[Lifestyle modification and risk factor control in the prevention and treatment of atrial fibrillation]. / Modificaciones en el estilo de vida y control de los factores de riesgo en la prevención y el tratamiento de la fibrilación auricular.

Atrial fibrillation (AF) is the most prevalent arrhythmia and is related with significant morbidity, mortality and costs. In spite of relevant advances in the prevention of embolic events and rhythm control, little has been done to reduce its prevalence, progression and impact, since it increases with ageing as well as with common risk factors such as alcohol intake, tobacco use and stress as well as with arterial hypertension, diabetes mellitus, heart failure, sleep apnea, kidney failure, chronic pulmonary obstructive disease, ischemic heart disease and stroke, among other important comorbidities. Fortunately, new evidence suggests that lifestyle modifications and adequate risk factors and comorbidities control could be effective in primary and secondary AF prevention, especially in its paroxysmal presentations. This is why a multidisciplinary approach integrating lifestyle modifications, risk factors and comorbidities control, is necessary in conjunction with rhythm or rate control and anticoagulation. Unfortunately, that holistic approach strategy is not considered, is scarcely studied or is subtilized in general clinical practice. The present statement's objectives are to: 1) review the relationship between habits, risk factors and illnesses with AF, 2) review the individual and common physiopathology mechanisms of each one of those conditions that may lead to AF, 3) review the effect of control of habits, risk factors and co-morbidities on the control and impact of AF, and 4) supply guidelines and recommendations to start multidisciplinary and integrative AF treatment.

La fibrilación auricular (FA) es la arritmia más frecuente y se asocia con importante morbilidad, mortalidad y costos. A pesar de los grandes avances en la prevención de eventos embólicos y en el control del ritmo, poco se ha realizado para reducir su prevalencia, progresión e impacto, debido a que incrementa con la edad y con la presencia de múltiples factores de riesgo muy comunes en la población, como obesidad, sedentarismo, alcoholismo, tabaquismo y estrés, así como con hipertensión arterial sistémica, diabetes mellitus, insuficiencia cardiaca, apnea del sueño, enfermedad renal crónica, enfermedad pulmonar obstructiva crónica, cardiopatía isquémica y enfermedad vascular cerebral, entre otra comorbilidad importante. Afortunadamente, nuevas evidencias demuestran que las modificaciones en el estilo de vida y el control adecuado de los factores de riesgo y de la comorbilidad pueden ser efectivos en la prevención primaria y secundaria de la FA, en especial en sus formas paroxísticas; para ello, es necesario un manejo multidisciplinario que integre las modificaciones en el estilo de vida, el manejo de los factores de riesgo y el control de la comorbilidad en el tratamiento de la FA en conjunto con el control del ritmo o de la frecuencia y la anticoagulación. Por desgracia, en la práctica clínica estas estrategias a menudo no se tienen en cuenta, son infrautilizadas y poco estudiadas. Los objetivos del presente posicionamiento son: 1) revisar la relación de los factores de riesgo y la comorbilidad con la FA, 2) revisar los mecanismos fisiopatológicos de cada una de estas condiciones, 3) revisar el impacto del control de los factores de riesgo y de la comorbilidad en el control y en el impacto de la FA, y 4) proporcionar guías y recomendaciones para la puesta en práctica de programas de tratamiento multidisciplinario e integral en pacientes con FA.

Seroprevalence of Dengue, Chikungunya and Zika at the epicenter of the congenital microcephaly epidemic in Northeast Brazil: A population-based survey.

BACKGROUND: The four Dengue viruses (DENV) serotypes were re-introduced in Brazil's Northeast region in a couple of decades, between 1980's and 2010's, where the DENV1 was the first detected serotype and DENV4 the latest. Zika (ZIKV) and Chikungunya (CHIKV) viruses were introduced in Recife around 2014 and led to large outbreaks in 2015 and 2016, respectively. However, the true extent of the ZIKV and CHIKV outbreaks, as well as the risk factors associated with exposure to these viruses remain vague. METHODS: We conducted a stratified multistage household serosurvey among residents aged between 5 and 65 years in the city of Recife, Northeast Brazil, from August 2018 to February 2019. The city neighborhoods were stratified and divided into high, intermediate, and low socioeconomic strata (SES). Previous ZIKV, DENV and CHIKV infections were detected by IgG-based enzyme linked immunosorbent assays (ELISA). Recent ZIKV and CHIKV infections were assessed through IgG3 and IgM ELISA, respectively. Design-adjusted seroprevalence were estimated by age group, sex, and SES. The ZIKV seroprevalence was adjusted to account for the cross-reactivity with dengue. Individual and household-related risk factors were analyzed through regression models to calculate the force of infection. Odds Ratio (OR) were estimated as measure of effect. PRINCIPAL FINDINGS: A total of 2,070 residents' samples were collected and analyzed. The force of viral infection for high SES were lower as compared to low and intermediate SES. DENV seroprevalence was 88.7% (CI95%:87.0-90.4), and ranged from 81.2% (CI95%:76.9-85.6) in the high SES to 90.7% (CI95%:88.3-93.2) in the low SES. The overall adjusted ZIKV seroprevalence was 34.6% (CI95%:20.0-50.9), and ranged from 47.4% (CI95%:31.8-61.5) in the low SES to 23.4% (CI95%:12.2-33.8) in the high SES. The overall CHIKV seroprevalence was 35.7% (CI95%:32.6-38.9), and ranged from 38.6% (CI95%:33.6-43.6) in the low SES to 22.3% (CI95%:15.8-28.8) in the high SES. Surprisingly, ZIKV seroprevalence rapidly increased with age in the low and intermediate SES, while exhibited only a small increase with age in high SES. CHIKV seroprevalence according to age was stable in all SES. The prevalence of serological markers of ZIKV and CHIKV recent infections were 1.5% (CI95%:0.1-3.7) and 3.5% (CI95%:2.7-4.2), respectively. CONCLUSIONS: Our results confirmed continued DENV transmission and intense ZIKV and CHIKV transmission during the 2015/2016 epidemics followed by ongoing low-level transmission. The study also highlights that a significant proportion of the population is still susceptible to be infected by ZIKV and CHIKV. The reasons underlying a ceasing of the ZIKV epidemic in 2017/18 and the impact of antibody decay in susceptibility to future DENV and ZIKV infections may be related to the interplay between disease transmission mechanism and actual exposure in the different SES.

Fibrilación auricular en población mexicana: Diferencias en presentación, comorbilidades y factores de riesgo entre hombres y mujeres / Atrial fibrillation in Mexican population: Differences in presentation, comorbidities and risk factors between men and women

Resumen Objetivo: Conocer el comportamiento epidemiológico y asociaciones de la FA en población mexicana. Material y métodos: Analizamos 8,686 pacientes de 38 cardiólogos inscritos en REMECAR, divididos por edad y sexo. Comorbilidades estudiadas: obesidad, ERC, HTA, DM, dislipidemia, EVC, EPOC, hipotiroidismo, IC y CI. Programa: IBM SPSS. Resultados: FA en 498 pacientes (5.7%), mayor prevalencia en hombres (6.1 vs. 5.3%), mayor edad en mujeres (74.3 ± 12.1 vs. 70.5 ± 12.3 años, p < 0.0001). En mujeres menores de 60 años la FA se asoció con IC (p = 0.041), en hombres con ERC (p = 0.43), DM (p = 0.009), EVC (p = 0.001), hipotiroidismo (p = 0.001) e IC (p = 0.001). En mujeres mayores de 60 años se asoció con ERC (p = 0.001), dislipidemia (p = 0.001), EVC (p = 0.001), EPOC (p = 0.001) e IC (p = 0.001), en hombres con ERC (p = 0.002), EVC (p = 0.001), EPOC (p = 0.002), hipotiroidismo (p = 0.002), IC (p = 0.001) y CI (p = 0.033). En mujeres la FA se asoció con 1.13 veces mayor probabilidad de obesidad, 1.13 de HTA, 2.8 de ERC, 2.9 de EPOC, 4.3 de EVC y 6.5 de IC, en hombres la FA se asoció con 1.05 veces mas probabilidad de HTA, 1.4 de DM, 2.1 de ERC, 2.4 de EPOC, 3 de hipotiroidismo, 4.7 de EVC y 6 de IC. Conclusiones: La FA es una arritmia muy frecuente, con mayor prevalencia en pacientes que acuden a consulta de cardiología, en hombres y mayor edad de presentación en las mujeres. A mayor edad, mayor prevalencia de FA y de comorbilidades, la IC es la condición más frecuente con la que se asoció la FA.

Abstract Objective: To know the epidemiological behavior and associations of AF in Mexican population. Material and methods: 8,686 patients from 38 cardiologists participating in REMECAR were analyzed. They were divided by gender and age, the comorbidities studied were obesity, chronic kidney disease (CKD), high blood pressure (HBP), diabetes mellitus (DM), dyslipidemia, stroke, chronic obstructive pulmonary disease (COPD), hypothyroidism, heart failure (HF) and ischemic heart disease (IHD). Program used: IBM SPSS Statistic. Results: AF was diagnosed in 498 patients (5.7%), with higher prevalence in men (6.1% vs. 5.3%) and older age in women (74.3 ± 12.1 vs. 70.5 + -12.3 years, p<0.0001). In those under 60 years, AF was associated in women with HF, in men with CKD, DM, stroke, hypothyroidism and HF. In women older than 60 years, AF was associated with CKD, dyslipidemia, stroke, chronic COPD and HF, in men with CKD, stroke, COPD, hypothyroidism, HF and IHD. AF in women increase the probability 1.13 for obesity, 1.13 for HBP, 2.8 for CKD, 2.9 for COPD, 4.3 for stroke and 6.5 for HF, in men increase the probability 1.05 for HBP, 1.4 for DM, 2.1 for CKD, 2.4 for COPD, 3.0 for hypothyroidism, 4.7 for stroke and 6.0 for HF. Conclusions: AF is a very common arrhythmia, with a higher prevalence in patients attending the cardiology consultation, in men and with an older age of presentation in women. The older the age, the higher the prevalence of AF and comorbidities, HF is the most frequent condition associated with AF.

Atrial fibrillation in Mexican population: Differences in presentation, comorbidities and risk factors between men and women / Fibrilación auricular en población mexicana: Diferencias en presentación, comorbilidades y factores de riesgo entre hombres y mujeres

OBJECTIVE: To know the epidemiological behavior and associations of AF in Mexican population. MATERIAL AND METHODS: 8,686 patients from 38 cardiologists participating in REMECAR were analyzed. They were divided by gender and age, the comorbidities studied were obesity, chronic kidney disease (CKD), high blood pressure (HBP), diabetes mellitus (DM), dyslipidemia,stroke, chronic obstructive pulmonary disease (COPD), hypothyroidism, heart failure (HF) and ischemicheart disease (IHD). Program used: IBM SPSS Statistic. RESULTS: AF was diagnosed in 498 patients (5.7%), with higher prevalence in men (6.1% vs. 5.3%) and older age in women (74.3 ± 12.1 vs. 70.5 + -12.3 years, p<0.0001). In those under 60 years, AF was associated in women with HF, in men with CKD, DM, stroke, hypothyroidism and HF. In women older than 60 years, AF was associated with CKD, dyslipidemia, stroke, chronic COPD and HF, in men with CKD, stroke, COPD, hypothyroidism, HF and IHD. AF in women increase the probability 1.13 for obesity, 1.13 for HBP, 2.8 for CKD, 2.9 for COPD, 4.3 for stroke and 6.5 for HF, in men increase the probability 1.05 for HBP, 1.4 for DM, 2.1 for CKD, 2.4 for COPD, 3.0 for hypothyroidism, 4.7 for stroke and 6.0 for HF. CONCLUSIONS: AF is a very common arrhythmia, with a higher prevalence in patients attending the cardiology consultation, in men and with an older age of presentation in women. The older the age, the higher the prevalence of AF and comorbidities, HF is the most frequent condition associated with AF.

OBJETIVO: Conocer el comportamiento epidemiológico y asociaciones de la FA en población mexicana. MATERIAL Y MÉTODOS: Analizamos 8,686 pacientes de 38 cardiólogos inscritos en REMECAR, divididos por edad y sexo. Comorbilidades estudiadas: obesidad, ERC, HTA, DM, dislipidemia, EVC, EPOC, hipotiroidismo, IC y CI. Programa: IBM SPSS. RESULTADOS: FA en 498 pacientes (5.7%), mayor prevalencia en hombres (6.1 vs. 5.3%), mayor edad en mujeres (74.3 ± 12.1 vs. 70.5 ± 12.3 años,p < 0.0001). En mujeres menores de 60 años la FA se asoció con IC (p = 0.041), en hombres con ERC (p = 0.43), DM(p = 0.009), EVC (p = 0.001), hipotiroidismo (p = 0.001) e IC (p = 0.001). En mujeres mayores de 60 años se asoció conERC (p = 0.001), dislipidemia (p = 0.001), EVC (p = 0.001), EPOC (p = 0.001) e IC (p = 0.001), en hombres con ERC(p = 0.002), EVC (p = 0.001), EPOC (p = 0.002), hipotiroidismo (p = 0.002), IC (p = 0.001) y CI (p = 0.033). En mujeres la FA se asoció con 1.13 veces mayor probabilidad de obesidad, 1.13 de HTA, 2.8 de ERC, 2.9 de EPOC, 4.3de EVC y 6.5de IC, en hombres la FA se asoció con 1.05 veces mas probabilidad de HTA, 1.4 de DM, 2.1 de ERC, 2.4 de EPOC, 3 dehipotiroidismo, 4.7 de EVC y 6 de IC. CONCLUSIONES: La FA es una arritmia muy frecuente, con mayor prevalencia en pacientes que acuden a consulta de cardiología, en hombres y mayor edad de presentación en las mujeres. A mayor edad, mayor prevalencia de FA y de comorbilidades, la IC es la condición más frecuente con la que se asoció la FA.

Childhood and Adolescent Cancer in the State of Pernambuco, Brazil: Incidence, Geographical Distribution, and Association With Environmental Health Indicators.

Cases of childhood and adolescent cancer diagnosed from 2009 to 2012 in the state of Pernambuco, Brazil, were analyzed considering the patients' sex and age, the type of cancer and the municipality of living to determine the incidence, geographical distribution, and association with environmental health indicators. The spatial distribution pattern of the cancer incidence was estimated using the Global Moran's index. The association between environmental health indicators and cancer incidence was evaluated by multiple regression. From 2009 to 2012, 1261 new cases of cancer were diagnosed in patients younger than 20 years old in the state of Pernambuco. Leukemia/lymphoma were the most common type of cancer contemplating 45.28% of the cases. The average age-adjusted incidence rate was 113 cases per million with no spatial distribution pattern. The municipalities were clustered according to their degree of inequality (P=0.017), human development index (P=0.001), population growth rate (P=0.008), urbanization level (P=0.001), number of agricultural crops per capita (P=0.001), and number of industries per capita (P=0.030). However, only urbanization level was positive correlated with incidence of pediatric cancer (P=0.009) likely because in more developed cities, people are more exposed to potential oncogenic factors, such as air and water pollution and processed and ultraprocessed food. The better access to specialized health services, which increases the chances of early diagnosis, may also contributes for a higher number of cases in more developed cities.

Right aortic arch with situs solitus frequently heralds a vascular ring.

OBJECTIVE: We hypothesized that a right aortic arch in situs solitus, with or without an associated cardiovascular malformation, is often associated with a vascular ring. METHODS: From those born in Southern Nevada between March 2012 and March 2017, we identified 50 (3.6 per 10,000 live births) with a right aortic arch and situs solitus. From the 50 patients, 6 did not meet inclusion criteria for further analysis. RESULTS: Of the 44 remaining, 33 (75%) had a vascular ring. Of the 33 with a vascular ring, 26 (79%) occurred with an isolated right aortic arch, and 7 (21%) had an associated cardiovascular malformation. Of the total 44 patients with a right aortic arch in situs solitus, 34 (79%) were diagnosed prenatally. CONCLUSIONS: In conclusion, we found a right aortic arch in situs solitus was often associated with a vascular ring. Further, to the best of our knowledge, no previous general population study has demonstrated an equal or higher right aortic arch, prenatal detection rate of 79%.

Vascular Ring Diagnosis and Management: Notable Trends Over 25 Years.

BACKGROUND: Vascular rings (VRs) are recognized as uncommon but not rare cardiovascular malformations. METHODS: We analyzed data from all patients born in Southern Nevada, who underwent diagnosis and management of VR from 1990 to 2015, RESULTS: From 1990 to 2015, a total of 92 patients were diagnosed prenatally and postnatally. Of the 92 patients, 73 (79%) had right aortic arch and aberrant left subclavian artery (RAA-ALS) with a left ductus arteriosus or ligamentum, 17 (19%) had a double aortic arch (DAA), and 2 (2%) had a pulmonary artery sling. Of the 92 patients, 75 had an isolated VR and 17 VR had significant additional congenital heart disease (CHD). Of the 75 patients with an isolated VR, 52 underwent surgical repair, and the most common surgical diagnosis was DAA in 6 (66%) of 9 for the period 1990 to 2005 versus less common in 9 (21%) of 43 during the period 2006 to 2015, P < .05. The isolated VR repair age significantly negatively correlated with increasing time from 1990 to 2015, R = -0.7 (P < .0001). Of the 75 isolated VR, 23 remain asymptomatic. The 17 VR with CHD were treated during infant palliation or intracardiac repair. Of the total 92 VR, 60 were born after a 2004 community introduction of the three-vessel fetal echocardiography view, from then the prenatal-detection rate has significantly increased-2004 to 2006, 0 (0%) of 9; 2007 to 2009, 1 (9%) of 11; 2010 to 2012, 11 (55%) of 20; and 2013 to 1015, 14 (70%) of 20 (P < .0001). CONCLUSION: Over 25 years in Southern Nevada, VR prenatal diagnosis has increased, isolated VR age at surgery has decreased, and the percentage of those with RAA-ALS has increased.

Hybrid Palliation for Ductal-Dependent Systemic Circulation.

We reviewed our hybrid palliation experience for 91 neonates, with ductal-dependent systemic circulation, born between August 2007 and October 2015. For analysis, we stratified the 91 patients by a risk factor (RF) score and divided them into three groups: (1) high-risk two-functional ventricles (2V) median RF score of 3 (N = 20); (2) low-risk one-functional ventricle (1V) RF score 0-1 (N = 32); and (3) high-risk 1V RF score ≥2 (N = 39). Midterm survival (median 4 years) by group was: (1) 95 %, (2) 91 %, and (3) 15 %, (p = 0.001). In conclusion, hybrid palliation was associated with excellent midterm results for high-risk 2V and low-risk 1V patients with ductal-dependent systemic circulation. In contrast, high-risk 1V patients had significantly worse outcomes.

Correlation between platelet count and both liver fibrosis and spleen diameter in patients with schistosomiasis mansoni.

CONTEXT: Studies have described the correlation between platelet count and the stages of fibrosis in chronic viral hepatitis, but few publications have studied this correlation in Schistosomiasis mansoni. OBJECTIVES: Therefore, this study aimed to correlate platelet count with both the periportal fibrosis pattern and spleen diameter evaluated by ultrasound exam in patients with Schistosomiasis mansoni. METHODS: Patients with Schistosomiasis mansoni were evaluated by abdominal ultrasound by a single examiner for the determination of periportal fibrosis pattern (Niamey classification) and spleen diameter. Platelet counts were performed in an automated cell counter. RESULTS: One hundred eighty-seven patients with Schistosomiasis mansoni (mean age: 50.2 years) were included in the study, 114 of whom (61%) were women. Based on the Niamey classification, the ultrasound analysis revealed that 37, 64, 64 and 22 patients exhibited patterns C, D, E and F, respectively. In these four groups, the mean number of platelets was 264, 196, 127 and 103 x 109/L and mean spleen diameter was 9.2, 11.9, 14.9 and 16.2 centimeters, respectively. A reduction in platelet count was significantly associated with both the progression of the periportal fibrosis and the increase in spleen size. CONCLUSIONS: Platelet count in patients with Schistosomiasis mansoni was inversely correlated with the severity of periportal fibrosis and spleen diameter.

Correlation beteeen platelet count and both livr fibrosis and spleen diameter in patients with schistosomiasis mansnni / Correlação entre o número de plaquetas e o grau de fibrose hepática e o tamanho do baço em pacientes com Esquistossomose mansoni

Context Studies have described the correlation between platelet count and the stages of fibrosis in chronic viral hepatitis, but few publications have studied this correlation in Schistosomiasis mansoni. Objectives Therefore, this study aimed to correlate platelet count with both the periportal fibrosis pattern and spleen diameter evaluated by ultrasound exam in patients with Schistosomiasis mansoni. Methods Patients with Schistosomiasis mansoni were evaluated by abdominal ultrasound by a single examiner for the determination of periportal fibrosis pattern (Niamey classification) and spleen diameter. Platelet counts were performed in an automated cell counter. Results One hundred eighty-seven patients with Schistosomiasis mansoni (mean age: 50.2 years) were included in the study, 114 of whom (61%) were women. Based on the Niamey classification, the ultrasound analysis revealed that 37, 64, 64 and 22 patients exhibited patterns C, D, E and F, respectively. In these four groups, the mean number of platelets was 264, 196, 127 and 103 x 109/L and mean spleen diameter was 9.2, 11.9, 14.9 and 16.2 centimeters, respectively. A reduction in platelet count was significantly associated with both the progression of the periportal fibrosis and the increase in spleen size. Conclusions Platelet count in patients with Schistosomiasis mansoni was inversely correlated with the severity of periportal fibrosis and spleen diameter. .

Contexto Estudos vem descrevendo correlação entre o número de plaquetas e o grau de fibrose hepática na hepatite viral crônica, mas poucas publicações estudaram esta correlação em pacientes com Esquistossomose mansoni. Objetivos Correlacionar a contagem de plaquetas com o padrão de fibrose periportal e com o diâmetro do baço, avaliados pela ultrassonografia em pacientes com Esquistossomose mansoni. Métodos Os pacientes com Esquistossomose mansoni foram avaliados pela ultrassonografia abdominal, por um único examinador, para determinação do padrão de fibrose periportal (classificação de Niamey) e do diâmetro do baço. A contagem de plaquetas foi realizada em contador automatizado. Resultados Cento e oitenta e sete pacientes com Esquistossomose mansoni com média de idade de 50,2 anos foram incluídos no estudo, 114 (61%) dos quais eram mulheres. De acordo com a classificação de Niamey, a ultrassonografia revelou que 37, 64, 64 e 22 pacientes exibiam padrões C, D, E e F, respectivamente. Nestes quatro grupos, o número médio de plaquetas foi 264, 196, 127 e 103 x 109/L, respectivamente, e o diâmetro médio do baço foi 9,2, 11,9, 14,9 e 16,2 centímetros, respectivamente. Observou-se, portanto, redução significativa na contagem de plaquetas associada à progressão da fibrose periportal e ao aumento do tamanho do baço. Conclusões Neste estudo verificou-se que a contagem de plaquetas foi inversamente correlacionada com o padrão de fibrose periportal, como também com o diâmetro do baço nos pacientes com Esquistossomose mansoni. .

Comparison of the burden of diarrhoeal illness among individuals with and without household cisterns in northeast Brazil.

BACKGROUND: Lack of access to safe and secure water is an international issue recognized by the United Nations. To address this problem, the One Million Cisterns Project was initiated in 2001 in Brazil's semi-arid region to provide a sustainable source of water to households. The objectives of this study were to determine the 30-day period prevalence of diarrhoea in individuals with and without cisterns and determine symptomology, duration of illness and type of health care sought among those with diarrhoea. A subgroup analysis was also conducted among children less than five years old. METHODS: A face-to-face survey was conducted between August 20th and September 20th, 2007 in the Agreste Central Region of Pernambuco State, Brazil. Households with and without a cistern that had at least one child under the age of five years were selected using systematic convenient sampling. Differences in health outcomes between groups were assessed using Pearson's Chi-squared and two-way t-tests. Demographic variables were tested for univariable associations with diarrhoea using logistic regression with random effects. P-values of 0.05 or less were considered statistically significant. RESULTS: A total of 3679 people from 774 households were included in the analysis (1863 people from 377 households with cisterns and 1816 people from 397 households without cisterns). People from households with a cistern had a significantly lower 30-day period prevalence of diarrhoea (prevalence = 11.0%; 95% CI 9.5-12.4) than people from households without a cistern (prevalence = 18.2%; 95% CI 16.4-20.0). This significant difference was also found in a subgroup analysis of children under five years old; those children with a cistern had a 30-day period prevalence of 15.6% (95% CI 12.3-18.9) versus 26.7% (95% CI 22.8-30.6) in children without a cistern. There were no significant differences between those people with and without cisterns in terms of the types of symptoms, duration of illness and health care sought for diarrhoea. CONCLUSIONS: Our results indicate that the use of cisterns for drinking water is associated with a decreased occurrence of diarrhoea in this study population. Further research accounting for additional risk factors and preventative factors should be conducted.

Serum alanine aminotransferase levels, hematocrit rate and body weight correlations before and after hemodialysis session.

PURPOSE: To evaluate alanine aminotransferase levels before and after a hemodialysis session and to correlate these values with the hematocrit rate and weight loss during hemodialysis. PATIENTS AND METHODS: The serum alanine aminotransferase levels, hematocrit rate and body weight were measured and correlated before and after a single hemodialysis session for 146 patients with chronic renal failure. An receiver operating characteristic (ROC) curve for the serum alanine aminotransferase levels collected before and after hemodialysis was plotted to identify hepatitis C virus-infected patients. RESULTS: The mean weight loss of the 146 patients during hemodialysis was 5.3% (p < 0.001). The mean alanine aminotransferase levels before and after hemodialysis were 18.8 and 23.9 IU/, respectively, denoting a significant 28.1% increase. An equally significant increase of 16.4% in the hematocrit rate also occurred after hemodialysis. The weight loss was inversely correlated with the rise in both the alanine aminotransferase level (r = 0.3; p < 0.001) and hematocrit rate (r = 0.5; p < 0.001). A direct correlation was found between the rise in alanine aminotransferase levels and the hematocrit during the hemodialysis session (r = 0.4; p < 0.001). Based on the ROC curve, the upper limit of the normal alanine aminotransferase level should be reduced by 40% relative to the upper limit of normal if the blood samples are collected before the hemodialysis session or by 60% if blood samples are collected after the session. CONCLUSION: In the present study, significant elevations in the serum alanine aminotransferase levels and hematocrit rates occurred in parallel to a reduction in body weight after the hemodialysis session. These findings suggest that one of the factors for low alanine aminotransferase levels prior to hemodialysis could be hemodilution in patients with chronic renal failure.

Satisfação dos usuários do sistema de saúde brasileiro: fatores associados e diferenças regionais / User satisfaction in the Brazilian health system: associated factors and regional differences

Desenvolver modelos de avaliação de satisfação que permitam comparar sistemas de saúde de diversos países é um esforço recente no Brasil. Esse tipo de avaliação representa importante ferramenta para desenvolver estratégias de gestão para o setor. Objetivo: identificar fatores e avaliar diferenças regionais do grau de satisfação dos usuários do sistema de saúde brasileiro, analisando os resultados da Pesquisa Mundial de Saúde (PMS) e Pesquisa Mundial de Saúde com foco na Atenção Básica (PMS-AB). Foi realizado estudo avaliativo de corte transversal, onde as amostras foram selecionadas de forma aleatória. Foram incluídas pessoas maiores de 18 anos que utilizaram o sistema de saúde em períodos anteriores às coletas de dados. Enquadraram-se nos critérios de inclusão 3.932 usuários da PMS e 591 da PMS-AB. Aplicou-se modelo logístico multivariado, tendo como variável dependente a satisfação e, como variáveis independentes, sexo, idade, escolaridade, forma de pagamento de serviço, situação conjugal, autopercepção de saúde, doença de longa duração, diagnóstico de depressão, tristeza, número de moradores por domicílio, tipo de construção, estratos geográficos e indicador de bens. Os resultados revelaram que ser jovem, usuário exclusivo do SUS, ter baixa escolaridade e autopercepção de saúde ruim gerou mais chances de insatisfação dos usuários com o sistema de saúde brasileiro. Os moradores da Região Sul do país estão mais satisfeitos com o atendimento em saúde, enquanto para pernambucanos as chances de satisfação são menores quando se avalia a qualidade dos serviços de saúde. Os moradores desse estado apresentaram maior insatisfação na resolução de seus problemas de saúde quando precisaram de internação.

Is it better to be rich in a poor area or poor in a rich area? A multilevel analysis of a case-control study of social determinants of tuberculosis.

BACKGROUND: Tuberculosis is known to have socio-economic determinants at individual and at area levels, but it is not known whether they are independent, whether they interact and their relative contributions to the burden of tuberculosis. METHODS: A case-control study was conducted in Recife, Brazil, to investigate individual and area social determinants of tuberculosis, to explore the relationship between determinants at the two levels and to calculate their relative contribution to the burden of tuberculosis. It included 1452 cases of tuberculosis diagnosed by the tuberculosis services and 5808 controls selected at random from questionnaires completed for the demographic census. Exhaustive information on social factors was collected from cases, using the questionnaire used in the census. Socio-economic information for areas was downloaded from the census. Multilevel logistic regression investigated individual and area effects. RESULTS: There was a marked and independent influence of social variables on the risk of tuberculosis, both at individual and area levels. At individual level, being aged >or=20, being male, being illiterate, not working in the previous 7 days and possessing few goods, all increased the risk of tuberculosis. At area level, living in an area with many illiterate people and where few households own a computer also increased this risk; individual and area levels did not appear to interact. Twice as many cases were attributable to social variables at individual level than at area level. CONCLUSIONS: Although individual characteristics are the main contributor to the risk of tuberculosis, contextual characteristics make a substantial independent contribution.

Cellular immune response profile in patients with American tegumentary leishmaniasis prior and post chemotherapy treatment.

In this study, we have the objective of evaluating the lymphoproliferative response and determining interferon (IFN)-gamma and interleukin (IL)-10 cytokine production in the peripheral blood mononuclear cells (PBMC) of patients with American tegumentary leishmaniasis prior and post 12 months of chemotherapy treatment with meglumine antimoniate compared with the PBMC of noninfected donors. Lymphoproliferation, such as cytokine production, was evaluated through in vitro stimulus with the soluble antigenic fraction from Leishmania (Viannia) braziliensis promastigotes (1.25 microg/ml) and Concanavalin A (2.5 microg/ml). Patients showed a significant lymphoproliferative response prior and post treatment compared with the control group. Similar result, prior to chemotherapy treatment, was observed in IFN-gamma and IL-10 production when patients were compared with the control group. After chemotherapy treatment, PBMC lymphoproliferative response of the patients revealed an increase, whereas patients have shown a decrease in IFN-gamma levels and an increase in IL-10, although without statistical difference. These results may indicate that the patients produced a specific cellular response to the soluble antigenic fraction suggesting that besides Th1 and Th2 dichotomy, immunological regulation mechanisms with the participation of memory T cells and regulatory T cells could be present in the clinical evolution of these patients. This understanding will allow the study and identification of new L. (V.) braziliensis molecules potentially candidates to vaccines.

Serum alanine aminotransferase levels, hematocrit rate and body weight correlations before and after hemodialysis session

PURPOSE: To evaluate alanine aminotransferase levels before and after a hemodialysis session and to correlate these values with the hematocrit rate and weight loss during hemodialysis. PATIENTS AND METHODS: The serum alanine aminotransferase levels, hematocrit rate and body weight were measured and correlated before and after a single hemodialysis session for 146 patients with chronic renal failure. An receiver operating characteristic (ROC) curve for the serum alanine aminotransferase levels collected before and after hemodialysis was plotted to identify hepatitis C virus-infected patients. RESULTS: The mean weight loss of the 146 patients during hemodialysis was 5.3 percent (p < 0.001). The mean alanine aminotransferase levels before and after hemodialysis were 18.8 and 23.9 IU/, respectively, denoting a significant 28.1 percent increase. An equally significant increase of 16.4 percent in the hematocrit rate also occurred after hemodialysis. The weight loss was inversely correlated with the rise in both the alanine aminotransferase level (r = 0.3; p < 0.001) and hematocrit rate (r = 0.5; p < 0.001). A direct correlation was found between the rise in alanine aminotransferase levels and the hematocrit during the hemodialysis session (r = 0.4; p < 0.001). Based on the ROC curve, the upper limit of the normal alanine aminotransferase level should be reduced by 40 percent relative to the upper limit of normal if the blood samples are collected before the hemodialysis session or by 60 percent if blood samples are collected after the session. CONCLUSION: In the present study, significant elevations in the serum alanine aminotransferase levels and hematocrit rates occurred in parallel to a reduction in body weight after the hemodialysis session. These findings suggest that one of the factors for low alanine aminotransferase levels prior to hemodialysis could be hemodilution in patients with chronic renal failure.

Modified De Vega mitral valve annuloplasty in an infant with endocarditis.

Surgical management of infant mitral valve regurgitation is challenging. There are no large surgical series of mitral valve repair in infants. Mitral valve repair is preferable to replacement. We report the modified De Vega adjustable annuloplasty with mitral valve repair in an infant with mitral valve regurgitation from endocarditis.

Prenatal detection of congenital heart disease in southern Nevada: the need for universal fetal cardiac evaluation.

OBJECTIVE: Congenital cardiac malformations are common developmental anomalies. In the United States, congenital heart disease is the number one cause of infant mortality from congenital malformations. Prenatal diagnosis of congenital heart defects aids treatment coordination. Our aim was to evaluate prenatal detection of serious congenital heart malformations in Clark County, Nevada. METHODS: We electronically searched our research department-maintained computer database for patients with serious congenital heart disease born in Clark County between May 2003 and April 2006. We excluded patients that did not have at least 1 local prenatal ultrasound examination. All pre-natal ultrasound studies were performed in obstetric offices, radiology imaging centers, or maternal-fetal medicine specialty practices. Fetal echocardiography was performed in maternal-fetal medicine specialists' offices under the supervision of a fetal cardiologist. Pediatric cardiologists performed all postnatal echocardiographic examinations. RESULTS: During the study period, we diagnosed serious congenital heart malformations in 161 patients among a total estimated 77,000 births (2/1000). Of the 161 patients, 58 (36%) had a prenatal diagnosis, and 103 (64%) had an exclusively postnatal diagnosis. CONCLUSIONS: Standard prenatal ultrasound fails to show congenital heart disease in most fetuses.