Right-Sided Cardiac Thrombosis and Pulmonary Thromboembolism in Chronic Chagas Disease: A Review of Clinical Features and Post-Mortem Examination.

Pulmonary thromboembolism (PE) is a potential major complication in patients with chronic Chagas heart disease (CChD). The source of PE is the right-sided chambers instead of deep vein thrombosis. Little is known regarding risk factors, clinical picture, and the clinical course of patients with PE secondary to CChD. The aim of this review was to try to provide doctors with such data. We searched for papers related to PE in CChD patients in the PUBMED from 1955 to 2020. Twenty-six manuscripts were retrieved, of which 12 fulfilled entry criteria and were included in the study. Right-sided cardiac thrombosis or PE was confirmed on morphological or imaging studies. A total of 431 patients with PE were reported. Age varied from 30 to 85 years. About 332 patients were reported to have chronic heart failure (CHF), whereas 41 (9%) sudden cardiac death (SCD) at autopsy. Clinical manifestations reported were sudden onset dyspnea was found in 1 patient, haemoptysis in 2, worsening CHF in 2, and chest pain in 1. An X-ray chest was reported for 6 patients: abnormalities consistent with PE were found in 3. The resting electrocardiogram (ECG) was reported for 5 patients: it was abnormal in all. One study reported a mean left ventricular ejection fraction of 42.1 ± 18.7%. The prevalence of right-sided cardiac thrombosis varied from 66% to 85% patients. PE was the cause of death in 17% of patients. The clinical diagnosis of PE in patients with Chagas cardiomyopathy (ChCM) is very difficult in the absence of a prediction score that performs well. However, in the presence of haemoptysis or worsening heart failure (HF), abnormal ECG, or chest X-ray, the diagnosis of PE should be raised, and patients promptly referred to detailed Doppler Tissue Echocardiography and computed tomography angiography, and treated in a timely manner.

Determination of the Th1, Th2, Th17, and Treg cytokine profile in patients with chronic Chagas heart disease and systemic arterial hypertension.

Chronic Chagas heart disease (CCHD affects about 30% of patients with chronic Chagas disease (CCD). Systemic arterial hypertension (SAH) afflicts about 25% of patients with CCD. The association of CCHD with SAH (CCHD-SAH) predisposes patients to develop chronic heart failure. The role of cytokines in disease progression in patients with CCHD-SAH is unknown. Accordingly, the aim of this study was to evaluate the plasma levels of cytokines expressing the Th1, Th2, Th17 pattern, as well as Treg cytokines, TNF-alpha, IL-1ß, IL-8, IL-7 in patients with SAH-CCHD to get insight into the immunomodulation process in patients with this condition. Fifteen patients with CCHD, 22 patients with CCHD-SAH, and 28 controls were studied. All patients underwent history-taking, physical examination, 12-lead resting ECG, chest X-ray, and Doppler-echocardiogram. Ten of 15 (66%) patients with CCHD, and 16 of 22 (73%) patients with CCHD-SAH had decreased left ventricular ejection fraction (p > 0.05). Cytokines levels were performed on plasma samples using the ELISA method. Overall, proinflammatory, anti-inflammatory, and regulatory cytokine levels were increased in patients with CCHD-SAH in comparison to patients with CCHD and controls. However, such a difference was higher regarding IL-2, IL-5, IL-17, IL-12, and TNF-alpha cytokine levels, respectively. Cytokine levels were higher in CCHD patients in comparison to controls. Patients with CCHD-SAH have increased plasma levels of pro-inflammatory, anti-inflammatory, and regulatory cytokines in comparison with CCHD patients, thus suggesting a higher level of immunomodulation in patients with CCHD-SAH.

A Comparison of the Academic Achievement at the End of the Medicine Undergraduate Degree Program Between Students Who Only Used the University Admission Test and Those Who Used the University Admission Test Plus Marks from the High School National Exam (ENEM) at a Single Brazilian Center.

Purpose: The role of marks in the University Admission Test (UAT) plus the marks from pre-university academic records in predicting academic achievement at the end of the Medicine undergraduate degree program is not completely known. This study was undertaken to compare the performance of marks in the UAT alone with those of the UAT plus marks from the National High School Exam (ENEM in Brazil) regarding students' outcomes at the end of the Medicine undergraduate degree program. Methods: Fifty-one (51) students from the last semester (12th) of our Medicine undergraduate degree program were included in the study. They were divided into a group of those who used the marks obtained in the UAT plus the marks obtained in the ENEM (ENEM group, n=9), and those who only used the marks in the UAT (non-ENEM group, n=42). We compared the academic achievement of the non-ENEM group with that of the ENEM group regarding the mean marks obtained in the clerkship, in the Progress Test (PT), and in the Objective Structured Clinical Examination (OSCE). Results: The mean scores obtained in the disciplines of the clerkship were higher in the non-ENEM group compared to the ENEM group (7.32 ± 0.41 vs 6.98 ± 0.31, p= 0.01). Both groups obtained similar mean marks in the OSCE and in the PT. A moderate correlation was observed between the marks in the clerkship with those of the UAT from the non-ENEM group (p=0.00006; r=0.45). Conclusion: Marks of the UAT alone appear to be associated with a higher academic achievement in the clerkship than marks of the UAT plus scores obtained from the ENEM at the end of the Medicine undergraduate degree program.

Nonpharmaceutical public health interventions to curb the COVID-19 pandemic: a narrative review.

Nonpharmaceutical Interventions (NPI) consist of compulsory (isolation, quarantine, stay-at-home orders, banning public gatherings, nonessential business closures, school closures), and voluntary (social distancing, handwashing, respiratory etiquette, and universal mask wearing) measures. The aim of this narrative review is to evaluate the different forms of NPI and their effectiveness in combating the pandemic. Isolation can be indicated for symptomatic and asymptomatic infected people at home or at hospitals depending on the patient's clinical picture. Quarantine is a social distancing intervention in asymptomatic uninfected people who had contact with SARS-CoV-2 infected individuals. Stay-at-home orders refer to statewide mandates imposing nonessential business closures, prohibition of public events and gatherings, and travel restrictions. Studies have suggested that stay-at-home orders may be associated with a reduction in the incidence of COVID-19 in some countries. Mask wearing decreases the risk of COVID-19 in the community, especially when the surgical masks are used for vulnerable people. N-95 respirators protect health workers from COVID-19. NPI may be helpful to curb the COVID-19 pandemic while mass vaccination worldwide is not attainable, and the threat of SARS-COV-2 variants remain on the horizon.

Management of Cardiovascular Disease in Patients With COVID-19 and Chronic Chagas Disease: Implications to Prevent a Scourge Still Larger.

Cardiovascular diseases (CVD) are the most important cause of morbidity and mortality in the general population. Because the high prevalence of COVID-19 and chronic Chagas disease (CCD) where the latter is endemic, all such diseases will likely be observed in the same patient. While COVID-19 can provoke generalized endotheliitis, which can lead to a cytokine storm and a hyper-coagulable state culminating into in-site and at a distance thrombosis. Therefore, small-vessel coronary artery disease (CAD), cerebrovascular disease, thromboembolism, and arrhythmias are prominent findings in COVID-19. In CCD, small-vessel CAD, cardioembolic stroke, pulmonary embolism, heart failure and arrhythmias are frequently observed as a result of a similar but less intense mechanism. Consequently, the association of CCD and COVID-19 will likely increase the incidence of CVD. Thus, doctors on the frontline should be on the alert for this diagnostic possibility so that the proper treatment can be given without any delay.

Pharmacological Treatment of Patients with Mild to Moderate COVID-19: A Comprehensive Review.

Mild to moderate COVID-19 can be found in about 80% of patients. Although mortality is low, mild to moderate COVID-19 may progress to severe or even critical stages in about one week. This poses a substantial burden on the health care system, and ultimately culminates in death or incapacitation and hospitalization. Therefore, pharmacological treatment is paramount for patients with this condition, especially those with recognized risk factors to disease progression. We conducted a comprehensive review in the medical literature searching for randomized studies carried out in patients with mild to moderate COVID-19. A total of 14 randomized studies were identified, enrolling a total of 6848 patients. Nine studies (64%) were randomized, placebo-controlled trials, whereas five were open-label randomized trials (35%). We observed that Bamlanivimab and nitazoxanide reduced viral load, whereas ivermectin may have shortened time to viral clearance; Interferon Beta-1 reduced time to viral clearance and vitamin D reduced viral load; Favirapir, peginterferon, and levamisole improved clinical symptoms, whereas fluvoxamine halted disease progression; inhaled budesonide reduced the number of hospitalizations and visits to emergency departments; colchicine reduced the number of deaths and hospitalizations. Collectively, therefore, these findings show that treatment of early COVID-19 may be associated with reduced viral load, thus potentially decreasing disease spread in the community. Moreover, treatment of patients with mild to moderate COVID-19 may also be associated with improved clinical symptoms, hospitalization, and disease progression. We suggest that colchicine, inhaled budesonide, and nitazoxanide, along with nonpharmacological measures, based on efficacy and costs, may be used to mitigate the effects of the COVID-19 pandemic in middle-income countries.

Kinins and nitric oxide in patients with chronic chagas disease and systemic arterial hypertension.

BACKGROUND: Chronic Chagas disease (CCHD) associated with Systemic Arterial Hypertension (SAH) is frequently found in areas where the disease is endemic. The pathogenesis of patients with both pathologies (CCHD-SAH) is unsettled. Nitric Oxide (NO) and Kinins are important players in the myocardial inflammation process in experimental CCHD. No previous study has addressed this question in patients with CCHD, particularly in those with CCHD-SAH. Accordingly, this study was undertaken in an attempt to contribute to the understanding of the pathogenesis of patients with CCHD-SAH. METHODS: Thirty-seven patients with a positive serology for Chagas disease were enrolled; 15 had CCHD alone, 22 had CCHD-SAH (abnormal ECG/Doppler echocardiogram plus a systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg on admission), and 11 had SAH alone. Thirty healthy individuals matched by age and sex served as controls. Plasma High-molecular (Hkg) and low-molecular weight (LKg) kininogens, plasma kallikrein levels (Pkal and Tcal), Kininase II, and plasma NO were measured. RESULTS: HKg and LKg were lower in CCHD-SAH patients in comparison with other groups (P < .0001). Pkal and Tcal were higher in CCHD-SAH patients in comparison with the other groups (P< .0001). Kininase II levels were similar in SAH, CCHD, and CCHD-SAH patients, but lower in comparison with controls (P< .0001). NO levels were similar in CCHD and CCHD-SAH patients, but higher in comparison with SAH patients and controls (P > .0001). CONCLUSION: Such findings suggest increased Kinin and NO activity in patients with CCHD-SAH, thus contributing to the understanding of the pathogenesis of this condition.

University Admission Test Associates with Academic Performance at the End of Medical Course in a PBL Medical Hybrid Curriculum.

PURPOSE: Most studies assessing the value of the university admissions test (UAT) to predict academic performance at the end of a medical course were carried out on lecture-based medical courses. However, the association between performance in the UAT with academic achievement at the end of medical course in a problem-based learning (PBL) medical hybrid curriculum remains controversial. The aim of this study was to correlate marks in the UAT with those obtained in the Organized Structured Clinical Examination (OSCE), in the progress testing (PT), and in the final marks of the clerkship (FMC). METHODS: We used data from 48 medical students. A single and a multiple dependency studies were performed to assess bivariate and multiple correlation between the UAT or the essay scores (dependent variables) and the OSCE, PT, and FMC (independent variables). Pearson test, multiple linear regression, and ANOVA tests were used and a p-value < 0.05 was considered significant. RESULTS: In the bivariate analysis, only the UAT and FMC marks were correlated (r=0.34; p=0.02). However, the multiple dependency study showed a moderate correlation among UAT, OSCE, PT, and FMC marks (r=0.46; p=0.01). No correlation was found between the essay scores and PT, FMC, and OSCE scores. CONCLUSION: Our study shows that UAT marks, but not essay scores, can predict academic achievement, particularly in terms of clinical competence (FMC) at the end of a medical course in a PBL hybrid curriculum.

Abnormalities in electrocardiographic ventricular repolarization in patients with dengue virus infection.

INTRODUCTION: Dengue virus infection (DENV) is an arboviral disease that affects millions of people in many countries throughout the world every year. The disease is caused by the bite of a mosquito (Aedes aegypti and / or Aedes albopictus). The symptoms/signs observed in this arboviral disease are unspecific, and the blood count usually shows leukopenia and thrombocytopenia. Although ECG changes may be observed in DENV, little is known about parameters of ventricular repolarization in patients with this condition. Accordingly, the aim of this study was to evaluate the QTc and QT interval dispersion to detect ventricular repolarization changes in patients with DENV. METHODOLOGY: Ninety-three consecutive patients seen during DENV epidemics in a small town with non-complicated DENV were included; 93 normal individuals served as controls. Clinical data, blood count and the 12-lead ECG were obtained from each individual. RESULTS: The QTc duration was higher in patients with DENV in comparison to controls. Furthermore, 5% of DENV patients had abnormal lengthening of the QTc interval. No difference regarding QT interval dispersion was observed between DENV patients and controls. No DENV patient had increased lengthening of the QT interval dispersion. CONCLUSIONS: Myocardial repolarization changes do occur in patients with DENV. Having into account the potential impact of these changes on patients' outcome, and because 12-lead ECG is not routinely recommended in the setting of DENV in our country, we recommend that a 12-lead ECG be taken from each patient with this condition during DENV epidemics.