined velocity and pressure fields were compared with the outcome of aneurysm growth. Through a statistical analysis, hemodynamic characteristics were found to be associated with aneurysm growth: average and maximum high pressure (superior to 100 Pa); average and maximum high wall shear stress (superior to 7 Pa) combined with high pressure (>100 Pa); and stress load over time (maximum pressure multiplied by the time interval between the exams). This study provides insights into a worse prognosis of this serious disease and may collaborate for the expansion of knowledge about mechanobiology in the progression of AAoA.

Combined use of body condition score, radiography, ultrasonography and computed tomography in body condition evaluation of crab-eating fox (Cerdocyon thous).

This study aimed to evaluate the application of radiography, ultrasonography, and computed tomography (CT) as auxiliaries in the determination of body fat and musculature in crab-eating foxes (Cerdocyon thous). Eight animals were evaluated and classified based on the body condition score (BCS) scale. The total cut volume, total visceral volume, total subcutaneous volume, visceral fat volume, subcutaneous fat volume, and total fat volume were measured. The correlation of the BCS with the other data was determined. In the ultrasound, there was a correlation of the vertebral epaxial musculature score (VEMS) with body weight, BCS, muscle mass score (MMS), animal's height, and height at the withers. In the radiographic analysis, the amount of subcutaneous fat obtained in L3 vertebrae did not present a significant correlation with BCS, as opposed to L6. In the tomographic analysis, TFV/L6, VFV/L6, and SFV/L6 correlated with BCS in L3, and only SFV /L6 in L6. When the ratios between fat volumes were correlated, the correlation with BCS occurred only in L6 in the TFV/TBV, SFV/SVC, and VFW variants. Radiography and CT were effective and had a good association with BCS. With the CT it was possible to demonstrate the distribution of total fat at the level of the L3 slice. The ratio of calculations considering the length of the L6 vertebra was more adequate, while at the level of L6 the ratio between the volumes of the compartments was more effective.

Impact of the immune profiles of hypertensive patients with and without obesity on COVID-19 severity.

BACKGROUND: Comorbidities such as obesity, hypertension, and diabetes are associated with COVID-19 development and severity, probably due to immune dysregulation; however, the mechanisms underlying these associations are not clear. The immune signatures of hypertensive patients with obesity with COVID-19 may provide new insight into the mechanisms of immune dysregulation and progression to severe disease in these patients. METHODS: Hypertensive patients were selected prospectively from a multicenter registry of adults hospitalized with COVID-19 and stratified according to obesity (BMI ≥ 30 kg/m²). Clinical data including baseline characteristics, complications, treatment, and 46 immune markers were compared between groups. Logistic regression was performed to identify variables associated with the risk of COVID-19 progression in each group. RESULTS: The sample comprised 213 patients (89 with and 124 without obesity). The clinical profiles of patients with and without obesity differed, suggesting potential interactions with COVID-19 severity. Relative to patients without obesity, patients with obesity were younger and fewer had cardiac disease and myocardial injury. Patients with obesity had higher EGF, GCSF, GMCSF, interleukin (IL)-1ra, IL-5, IL-7, IL-8, IL-15, IL-1ß, MCP 1, and VEGF levels, total lymphocyte counts, and CD8+ CD38+ mean fluorescence intensity (MFI), and lower NK-NKG2A MFI and percentage of CD8+ CD38+ T cells. Significant correlations between cytokine and immune cell expression were observed in both groups. Five variables best predicted progression to severe COVID-19 in patients with obesity: diabetes, the EGF, IL-10, and IL-13 levels, and the percentage of CD8+ HLA-DR+ CD38+ cells. Three variables were predictive for patients without obesity: myocardial injury and the percentages of B lymphocytes and HLA-DR+ CD38+ cells. CONCLUSION: Our findings suggest that clinical and immune variables and obesity interact synergistically to increase the COVID-19 progression risk. The immune signatures of hypertensive patients with and without obesity severe COVID-19 highlight differences in immune dysregulation mechanisms, with potential therapeutic applications.

Espiritualidade e religiosidade na prática médica em um hospital universitário / Spirituality and religiosity in medical practice at a university hospital / Espiritualidad y religiosidad en la práctica médica en un hospital universitario

Resumo A religiosidade e a espiritualidade desempenham papéis cruciais na medicina, especialmente na abordagem centrada no paciente, melhorando a relação médico-paciente. Apesar disso, muitos médicos ainda subutilizam esses recursos, muitas vezes devido a insegurança ao lidar com a esfera pessoal da vida dos pacientes. Para abordar essa questão, conduziu-se pesquisa com 128 médicos, incluindo residentes, em um hospital universitário de Minas Gerais, entre agosto e dezembro de 2021, mediante aplicação dos questionários Inventário de Religiosidade de Duke e Escala Multidimensional de Reatividade Interpessoal, além de questões levantadas em estudos anteriores sobre saúde e espiritualidade. Com isso, buscou-se avaliar de que forma profissionais percebem a importância da religiosidade e da espiritualidade na prática clínica e sua relação com posturas éticas e humanistas. Os resultados revelaram correlação significativa entre as duas escalas, indicando associação positiva entre religiosidade e espiritualidade e empatia.

Abstract Religiosity and spirituality are pivotal in medical practice, particularly in fostering a patient-centered approach that enhances the physician-patient relationship. Despite this, many physicians still underutilize these invaluable resources, often due to feelings of uncertainty when navigating the personal aspects of patients' lives. To address this challenge, a survey involving 128 physicians, including residents, was conducted at a university hospital in Minas Gerais between August and December 2021. Utilizing the Duke Religiosity Inventory and Multidimensional Interpersonal Reactivity Scale questionnaires, alongside inquiries drawn from prior studies on health and spirituality, the goal was to assess professionals' perceptions of the significance of religiosity and spirituality in clinical practice and their interplay with ethical and humanistic attitudes. The findings unveiled a significant correlation between the two scales, underscoring a positive connection between religiosity, spirituality, and empathy.

Resumen La religiosidad y la espiritualidad desempeñan un papel clave en la medicina, especialmente en el enfoque centrado en el paciente al mejorar la relación médico-paciente. Muchos médicos aún no utilizan este recurso, debido a la inseguridad a menudo de enfrentar la vida personal de los pacientes. En este estudio se aplicó a 128 médicos y residentes de un hospital universitario de Minas Gerais (Brasil) los cuestionarios Índice de Religiosidad de Duke y Índice de Reactividad Interpersonal Multidimensional entre agosto y diciembre de 2021, así como preguntas planteadas en estudios anteriores sobre salud y espiritualidad. Se pretendió evaluar la percepción de los profesionales sobre la importancia de la religiosidad y la espiritualidad en la práctica clínica y su relación con las actitudes éticas y humanistas. Los resultados revelaron una correlación significativa entre las dos escalas, lo que indica una asociación positiva entre la religiosidad y espiritualidad y la empatía.

How Cardiac Fibrosis Assessed via T1 Mapping Is Associated with Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease.

(1) Background: Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases worldwide. Although cardiovascular and NAFLD risk factors overlap, an independent association between these conditions may exist. Hepatic and cardiac fibrosis are important markers of mortality, but the correlation between these markers in patients with NAFLD has not been well studied. Our main objective was to determine the degree of myocardial fibrosis in patients with NAFLD and its correlation with the severity of liver fibrosis. (2) Methods: In this cross-sectional study, patients with NAFLD were allocated to two groups according to the stage of liver fibrosis assessed using MRI: no or mild fibrosis (F0-F1) and significant fibrosis (F2-F4). Framingham risk scores were calculated to evaluate cardiovascular risk factors, and patients underwent multiparametric cardiac and abdominal MRIs. (3) Results: The sample comprised 44 patients (28 with no or mild liver fibrosis and 16 with significant liver fibrosis). The mean age was 57.9 ± 12 years, and 41% were men. Most patients had high cardiac risk factors and carotid disease. Relative to patients with no or mild liver fibrosis, those with significant fibrosis had a higher median calcium score (p = 0.05) and increased myocardial extracellular volume (ECV; p = 0.02). Liver fibrosis correlated with cardiac fibrosis, represented by the ECV (r = 0.49, p < 0.001). The myocardial ECV differentiated patients with and without significant liver fibrosis (AUC = 0.78). (4) Conclusion: This study showed that diffuse myocardial fibrosis is associated with liver fibrosis in patients with NAFLD.

Hypoglycaemia management with a hypercaloric supplementation in neonatal puppies delivered by caesarean section.

There is a high perinatal mortality rate in dogs, estimated at 20%, and one of the leading causes of this rate is hypoglycaemia. Therefore, we aimed to evaluate the efficacy of a hypercaloric supplement containing vitamins and amino acids in newborn puppies presenting hypoglycaemia at birth. Ninety-nine pups were divided into four groups: normoglycaemic caesarean section (NORMOCS), hypoglycaemic caesarean section supplemented with the hypercaloric (SUPLCS), hypoglycaemic caesarean section supplemented with glucose (GLICCS) and eutocic delivery (EUT). We evaluated the following parameters glycaemia, Apgar score, neurological reflexes and rectal temperature of neonates at the following moments 5 min (M5), 30 min (M30) and 60 min (M60) after birth. Brachycephalic dogs were 73.3% (22/30) of caesarean sections (c-sections). The puppy's average glycaemia represented about 90% of the maternal glycaemia, while 15.1% (14/99) of the neonates had hypoglycaemia (<90 mg/dL) at M0 and 46.5% (44/99) at M60. Only four neonates had glycaemia below 40 mg/dL at M30 but without showing any clinical signs. The puppy's fasting while waiting for the intraoperative period and the dam's anaesthetic recovery was considered risk factors for hypoglycaemia. There was no difference in mean blood glucose levels or vitality parameters among puppies from the SUPLCS and GLICCS. In conclusion, the hypercaloric supplement can be used as a replacement for glucose in hypoglycaemic puppies and it can also bring nutritional benefits for the puppy. The prepartum glycaemia of the dam is an important parameter to be measured, and the appropriate management of it reduces the chances of the puppies being born with hypoglycaemia.

Morphology of the syrinx of three species of birds from Brazilian cerrado (Psittacara leucophthalmus, Rhynchotus rufescens and Cariama cristata): Gross anatomy and light microscopy study.

The aim of this study was to describe the morphology of the trachea and syrinx at macroscopic and light microscopy levels of three species of birds from different orders that inhabit the Brazilian cerrado. For that, five adult specimens (three males and two females of each species) of white-eyed parakeet (Psittacara leucophthalmus), red-winged tinamou (Rhynchotus rufescens) and red-legged seriema (Cariama cristata) were used. The trachea and syrinx of the birds were collected and destined for anatomical and histological studies. The trachea of the studied birds presented an elongated path and originated in the larynx and extended caudally to the syrinx. No sexual dimorphism was observed in the syrinx of the studied species, probably because it is associated with their song, which is very similar between males and females of these species. The findings of this study allowed us to classify the syrinx as tracheal in the white-eyed parakeet and tracheobronchial in the red-winged tinamou and red-legged seriema. In general, the morphological features of the trachea and syrinx were similar to those described for other species of birds, such as the presence of intrinsic and extrinsic syringeal muscles, and the lateral and medial tympaniform membranes, which would represent important anatomical structures in sound production through vibration during expiration and eventual inspiration. The morphological structure of the syrinx in the three avian species of the Brazilian cerrado is consistent with the ability of these avian species to perform a potential vocalization, especially the red-legged seriema that emits characteristic sounds very loud and can carry several kilometres.

New Insights on the Mechanisms of Myocardial Injury in Hypertensive Patients With COVID-19.

PURPOSE: Myocardial injury is common in hypertensive patients with 2019 coronavirus disease (COVID-19). Immune dysregulation could be associated to cardiac injury in these patients, but the underlying mechanism has not been fully elucidated. METHODS: All patients were selected prospectively from a multicenter registry of adults hospitalized with confirmed COVID-19. Cases had hypertension and myocardial injury, defined by troponin levels above the 99th percentile upper reference limit, and controls were hypertensive patients with no myocardial injury. Biomarkers and immune cell subsets were quantified and compared between the two groups. A multiple logistic regression model was used to analyze the associations of clinical and immune variables with myocardial injury. RESULTS: The sample comprised 193 patients divided into two groups: 47 cases and 146 controls. Relative to controls, cases had lower total lymphocyte count, percentage of T lymphocytes, CD8+CD38+ mean fluorescence intensity (MFI), and percentage of CD8+ human leukocyte antigen DR isotope (HLA-DR)+ CD38-cells and higher percentage of natural killer lymphocytes, natural killer group 2A (NKG2A)+ MFI, percentage of CD8+CD38+cells, CD8+HLA-DR+MFI, CD8+NKG2A+MFI, and percentage of CD8+HLA-DR-CD38+cells. On multivariate regression, the CD8+HLA-DR+MFI, CD8+CD38+MFI, and total lymphocyte count were associated significantly with myocardial injury. CONCLUSION: Our findings suggest that lymphopenia, CD8+CD38+MFI, and CD8+HLA-DR+MFI are immune biomarkers of myocardial injury in hypertensive patients with COVID-19. The immune signature described here may aid in understanding the mechanisms underlying myocardial injury in these patients. The study data might open a new window for improvement in the treatment of hypertensive patients with COVID-19 and myocardial injury.

Autonomic denervation, myocardial hypoperfusion and fibrosis may predict ventricular arrhythmia in the early stages of Chagas cardiomyopathy.

BACKGROUND: Sudden cardiac death (SCD) can be the first clinical event of Chagas heart disease (CHD). However, current guidelines contain no clear recommendation for early cardioverter-defibrillator implantation. Using imaging modalities, we evaluated associations among autonomic denervation, myocardial hypoperfusion, fibrosis and ventricular arrhythmia in CHD. METHODS AND RESULTS: Twenty-nine patients with CHD and preserved left ventricular function underwent 123I-metaiodobenzylguanidine (MIBG) scintigraphy, 99mTc-methoxyisobutylisonitrile (MIBI) myocardial perfusion and cardiac magnetic resonance imaging (MRI). They were divided into arrhythmic (≥ 6 ventricular premature complexes/h and/or non-sustained ventricular tachycardia on 24-hour Holter, n = 15) and non-arrhythmic (< 6 ventricular premature complexes/h and no ventricular tachycardia; n = 14) groups. The arrhythmic group had higher denervation scores from MIBG imaging (23.2 ± 18.7 vs 5.6 ± 4.9; P < .01), hypoperfusion scores from MIBI SPECT (4.7 ± 6.8 vs 0.29 ± 0.6: P = .02), innervation/perfusion mismatch scores (18.5 ± 17.5 vs 5.4 ± 4.8; P = .01) and fibrosis by late gadolinium enhancement on MRI (14.3% ± 13.5% vs 4.0% ± 2.9%; P = .04) than the non-arrhythmic group. CONCLUSION: These imaging parameters were associated with ventricular arrhythmia in early CHD and may enable risk stratification and the implementation of primary preventive strategies for SCD.

Two Types of Management for the Noninvasive Treatment of Pectus Excavatum in Neonatal Puppies-Case Reports.

Pectus excavatum is a deformity of the thorax characterized by ventrodorsal narrowing of the sternum bone and costal cartilages, which can lead to compression and cardiopulmonary alterations in dogs, presenting a high prevalence in brachycephalic breeds. The aim of this report was to describe two types of management for the noninvasive treatment of pectus excavatum in newborn puppies of the breeds French Bulldog and American Bully. The puppies presented dyspnea, cyanosis and substernal retraction during inspiration. The diagnosis was performed by physical examination and confirmed by chest X-ray. Two types of splints were performed (a circular splint with plastic pipe and a paper box splint on the chest), aiming at thoracic lateral compression and frontal chest remodeling. The management was effective for the conservative treatment of mild-grade pectus excavatum, resulting in the repositioning of the thorax and improvement of the respiratory pattern.

Perfil epidemiológico dos casos de neoplasias pulmonares durante a pandemia da COVID-19 no Brasil / Epidemiological profile of lung cancer cases during the COVID-19 pandemic in Brazil

Objetivo: analisar o perfil epidemiológico dos casos de neoplasia do sistema respiratório que foram diagnosticados e tratados nos anos de 2017 a 2019 e comparar com os casos ocorridos durante a pandemia da COVID-19 no Brasil. Método: estudo transversal com dados de neoplasia maligna da traqueia, dos brônquios e dos pulmões fornecidos pelo Departamento de Informática do Sistema Único de Saúde. Os casos foram coletados e analisados conforme a modalidade terapêutica e o sexo, por meio da incidência anual para cada região brasileira, comparando-se o período da pandemia e os anos de 2017, 2018 e 2019. Resultados: durante a pandemia, nos casos de neoplasias do sistema respiratório, que acometeram o sexo masculino, foram observadas reduções da realização de procedimentos terapêuticos em todas as regiões brasileiras, notando-se, principalmente, diminuições de 68,22%, 19,58% e 57,24% dos casos tratados com cirurgias, quimioterapia e radioterapia na Região Nordeste. Nos casos de neoplasias que acometeram o sexo feminino, foram detectados aumentos de cirurgias e reduções de radioterapia em todas as regiões federativas, notando-se, principalmente, um aumento de 64,03% e uma redução de 59,73%, respectivamente, dos casos tratados com cirurgia no Centro-Oeste e com radioterapia no Sudeste. Conclusão: o remanejamento dos tratamentos está correlacionado aos aumentos e às reduções dos casos tratados de neoplasias do sistema respiratório. Nesse contexto, os serviços de saúde devem adotar medidas para reduzir a exposição e a contaminação dos indivíduos com a COVID-19, de modo que os tratamentos oncológicos não sejam afetados, e evitar desfechos graves.

Objective: to analyze the epidemiological profile of cases of neoplasms of the respiratory system, which were diagnosed and treated in the years 2017 to 2019, and to compare with the cases that occurred during the COVID-19 pandemic in Brazil. Method: a cross-sectional study with data on the malignant neoplasm of the trachea, bronchi, and lungs provided by the Department of Informatics of the Unified Health System. The cases were collected and analyzed according to the therapeutic modality and sex through the annual incidence for each Brazilian region, comparing the period of the pandemic and the years 2017, 2018, and 2019. Results: during the pandemic, cases of respiratory system neoplasms that affected males and reductions in the performance of therapeutic procedures were observed in all Brazilian regions, noting mainly, decreases of 68.22%, 19.58%, and 57.24% of cases treated with surgeries, chemotherapy, and radiotherapy in the Northeast region. In the cases of neoplasms that affected females, increases in surgeries and reductions in radiotherapy were detected in all federative regions, noting, mainly, an increase of 64.03% and a reduction of 59.73%, respectively, of the cases treated with surgery in the Midwest and with radiotherapy in the Southeast. Conclusion: the relocation of treatments is correlated with increases and decreases in cases of treated respiratory system neoplasms. In this context, health services must adopt measures to reduce the exposure and contamination of individuals with COVID-19 so that cancer treatments are not affected and avoid serious outcomes.

Troponin in COVID-19: To Measure or Not to Measure? Insights from a Prospective Cohort Study.

Myocardial injury (MI), defined by troponin elevation, has been associated with increased mortality and adverse outcomes in patients with coronavirus disease 2019 (COVID-19), but the role of this biomarker as a risk predictor remains unclear. Data from adult patients hospitalized with COVID-19 were recorded prospectively. A multiple logistic regression model was used to quantify associations of all variables with in-hospital mortality, including the calculation of odds ratios (ORs) and confidence intervals (CI). Troponin measurement was performed in 1476 of 4628 included patients, and MI was detected in 353 patients, with a prevalence of 23.9%; [95% CI, 21.8-26.1%]. The total in-hospital mortality rate was 10.9% [95% CI, 9.8-12.0%]. The mortality was much higher among patients with MI than among those without MI, with a prevalence of 22.7% [95% CI, 18.5-27.3%] vs. 5.5% [95% CI, 4.3-7.0%] and increased with each troponin level. After adjustment for age and comorbidities, the model revealed that the mortality risk was greater for patients with MI [OR = 2.99; 95% CI, 2.06-4.36%], and for those who did not undergo troponin measurement [OR = 2.2; 95% CI, 1.62-2.97%], compared to those without MI. Our data support the role of troponin as an important risk predictor for these patients, capable of discriminating between those with a low or increased mortality rate. In addition, our findings suggest that this biomarker has a remarkable negative predictive value in COVID-19.

Analysis of Three-Dimensional Scar Architecture and Conducting Channels by High-Resolution Contrast-Enhanced Cardiac Magnetic Resonance Imaging in Chagas Heart Disease.

BACKGROUND: We aimed to describe the morphology of the border zone of viable myocardium surrounded by scarring in patients with Chagas heart disease and study their association with clinical events. METHODS: Adult patients with Chagas heart disease (n=22; 55% females; 65.5 years, SD 10.1) were included. Patients underwent high-resolution contrast-enhanced cardiac magnetic resonance using myocardial delayed enhancement with postprocessing analysis to identify the core scar area and border zone channels number, mass, and length. The association between border zone channel parameters and the combined end-point (cardiovascular mortality or internal cardiac defibrillator implantation) was tested by multivariable Cox proportional hazard regression analyses. The significance level was set at 0.05. Data are presented as the mean (standard deviation [SD]) or median (interquartile range). RESULTS: A total of 44 border zone channels (1[1-3] per patient) were identified. The border zone channel mass per patient was 1.25 (0.48-4.39) g, and the extension in layers of the border zone channels per patient was 2.4 (1.0-4.25). Most border zone channels were identified in the midwall location. Six patients presented the studied end-point during a mean follow-up of 4.9 years (SD 1.6). Border zone channel extension in layers was associated with the studied end-point independent from left ventricular ejection fraction or fibrosis mass (HR=2.03; 95% CI 1.15-3.60). CONCLUSIONS: High-resolution contrast-enhanced cardiac magnetic resonance can identify border zone channels in patients with Chagas heart disease. Moreover, border zone channel extension was independently associated with clinical events.

Análise da Custo-Efetividade da Angiotomografia Coronariana no SUS, em Comparação com Outros Métodos Não Invasivos na Suspeita de DAC Estável / Cost-Effectiveness Analysis of CCTA in SUS, as Compared to Other Non-Invasive Imaging Modalities in Suspected Obstructive CAD

Resumo Fundamento Atualmente o sistema de saúde público brasileiro (SUS) não contempla a angiotomografia de coronárias. Objetivos Ranquear sob a perspectiva do SUS, a custo-efetividade de estratégias diagnósticas combinando teste ergométrico, cintilografia miocárdica, ecocardiograma por estresse e angiotomografia de coronárias para o diagnóstico de doença arterial coronariana em uma coorte hipotética de pacientes com probabilidade pré-teste intermediária. Métodos Análise de custo-efetividade por meio de árvore de decisão. Foram analisados a relação de custo-efetividade incremental e o benefício líquido em saúde das estratégias diagnósticas, com a adoção de múltiplos limiares de disposição a pagar entre 0,05 e 1 PIB per capita por diagnóstico correto. Nos casos de testes sequenciais, um segundo teste confirmatório era realizado quando o primeiro fosse positivo. Resultados Após exclusão das estratégias diagnósticas dominadas ou com dominância estendida, a fronteira de eficiência foi composta por três estratégias: teste ergométrico, teste ergométrico seguido de ecocardiograma de estresse, e ecocardiograma de estresse seguido de angiotomografia de coronárias, sendo esta última a estratégia mais custo-efetiva. Pelo critério do benefício líquido, o ranqueamento das estratégias mais custo-efetivas variou conforme a disposição a pagar. Conclusão Utilizando conceitos atuais de avaliação de tecnologias em saúde, este estudo fornece um ranqueamento para a tomada de decisão sobre qual estratégia diagnóstica utilizar, em uma população com risco pré-teste intermediário para DAC. Com estimativa factível de custos para a ATC, o impacto da inclusão desta ao rol do arsenal diagnóstico representaria uma estratégia custo-efetiva na maioria dos cenários avaliados nas variações de disposição a pagar.

Abstract Background The Brazilian public health system does not include computed tomography angiography (CTA). Objective Rank, according to the Brazilian public health system, the cost-effectiveness of different strategies for the diagnosis of coronary artery disease (CAD), combining exercise tests (ET), myocardial scintigraphy (MS), stress echocardiography (SE), and CTA in a hypothetical intermediate pre-test probability cohort of patients. Methods This study implemented a cost-effectiveness analysis through a decision tree. The incremental cost-effectiveness ratio (ICER) and net benefit were analyzed by adopting multiple thresholds of willingness to pay, from 0.05 to 1 GDP per capita per correct diagnosis. In sequential tests, a second confirmatory test was performed only when the first was positive. Results After excluding dominated or extended dominance diagnostic strategies, the efficiency frontier consisted of three strategies: ET, ET followed by SE, and SE followed by CTA, the last being the most cost-effective strategy. Through the net benefit, the ranking of the most cost-effective strategies varied according to willingness to pay. Conclusions Using current concepts of health technology assessment, this study provides a ranking for decision-making concerning which diagnostic strategy to use in a population with an intermediate pre-test risk for CAD. With a feasible cost estimate adopted for CTA, the impact of including this to the list of the diagnostic arsenal would represent a cost-effective strategy in most of the evaluated scenarios with broad variations in the willingness to pay.

Cost-Effectiveness Analysis of CCTA in SUS, as Compared to Other Non-Invasive Imaging Modalities in Suspected Obstructive CAD. / Análise da Custo-Efetividade da Angiotomografia Coronariana no SUS, em Comparação com Outros Métodos Não Invasivos na Suspeita de DAC Estável.

BACKGROUND: The Brazilian public health system does not include computed tomography angiography (CTA). OBJECTIVE: Rank, according to the Brazilian public health system, the cost-effectiveness of different strategies for the diagnosis of coronary artery disease (CAD), combining exercise tests (ET), myocardial scintigraphy (MS), stress echocardiography (SE), and CTA in a hypothetical intermediate pre-test probability cohort of patients. METHODS: This study implemented a cost-effectiveness analysis through a decision tree. The incremental cost-effectiveness ratio (ICER) and net benefit were analyzed by adopting multiple thresholds of willingness to pay, from 0.05 to 1 GDP per capita per correct diagnosis. In sequential tests, a second confirmatory test was performed only when the first was positive. RESULTS: After excluding dominated or extended dominance diagnostic strategies, the efficiency frontier consisted of three strategies: ET, ET followed by SE, and SE followed by CTA, the last being the most cost-effective strategy. Through the net benefit, the ranking of the most cost-effective strategies varied according to willingness to pay. CONCLUSIONS: Using current concepts of health technology assessment, this study provides a ranking for decision-making concerning which diagnostic strategy to use in a population with an intermediate pre-test risk for CAD. With a feasible cost estimate adopted for CTA, the impact of including this to the list of the diagnostic arsenal would represent a cost-effective strategy in most of the evaluated scenarios with broad variations in the willingness to pay.

FUNDAMENTO: Atualmente o sistema de saúde público brasileiro (SUS) não contempla a angiotomografia de coronárias. OBJETIVOS: Ranquear sob a perspectiva do SUS, a custo-efetividade de estratégias diagnósticas combinando teste ergométrico, cintilografia miocárdica, ecocardiograma por estresse e angiotomografia de coronárias para o diagnóstico de doença arterial coronariana em uma coorte hipotética de pacientes com probabilidade pré-teste intermediária. MÉTODOS: Análise de custo-efetividade por meio de árvore de decisão. Foram analisados a relação de custo-efetividade incremental e o benefício líquido em saúde das estratégias diagnósticas, com a adoção de múltiplos limiares de disposição a pagar entre 0,05 e 1 PIB per capita por diagnóstico correto. Nos casos de testes sequenciais, um segundo teste confirmatório era realizado quando o primeiro fosse positivo. RESULTADOS: Após exclusão das estratégias diagnósticas dominadas ou com dominância estendida, a fronteira de eficiência foi composta por três estratégias: teste ergométrico, teste ergométrico seguido de ecocardiograma de estresse, e ecocardiograma de estresse seguido de angiotomografia de coronárias, sendo esta última a estratégia mais custo-efetiva. Pelo critério do benefício líquido, o ranqueamento das estratégias mais custo-efetivas variou conforme a disposição a pagar. CONCLUSÃO: Utilizando conceitos atuais de avaliação de tecnologias em saúde, este estudo fornece um ranqueamento para a tomada de decisão sobre qual estratégia diagnóstica utilizar, em uma população com risco pré-teste intermediário para DAC. Com estimativa factível de custos para a ATC, o impacto da inclusão desta ao rol do arsenal diagnóstico representaria uma estratégia custo-efetiva na maioria dos cenários avaliados nas variações de disposição a pagar.