Cyclical iron supplementation to reduce anemia among Brazilian preschoolers: a randomized controlled trial.

BACKGROUND: Iron-deficiency anemia is the most common type of nutritional disorder. New strategies for the treatment of anemia are very important for its reduction. The aim of this study was to assess the efficacy and feasibility of cyclical iron supplementation as a strategy to reduce the prevalence of anemia among preschoolers. METHODS: A randomized controlled trial was performed in the entire population of under five-year-old children who attended government daycare centers in a small town in the State of Sao Paulo, Brazil. The children were randomly allocated into two intervention groups: the Weekly and Cyclical Groups. During a ten-month period, the Weekly Group (n = 51) received weekly doses of 30 mg elemental iron (40 doses) and the Cyclical Group (n = 48) received two cycles of 20 daily doses of 30 mg elemental iron separated by a four-month period (40 doses). RESULTS: Overall, at the end of ten months, the prevalence of anemia of the children on both supplementation regimens showed a significant decrease from 20.20% to 5.05% (p-value < 0.0005). There was no significant difference in the anemia between the two groups (p-value = 0.35). The mean hemoglobin concentration increased by 0.27 g/dL (p-value < 0.016) and 0.47 g/dL (p-value < 0.0005) in the Weekly and Cyclical Groups, respectively; again there was no significant difference between groups (p-value = 0.17). However, the cyclical regimen was easier to manage. CONCLUSIONS: Both supplementation regimens significantly reduced the prevalence of anemia however administration of the Cyclical Group was easier to carry out and control. CLINICAL TRIAL REGISTRATION NUMBER: NCT00992823.

Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients.

BACKGROUND: Prediction of perioperative cardiac complications is important in the medical management of patients undergoing noncardiac surgery. However, these patients frequently die as a consequence of primary or secondary multiple organ failure (MOF), often as a result of sepsis. We investigated the early perioperative risk factors for in-hospital death due to MOF in surgical patients. METHODS: This was a prospective, multicenter, observational cohort study performed in 21 Brazilian intensive care units (ICUs). Adult patients undergoing noncardiac surgery who were admitted to the ICU within 24 hours after operation were evaluated. MOF was characterized by the presence of at least 2 organ failures. To determine the relative risk (RR) of in-hospital death due to MOF, we performed a logistic regression multivariate analysis. RESULTS: A total of 587 patients were included (mean age, 62.4 ± 17 years). ICU and hospital mortality rates were 15% and 20.6%, respectively. The main cause of death was MOF (53%). Peritonitis (RR 4.17, 95% confidence interval [CI] 1.38-12.6), diabetes (RR 3.63, 95% CI 1.17-11.2), unplanned surgery (RR 3.62, 95% CI 1.18-11.0), age (RR 1.04, 95% CI 1 0.01-1.08), and elevated serum lactate concentrations (RR 1.52, 95% CI 1.14-2.02), a high central venous pressure (RR 1.12, 95% CI 1.04-1.22), a fast heart rate (RR 3.63, 95% CI 1.17-11.2) and pH (RR 0.04, 95% CI 0.0005-0.38) on the day of admission were independent predictors of death due to MOF. CONCLUSIONS: MOF is the main cause of death after surgery in high-risk patients. Awareness of the risk factors for death due to MOF may be important in risk stratification and can suggest routes for therapy.

BWDAT: A research tool for analyzing the consumption of VOD content at home.

INTRODUCTION: New approaches to the study of the binge-watching phenomenon require new technology, leading to the development of a non-intrusive and low-cost analytical research software that facilitates a holistic understanding of binge-watching in an uncontrolled environment remotely (e.g., the home). BWDAT was developed to allow the collection of three types of data: users' physiological data gathered from a smartwatch, users' interactions from video-on-demand interfaces, and self-reported data. This tool offers the possibility to generate automatic data analysis reports, facilitating researchers' data analysis tasks. METHODS: Two trial studies and a long-term study were used to evaluate the design and the technical implementation of the BWDAT tool. The metrics used were the BWDAT smartwatch's App data coverage of the viewing sessions, and the data's reliability of the viewer's interactions with the Netflix interface, collected by the BWDAT Chrome Extension. RESULTS: High percentages of data coverage and content coverage were verified in the sessions collecting the smartwatch's data. The reporting system developed proved to be useful in the collection and synchronization of physiological and users' interaction data with Netflix interface, both generated in uncontrolled environments. Furthermore, the BWDAT tool facilitated the analysis of a large amount of nuanced data. CONCLUSION: The results obtained confirm the reliability, accuracy, and usability of BWDAT. This tool has the potential to help researchers shed new light on the field of media and audience studies, and in particular on binge-watching.

Prevalence and risk factors for acute kidney injury associated with parenteral polymyxin B use.

BACKGROUND: The main adverse effect of polymyxin B is nephrotoxicity. There are few data on polymyxin-associated renal injury. OBJECTIVE: To assess the prevalence of and risk factors for acute kidney injury (AKI) in patients treated with polymyxin B. METHODS: The studied population included 114 patients who received at least 3 consecutive days of intravenous polymyxin B and had baseline serum creatinine (SCr) and at least one further SCr measurement during treatment. AKI was defined as an SCr increase to 1.8 mg/dL or greater in patients with baseline SCr less than 1.5 mg/dL, or an increase greater than or equal to 50% in baseline SCr when it was already greater than or equal to 1.5 mg/dL, or need for dialysis. RESULTS: AKI developed in 22% of the patients. They were older, had a higher baseline SCr, had a higher frequency of baseline SCr greater than or equal to 1.5 mg/dL, used other nephrotoxic drugs and furosemide more often, and required vasoactive drugs and mechanical ventilation more frequently. Progression to renal failure was significantly more probable when the bacteria were isolated in the abdomen, catheter, or blood. AKI patients had a higher mortality rate (92% vs 53%; p < 0.001). Logistic regression identified abnormal baseline SCr (odds ratio [OR] 3.51); need for vasoactive drugs (OR 3.03); and abdomen, blood, or catheter as the infection site (OR 3.82) as independent risk factors for AKI. CONCLUSIONS: Patients who developed AKI had a strikingly elevated mortality rate. Polymyxin B should be used with extreme caution in patients who have an abnormal baseline SCr; use vasoactive drugs; or have abdomen, blood, or catheter as the infection site.

Predictors of all-cause mortality for patients with chronic Chagas' heart disease receiving implantable cardioverter defibrillator therapy.

BACKGROUND: Implantable Cardioverter Defibrillators (ICD) have sporadically been used in the treatment of either Sustained Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF) in Chagas' disease patients. This study aimed at determining predictors of all-cause mortality for Chagas' disease patients receiving ICD therapy. METHODS AND RESULTS: Ninety consecutive patients were entered the study. Mean left ventricular ejection fraction was 47 +/- 13%. Twenty-five (28%) patients had no left ventricular systolic dysfunction. After device implantation, all patients were given amiodarone (mean daily dose = 331, 1 +/- 153,3 mg), whereas a B-Blocking agent was given to 37 (40%) out of 90 patients. RESULTS: A total of 4,274 arrhythmias were observed on stored electrogram in 64 (71%) out of 90 patients during the study period; SVT was observed in 45 out of 64 (70%) patients, and VF in 19 (30%) out of 64 patients. Twenty-six (29%) out of 90 patients had no arrhythmia. Fifty-eight (64%) out of 90 patients received appropriate shock, whereas Antitachycardia Pacing was delivered to 58 (64%) out of 90 patients. There were 31 (34%) deaths during the study period. Five patients were lost to follow up. Sudden cardiac death affected 2 (7%) out of 26 patients, whereas pump failure death was detected in the remaining 24 (93%) patients. Number of shocks per patient per 30 days was the only independent predictor of mortality. CONCLUSION: Number of shocks per patient per 30 days predicts outcome in Chagas' disease patients treated with ICD.

Methylation profile of genes CDKN2A (p14 and p16), DAPK1, CDH1, and ADAM23 in head and neck cancer.

Hypermethylation in the promoter region has been associated with a loss of gene function that may give a selective advantage to neoplastic cells. In this study, the methylation pattern of genes CDKN2A (alias p14, p14(ARF), p16, p16(INK4a)), DAPK1, CDH1, and ADAM23 was analyzed in 43 samples of head and neck tumors using methylation-specific polymerase chain reaction. In the oropharynx, there was a statistically significant association between hypermethylation of the DAPK1 gene and the occurrence of lymph node metastases, and in the larynx there was statistically significant evidence of an association between hypermethylation of the ADAM23 gene and advanced stages of the tumors. Thus, a correlation was observed between hypermethylation of the promoter region of genes DAPK1 and ADAM23 and the progression of head and neck cancer.

Switch from calcineurin inhibitors to sirolimus-induced renal recovery in heart transplant recipients in the midterm follow-up.

BACKGROUND: Calcineurin inhibitor (CI)-based immunosuppression has prolonged the survival of heart transplant recipients. However, CI-induced renal injury remains as a major problem in these patients. Sirolimus is an immunosuppressant with no significant impact on renal function. A limited number of recent papers have showed that the switch from CI to sirolimus improved renal function in late follow-up of heart transplant patients with CI-related nephrotoxicity. METHODS: Ten heart transplant recipients with CI-induced nephrotoxicity (creatinine 3.9+/-1.8 mg/dl) at a median of 701 (465 to 1325) days posttransplant had CI switched to sirolimus (target though levels 10 to 14 ng/ml) while mycophenolate mofetil (MMF, 3g/day) was maintained and adjusted according to white blood cell count. RESULTS: This maneuver caused a marked decrease in serum creatinine (P<0.00001) at 30 (1.2+/-0.4 mg/dl), 90 (1.3+/-0.4 mg/dl) and 180 (1.3+/-0.4 mg/dl) days post-conversion and a significant decrease in serum potassium levels (5.1+/-0.5 at baseline vs. 3.9+/-0.3 at 180 days, P<0.00005). After the drugs switch no changes in hemoglobin levels, white blood cell count, platelets count, blood glucose and glutamic oxaloacetic transaminase plasma levels were observed. Total cholesterol increased from 242+/-28 to 290+/-117 mg/dl (P>0.05) after 90 days and decreased to 216+/-58 mg/dl at day 180 (P>0.05) after statins dose adjustment. Rejection and infection rates were not modified by sirolimus. CONCLUSIONS: Conversion to a sirolimus-based immunosuppression regimen associated with MMF allowed striking renal function recovery in heart transplant recipients with calcineurin inhibitor-induced renal impairment at midterm follow-up.

QT interval dispersion in patients with chronic heart failure secondary to Chagas' cardiomyopathy: correlation with clinical variables of prognostic significance.

BACKGROUND: QTc interval dispersion has rarely been studied in patients with chronic heart failure (CHF) secondary to Chagas' cardiomyopathy. One study has demonstrated an association between QT interval dispersion and sudden cardiac death. No data exist regarding the association of clinical variables and QT interval dispersion in patients with this condition. METHODS: Sixty three patients with CHF due to Chagas' cardiomyopathy, 34 Chagas' disease patients with no systolic dysfunction on echocardiography, and 36 individuals with no previous cardiac history, matched by sex and a 10-year age interval, were included in the investigation. The QTc interval dispersion was defined as the difference between maximum and minimum QTc. RESULTS: The mean QTc interval dispersion was 74+/-30.3 ms in surviving and 87+/-30.6 ms in nonsurviving patients (P=.13). Mean QTc dispersion was 95.20+/-28.46 ms in patients who died from pump failure, 73.33+/-29.61 ms in patients who died suddenly, and 74.46+/-30.27 in survivors (P=.07). Mean QTc dispersion value was higher in patients in the Class III or IV (P=.01).). Mean QTc interval dispersion was 67.2+/-22.7 ms in patients with and 85.5+/-33.5 ms in patients without premature ventricular contractions (P=.01), and 67.5+/-29.8 ms in patients with and 84.7+/-31.8 ms in patients without left ventricular apical aneurysm (P=.03). A correlation could be observed in QTc interval dispersion and left atrium dimension (r=.32; P=.009) Thus, QTc interval dispersion is associated to some prognostic indicators in patients with CHF secondary to Chagas' cardiomyopathy.

Assessment of quality of life in patients with chronic heart failure secondary to Chagas' cardiomyopathy.

Quality of Life was assessed by the Minnesota Living With Heart Failure Questionnaire in 61 patients with Chronic Systolic Heart Failure secondary to Chagas' cardiomyopathy. Mean total score was 37.3+/-21.4, mean physical dimension score 15.3+/-9.9 and mean emotional dimension score 7.4+/-5.2. A negative correlation between total score and hemoglobin levels, Systolic and Diastolic Blood Pressure and the 6-Minute Walk Test were observed. Total score was higher in patients in Class IV, on amiodarone, furosemide and carvedilol, and in non-sinus rhythm patients. Quality of Life Assessment in chagasic patients is similar to that found in patients with nonchagasic heart failure.

Genetic diversity and differentiation in natural Plasmodium falciparum populations inferred by molecular typing of the merozoite surface proteins 1 and 2.

Genetic diversity and differentiation, inferred by typing the polymorphic genes coding for the merozoite surface proteins 1 (Msp-1) and 2 (Msp-2), were compared for 345 isolates belonging to seven Plasmodium falciparum populations from three continents. Both loci yielded similar estimates of genetic diversity for each population, but rather different patterns of between-population differentiation, suggesting that natural selection on these loci, rather than the transmission dynamics of P. falciparum, determines the variation in allele frequencies among populations.

Urban prevalence of epilepsy: populational study in São José do Rio Preto, a medium-sized city in Brazil.

UNLABELLED: The aim of this study was to determine the prevalence of epilepsy in the urban population of São José do Rio Preto. This is a medium-sized city of 336000 inhabitants, located in the northwest of the state of São Paulo, Brazil. METHOD: A cross-sectional epidemiological investigation with a randomized sample was performed in two phases, a screening phase and a confirmation of the diagnosis phase. The gold standard was a clinical investigation and neurological examination. The chi-square test was used in analysis of the results and p-value value < 0.05 was considered significant. Prevalence was calculated with 95% confidence interval. RESULTS: The study sample size was 17293 individuals, with distributions of gender, age, and race similar to the general population. The prevalence per 1000 inhabitants of epilepsy was 18.6, of these 8.2 were active, defined as at least one seizure within the last two years. The prevalence per 1000 inhabitants for the age groups (years) was 4.9 (04), 11.7 (514), 20.3 (1564) and 32.8 (65 or over). CONCLUSION: Prevalence of both accumulated and active epilepsy was elevated, comparable to other developing nations, in particular those of Latin America. However, the prevalence of epilepsy in childhood was low, whilst in aged individuals it was high similar to industrialized nations.

[Evaluation of the understanding level of pediatric prescription]. / Avaliação do nível de compreensão da prescrição pediátrica.

OBJECTIVE: This study intends to establish the relation between the understanding level of pediatric prescription by the mother, or other adult, accompanying the child to a doctors visit and the probable causes of noncompliance with the treatment, in order to improve the quality of pediatric health care. METHODS: We randomly interviewed one hundred adults who accompanied children to the pediatric outpatient clinic of Hospital Universitário. They received medical orientation and/or prescriptions. The interviews were made from April to October 2000 and we used a questionnaire to evaluate social, economic and cultural status. We also evaluated aspects related to the appointment and treatment, and the understanding of doctors handwriting and prescription. RESULTS: Eighty-three percent of them received a prescription and 17% received only orientation; 88% were the mothers and 63% had not finished elementary school. Concerning the appointment, 80% felt satisfied. Seventy-one percent among those who received prescriptions could understand the doctor's handwriting and 29% had some or none understanding of it. Forty-seven percent of the prescriptions had symbols and/or abbreviations that could not be understood by 59% of the adults. Seventy-one percent could remember all the prescribed drugs without looking at the prescription; 15.7% needed to read it in order to remember the drugs; 7.2% could not remember the drugs and said that a pharmacist had to help them and 6% could not remember or read the prescription. CONCLUSION: Aspects related to the poor understanding of pediatric prescriptions are caused by the low social, economic and cultural status of the adult accompanying the child; as well as aspects regarding physicians such as the use of symbols and abbreviations, illegible handwriting and verbal orientation only.

Prognostic determinants of patients with chronic systolic heart failure secondary to systemic arterial hypertension.

BACKGROUND: Systemic arterial hypertension (SAH) is an important cause of chronic systolic heart failure (CHF) in underdeveloped countries. It would be desirable to know predictors of mortality for patients with this condition in order to provide proper scientific treatment. OBJECTIVE: To determine risk factors for all-cause mortality in patients with CHF secondary to SAH in the current era of heart failure therapy for left ventricular systolic dysfunction. METHODS: All patients routinely and prospectively followed at the Cardiomyopathy Clinic of our Institution from January, 2000 to April, 2008 with the diagnosis of CHF secondary to SAH were screened for the study. Cox proportional hazards model was used to establish independent predictors of all-cause mortality. RESULTS: One hundred thirty patients were included; 74 (57%) were male. Thirty one (24%) patients died, 5 (4%) underwent heart transplantation, and 94 (72%) were alive at study end. Survival probability at 12, 24, 36, 48, and 60 months was 96%, 93%, 84%, 79%, and 76%, respectively. Age (Hazard Ratio=1,05, 95% Confidence Interval 95% 1,01 to 1,08, p value=0,01), left ventricular diastolic dimension (Hazard Ratio=1,08; 95% Confidence Interval 1,02 to 1,09; p value=0,003), and B-Blocker therapy (Hazard Ratio=0,41; 95% Confidence Interval 0,19 to 0,86; p value=0,02) were found to be independent predictors of mortality. CONCLUSION: Age, left ventricular diastolic dimension and underuse of Beta-Blocker therapy were independent predictors of mortality for patients with CHF secondary to SAH in the population studied.

Effects of B-Blockers on outcome of patients with Chagas' cardiomyopathy with chronic heart failure.

BACKGROUND: A few studies have shown a beneficial effect of B-Blocker therapy on cardiac function and functional status in patients with chronic heart failure secondary to Chagas' cardiomyopathy. METHODS: The medical charts of patients routinely followed from January, 2000 to January, 2007 were reviewed to collect clinical, standard laboratory tests, 12-lead electrocardiogram, chest X-Ray, and Doppler echochardiogram variables. A Cox proportional hazards model was used to establish independent predictors of all-cause mortality for patients with Chagas' cardiomyopathy with chronic heart failure. RESULTS: A total of 231 consecutive patients were enrolled in the study. Median follow up was 19 (7, 46) months. Twenty (9%) patients underwent heart transplantation and 120 (52%) died during the investigation. Left ventricular systolic dimension (hazard ratio=1.04; 95% confidence interval=1.02 to 1.06; p<0.005) and need of inotropic support (hazard ratio=1.80; 95% confidence interval 1.2 to 2.60; p=0,03), were positively associated, whereas B-Blocker therapy (HR=0.34; 95% confidence interval 0.23 to 0.51; p<0.0005) was negatively associated with mortality. Mortality was significantly lower in patients taking in comparison to those not taking B-Blockers. Patients taking a mean daily dose of carvedilol>or=to 9.375mg had a marked decrease in mortality in comparison to those not on carvedilol therapy. CONCLUSION: B-Blockers are effective, not detrimental, and may improve survival in Chagas' disease patients with chronic heart failure. A randomized trial is necessary to confirm these findings.

Prognostic impact of Chagas' disease in patients awaiting heart transplantation.

BACKGROUND: The role of Chagas' etiology of chronic heart failure in predicting patient outcomes while awaiting heart transplantation is unknown. Accordingly, in this study we compare outcomes in Chagas' disease with non-Chagas'-disease-related advanced heart failure among patients on the waiting list for heart transplantation. METHODS: We reviewed the clinical outcomes of 103 consecutive patients with chronic heart failure listed for heart transplantation from August 2000 to January 2008 at a single institution. Forty-six (44%) patients were diagnosed with Chagas' disease on the basis of positive serology. A Cox proportional hazards model was used to establish independent predictors of mortality, whereas competing risk analysis was used to estimate time-related prevalence of death and heart transplantation in Chagas' disease and non-Chagas' disease patients. RESULTS: In the multivariate model, inotropic support (p < 0.0005; hazard ratio = 5.96; 95% confidence interval [CI] 2.41 to 14.71) and Chagas' disease etiology of heart failure (p = 0.02; hazard ratio = 2.27; 95% CI 1.14 to 4.52) were retained as independent predictors of mortality. Prevalence of death at 100 days after listing was 30% in Chagas' disease and 16% in non-Chagas' disease patients (p = 0.02), despite no difference in the competing rates of transplantation (30% in Chagas' and 37% in non-Chagas' patients, p = 0.5). CONCLUSIONS: Chagas' disease etiology serves as an independent predictor of mortality in patients listed for heart transplantation, with a worse outcome when compared with non-Chagas' disease patients.

Epidemiology and control of frontier malaria in Brazil: lessons from community-based studies in rural Amazonia.

We describe the epidemiology of malaria in a frontier agricultural settlement in Brazilian Amazonia. We analysed the incidence of slide-confirmed symptomatic infections diagnosed between 2001 and 2006 in a cohort of 531 individuals (2281.53 person-years of follow-up) and parasite prevalence data derived from four cross-sectional surveys. Overall, the incidence rates of Plasmodium vivax and P. falciparum were 20.6/100 and 6.8/100 person-years at risk, respectively, with a marked decline in the incidence of both species (81.4 and 56.8%, respectively) observed between 2001 and 2006. PCR revealed 5.4-fold more infections than conventional microscopy in population-wide cross-sectional surveys carried out between 2004 and 2006 (average prevalence, 11.3 vs. 2.0%). Only 27.2% of PCR-positive (but 73.3% of slide-positive) individuals had symptoms when enrolled, indicating that asymptomatic carriage of low-grade parasitaemias is a common phenomenon in frontier settlements. A circular cluster comprising 22.3% of the households, all situated in the area of most recent occupation, comprised 69.1% of all malaria infections diagnosed during the follow-up, with malaria incidence decreasing exponentially with distance from the cluster centre. By targeting one-quarter of the households, with selective indoor spraying or other house-protection measures, malaria incidence could be reduced by more than two-thirds in this community.

Predictors of all-cause mortality for patients with Chagas' cardiomyopathy listed for heart transplantation.

This study sought to determine independent predictors of all-cause mortality for patients with Chagas' disease heart failure listed for heart transplantation. Need of inotropic support (p=0.01; hazard ratio=14.68, 95% Confidence Interval 1.86 to 115.82) and the Transpulmonary Gradient (p=0.02; HR=1.15, 95% Confidence Interval 1.03 to 1.30) were established independent predictors of all-cause mortality.

Evaluation of the awareness, control and cost-effectiveness of hypertension treatment in a Brazilian city: populational study.

OBJECTIVES: Hypertension is a highly prevalent disease worldwide, constituting one of the main risk factors for cardiovascular morbidity and mortality. The aims of this study were to evaluate the level of awareness and control of hypertension comparing sex, socioeconomic and educational level, BMI and drug therapy in over 40-year-old patients. The cost-effectiveness of the main pharmacologic classes of antihypertensives, as monotherapy and combination therapy, was also assessed. METHODS: In this randomized and cross-sectional populational study, a sample of 738 hypertensive adults with ages at least 40 years were evaluated. Of these, 345 (46.7%) were men and 393 (53.3%) were women. RESULTS: A total of 72.9% of the hypertensives knew about their disease. Women in the 40-49 and 50-59 age groups and obese individuals had a higher rate of awareness of their hypertensive status. The rates of awareness were similar in different social classes and educational levels, however, blood pressure control varied. beta-Blockers were the most effective drugs to control blood pressure with no differences being observed between monotherapy and combinations. Diuretics were the most cost-effective. CONCLUSION: Approximately half of the participants received monotherapy. The best percentage of control with monotherapy was obtained with beta-blockers but the diuretics treatment was the most cost-effective. The levels of awareness and control were high compared with developed countries, most evident in the higher social classes and higher education levels.