Detection of DENV-2 and ZIKV coinfection in southeastern Brazil by serum and urine testing.

PURPOSE: Aedes aegypti mosquito-borne diseases have a significant impact on public health in Brazil. In this study, we investigated the presence of the Zika virus (ZIKV) and dengue virus (DENV) in serum and urine samples from symptomatic participants who attended an Emergency Care Unit located in a city in the northwestern region of São Paulo between February 2018 and April 2019. METHODS: Serum and urine samples were collected from participants suspected of having arbovirus infection. After the extraction of viral RNA, viral detection was performed by real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) (One-Step RT-qPCR). RESULTS: A total of 305 participants participated in this study. A total of 283 blood and 270 urine samples were collected. Of 305 patients, 36.4% (111/305) were positive for ZIKV, 43.3% (132/305) for DENV2, and 0.3% (1/305) for DENV1. Coinfection with ZIKV/DENV2 was observed in 13.1% of participants. If only serum samples were used, ZIKV detection would have decreased to 23.3% (71/305). Of all the participants included in the study, only one was suspected of having ZIKV infection based on clinical diagnosis, and the remaining participants were suspected of having DENV. CONCLUSION: By testing serum and urine samples, we increased the detection of both viruses and detected considerable levels of ZIKV and DENV-2 coinfection when compared to other studies. Additionally, we detected an unnoticed ZIKV outbreak in the city. These findings highlight the importance of the molecular diagnosis of arboviruses to aid public health surveillance and management strategies.

Detection of Zika virus in urine from randomly tested individuals in Mirassol, Brazil.

PURPOSE: Studies show that around 80% of Zika virus (ZIKV) infections are asymptomatic. The present study tested urine samples from volunteers, unsuspected of arboviral infection, which attended an emergency care unit (ECU) in Mirassol, Brazil, from March 2018 to April 2019. METHODS: The volunteers were divided into two groups. The first group was composed of outpatients who were not suspected to have an arbovirus infection. This first group was subdivided into two subgroups: outpatients with and without arbovirus-like symptoms. The second group consisted of companions of outpatients treated at the ECU. The second group was also subdivided into two subgroups: totally asymptomatic individuals and those who had arbovirus-like symptoms. RNA was extracted from urine samples, followed by RT-qPCR for ZIKV. RESULTS: We found that 11% (79/697) of the samples tested positive for ZIKV-RNA. Among the ZIKV-RNA-positive individuals, 16.5% (13/79) were companions, of which 61.5% (8/13) were totally asymptomatic and 38.5% (5/13) reported symptoms that could be suggestive of arbovirus infection. In addition, 83.5% (66/79) of the ZIKV-RNA-positive individuals were outpatients without a clinical diagnosis of arbovirus. Of these undiagnosed ZIKV-RNA-positive outpatients, 47% (31/66) had no arbovirus-related symptoms. CONCLUSION: Our study shows the effectiveness of urine as a non-invasive sample to detect the incidence of ZIKV infection. We also highlight the importance of ZIKV molecular diagnosis to aid public health surveillance and prevention of congenital Zika syndrome and other ZIKV-associated diseases.

Heart Rate Variability Assessment and Its Application for Autonomic Function Evaluation in Patients with Hyperhidrosis.

BACKGROUND: Pathophysiology mechanism of primary focal hyperhidrosis (PFHH) is controversial. Heart rate variability (HRV) could explain if there is a systemic component present. We aimed to investigate the functions of the autonomic nervous system in patients diagnosed with PFHH compared to controls using the analysis of HRV in the domains of time, frequency, and nonlinearity, as well as analysis of the recurrence plots (RPs). METHODS: We selected 34 patients with PFHH (29.4 ± 10.2 years) and 34 controls (29.2 ± 9.6 years) for HRV analysis. Heart beats were recorded with Polar RS800CX monitor (20 min, at rest, in supine position), and RR intervals were analyzed with Kubios Premium HRV software. RPs were constructed with Visual Recurrence Analysis software. Statistical analysis included unpaired t test (p < 0.05). RESULTS: Our results showed that HRV parameters in the 3 domains evaluated did not show any differences between the groups. The same was observed with RPs. CONCLUSIONS: The findings suggest that PFHH, from the pathophysiological point of view, may be caused by peripheral involvement of the sympathetic nervous system (glandular level or nerve terminals), as there was no difference between the groups studied. More specific studies should help elucidate this issue.

Does heart rate variability improve prediction of failed extubation in preterm infants?

Background Prematurity and its respective comorbidities may result in longer periods of mechanical ventilation in intensive care units (ICU). A method for the assessment of organic maturity would be useful for this population. Heart rate variability (HRV), as an indicator of homeostasis, is a well-established tool for this approach. The objective of the study was to assess HRV in intubated preterm infants in ICU immediately prior to extubation and correlate HRV with clinical evaluation outcomes. Methods A total of 46 preterm infants, 13 (28.2%) males, were prospectively studied and divided into a group with failed extubation (FEG: n=11) and a group with successful extubation (SEG: n=35). HRV was evaluated in time, frequency and nonlinear domains with a Polar RS800 device. HRV measurements were assessed with Kubios HRV Premium Software and statistically analyzed with the StatsDirect Statistical Software, version 1.9.2015 (2002). P<0.05 values were considered as statistically significant. Results There were no significant differences between heart rate variables of failed and successful extubation when analyzing the total group. However, the analysis of the sub-group of preterm infants weighing less than 1000 g showed a clear differentiation between the groups, when the nonlinear variables (approximate entropy, sample entropy and multiscale entropy 1, 2 and 3) were used, demonstrating that the group with successful extubation shows greater complexity and, therefore, relatively greater autonomic stability. Conclusion HRV was effective in predicting failed extubation in preterm infants when evaluated in a nonlinear domain and in preterm infants weighing less than 1000 g.

Effects of acute blood pressure elevation on biochemical-metabolic parameters in individuals with hypertensive crisis.

Hypertensive crisis is a common clinical situation that presents a high rate of morbidity and mortality and it is characterized by symptomatic rise of blood pressure (BP), systolic (SBP) ≥ 180 mmHg and/or diastolic (DBP) ≥ 120 mmHg. It is classified as emergency (HE) or hypertensive urgency (HU). There is no description of laboratory findings in patients who present acute BP elevation. Thus, this study had the objective to assess the biochemical-metabolic parameters of patients with HC. We studied 74 normotensive individuals (NT), 74 controlled hypertensive patients (ContrHT), 50 subjects with HU, and 78 with HE for evaluating biochemical-metabolic parameters. HE occurs in older individuals and more frequently in those with known hypertension. More patients with HE had dyslipidemia than those with HU (58% vs. 38%). The diastolic BP and heart rate were higher in the HE group (120 mmHg and 87 bpm) compared to ContrHT (71 mmHg and 71 bpm; p < 0.0001) and NT groups (75 mmHg and 68 bpm; p < 0.0001). Glycemia was higher in HE vs. NT and ContrHT (p < 0.05). HDL cholesterol was lower in HE than NT (p = 0.0088). Potassium was lower in HE vs. NT, ContrHT and HU groups (p < 0.05). Creatinine was higher in the HC group vs. NT and ContrHT (p < 0.05). The GFR was significantly lower in HE group vs. HU, ContrHT and NT (p < 0.001). In conclusion, individuals with HC show biochemical alterations when compared to ContrHT and NT. Acute BP elevations are associated with hyperglycemia, dyslipidemia, and higher potassium and creatinine levels and lower renal function. Abbreviations BMI = body mass index BP = blood pressure CH = hypertensive crisis ContrHT = controlled hypertensive DBP = diastolic blood pressure GFR = glomerular filtration rate HbA1c = glycated hemoglobin HDLc = high-density lipoprotein cholesterol HE = hypertensive emergency HPLC = high-performance liquid chromatography HR = heart rate HU = hypertensive urgency JNC 7 = VII Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure LDLc = low-density lipoprotein cholesterol MDRD = Modification of Diet in Renal Disease NT = normotensive RASB = renin-angiotensin system blockers SBP = systolic blood pressure TC = total cholesterol TG = triglycerides.

Cardiac autonomic modulation of children with Down syndrome.

The aim of this study is to analyze the autonomic modulation in children with Down syndrome (DS). The study was conducted with a convenience sample of children with DS and without heart disease, from the Genetics Clinic of the Hospital Infantil Darcy Vargas and APAE São Paulo, São Paulo, SP, Brazil. The control group was matched for sex and age. The analysis of autonomic modulation was performed using the indices of heart rate variability (HRV). The children remained in the supine position with spontaneous breathing for 20 min. Heart rate was recorded beat-to-beat. HRV analysis was performed in time and frequency domain. For data analysis, we used Student's t test: unpaired and Mann-Whitney. It was considered statistically significant at p < 0.05. From 75 children with DS, 50 were excluded, a total of 25 children [16 boys, 8.6 (1.4) years] participated in this study, and the control group also consisted of 25 children [16 boys, 9.0 (1.2) years] without the syndrome. The BMI of the volunteers with DS was higher than the controls [19.1 (2.9) vs. 15.8 (1.2), p < 0.0001]. There were differences between groups in the indices in frequency domain: LFms(2) [1242.1 (788.25) vs. 786.44 (481.90), p = 0.040], LFun [69.104 (11.247) vs. 57.348 (11.683), p = 0.0004], HFun [30.896 (11.247) vs. 42.520 (11.634), p = 0.0004] and LF/HF [2.594 (1.104) vs. 1.579 (0.9982), p = 0.0004]. No differences were observed in time domain indices. The results indicate increased indices representing the sympathetic branch of the autonomic nervous system and those that indicate the overall modulation in children with DS.

Quantification of fractal dimension and Shannon's entropy in histological diagnosis of prostate cancer.

BACKGROUND: Prostate cancer is a serious public health problem that affects quality of life and has a significant mortality rate. The aim of the present study was to quantify the fractal dimension and Shannon's entropy in the histological diagnosis of prostate cancer. METHODS: Thirty-four patients with prostate cancer aged 50 to 75 years having been submitted to radical prostatectomy participated in the study. Histological slides of normal (N), hyperplastic (H) and tumor (T) areas of the prostate were digitally photographed with three different magnifications (40x, 100x and 400x) and analyzed. The fractal dimension (FD), Shannon's entropy (SE) and number of cell nuclei (NCN) in these areas were compared. RESULTS: FD analysis demonstrated the following significant differences between groups: T vs. N and H vs. N groups (p < 0.05) at a magnification of 40x; T vs. N (p < 0.01) at 100x and H vs. N (p < 0.01) at 400x. SE analysis revealed the following significant differences groups: T vs. H and T vs. N (p < 0.05) at 100x; and T vs. H and T vs. N (p < 0.001) at 400x. NCN analysis demonstrated the following significant differences between groups: T vs. H and T vs. N (p < 0.05) at 40x; T vs. H and T vs. N (p < 0.0001) at 100x; and T vs. H and T vs. N (p < 0.01) at 400x. CONCLUSIONS: The quantification of the FD and SE, together with the number of cell nuclei, has potential clinical applications in the histological diagnosis of prostate cancer.

Use of Ozonized Water in the Prevention of Surgical Site Infection in Children Undergoing Cardiovascular Surgery.

INTRODUCTION: Since the reduction of healthcare-associated infections has been a focus for quality patient care, this study aimed to evaluate the surgical site infection rate of children who underwent cardiovascular surgery after implementation of ozonized water system for hand and body hygiene allied to previously implemented preventive measures. METHODS: Two uniformly comparable groups of pediatric patients underwent cardiovascular surgery. Group A (187) patients were operated prior to installation of ozonized water system (March 1 to August 31, 2019), and group B (214) patients were operated after installation of ozonized water system (October 1, 2019, to March 31, 2020). Ozonized water was used for professional hand hygiene and patient body hygiene. RESULTS: There was statistical significance for surgical site infection reduction in group B (P=0.0289), with a relative risk of 0.560 (95% confidence interval = 0.298 to 0.920), inferring the risk of being diagnosed with surgical site infections in group B was 44% less than in group A. There was no statistical significance regarding mechanical ventilation time (P=0.1998) or mortality (P=0.4457). CONCLUSION: Ozonized water for professional hand hygiene and patient body hygiene was an adjuvant combined with traditional preventive methods to reduce the risk of surgical site infection, although no impact on hospital stay or mortality was observed.

The impact of chronic cardiovascular disease on COVID-19 clinical course.

Background: According to previous univariate analyses, chronic cardiovascular disease (CVD) has been associated with worse prognoses in severe cases of coronavirus disease 2019 (COVID-19). However, in the presence of a complex system, such as a human organism, the use of multivariate analyses is more appropriate and there are still few studies with this approach. Aim: Using a significant sample of patients hospitalized in a single center, this study aimed to evaluate, whether the presence of CVD was an independent factor in death due to COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We also aimed to identify the clinical and laboratory predictors of death in an isolated group of cardiac patients. Methods: This case-control study was conducted with patients admitted to a tertiary hospital and affected by COVID-19 in 2020. Variables were collected from the Brazilian surveillance system of hospitalized cases (SIVEP-Gripe) and electronic medical records. Multivariate logistic regressions with backward elimination were performed to analyze, whether CVD was an independent risk factor for death, and variables with P < 0.05 remained in the final model. Results: A total of 2675 patients were analyzed. The median age was 60.4 years, and 55.33% of the patients were male. Odds ratios showed that age (OR 1.059), male sex (OR 1.471), Down syndrome (OR 54.980), diabetes (OR 1.626), asthma (OR 1.995), immunosuppression (OR 2.871), obesity (OR 1.432), chronic lung disease (OR 1.803), kidney disease (OR 1.789), and neurological diseases (OR 2.515) were independently associated with death. Neither the presence of heart disease nor the isolated analysis of each chronic CVD element (systemic arterial hypertension, congenital heart disease, previous acute myocardial infarction and cardiac surgery, obstructive coronary artery disease, valvular heart disease, and pacemaker use) showed as independent risk factors for death. However, an analysis restricted to 489 patients with chronic CVD showed troponin T (TnT) as an independent predictor of death (OR 4.073). Conclusions: Neither chronic CVD nor its subcomponents proved to be independent risk factors for death due to SARS-CoV-2 infection. A TnT level of 14 pg/mL was associated with a higher occurrence of death in the isolated group of patients with chronic heart disease. Relevance for Patients: Patients with chronic CVD may require more attention in the context of COVID-19 due to higher proportions of these individuals having a more severe progression of disease. However, regarding mortality in these patients, further studies should be conducted concerning comorbidities and acute myocardial injury.

Pediatric Heart Transplant: Initial Experience in a Tertiary Center in Brazil.

INTRODUCTION: Pediatric heart transplantation is the definitive therapy for children with end-stage heart failure. This paper describes our initial experience in pediatric heart transplantation in a tertiary center in Brazil. METHODS: This is a historical prospective descriptive cohort study based on a review of the medical records of children undergoing heart transplantation at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto. Variables were displayed as frequency, mean, or median. Statistical analysis and Kaplan-Meier actuarial curve were obtained with the aid of Microsoft® Excel® 2019 and STATSDirect version 3.3.5. RESULTS: Between January 2010 and December 2020, ten children underwent bicaval orthotopic heart transplantation, 30% of which were under one year of age. Nine patients had end-stage heart failure (International Society for Heart and Lung Transplantation-Heart Failure D) and 50% of the recipients were transplanted under conditions of progressive clinical deterioration (Interagency Registry for Mechanically Assisted Circulatory Support ≤ 2). Forty percent of the recipients had a panel-reactive antibody > 20% on virtual crossmatch. In the postoperative period, 80% of patients required high dose of inotropic support (vasoactive-inotropic score > 10) for > 48 hours. The death-free survival rate at 131 months was 77.1±14.4%. Most patients (88.9%) in late follow-up had an episode of active cytomegalovirus infection. Cellular rejection, with or without clinical repercussion, was present in 44.4% of the patients. CONCLUSION: Pediatric heart transplantation produces acceptable and feasible outcomes as definitive therapy for children with end-stage heart failure.

Linear and non-linear analyses of autonomic modulation in uncontrolled and controlled elderly resistant hypertensives.

Resistant hypertension (RHT) is associated with worse outcomes among patients, and sympathetic overactivity is a challenge in treating this clinical condition. Here, we evaluated the autonomic modulation (by linear and non-linear analyses), central blood pressure, and pulse wave velocity in controlled and uncontrolled RHT patients, as well as those in use of beta-blockers. We observed that uncontrolled RHT patients display, in addition to an increase in peripheral blood pressure, presented higher central blood pressure values concerning controlled RHT. Furthermore, despite the use of beta-blockers, both patients in the RHT + beta-blockers and uncontrolled RHT groups had negative changes in autonomic balance as compared with controlled RHT. These results reinforce the importance of autonomic nervous system interventions in managing arterial hypertension.

Influence of an Early Mobilization Protocol on the Autonomic Behavior of Patients Undergoing Percutaneous Transluminal Coronary Angioplasty. / Influência de um Protocolo de Mobilização Precoce no comportamento autonômico de pacientes submetidos a Angioplastia Coronária Transluminal Percutânea.

BACKGROUND: Recurrence Plots (RP) enable a nonlinear analysis of Heart Rate Variability (HRV) and provide information on the Autonomic Nervous System (ANS). OBJECTIVES: To evaluate whether early ambulation in patients undergoing Percutaneous Transluminal Coronary Angioplasty (PTCA) influences the quantitative and qualitative components of RP. METHODS: A total of 32 participants who underwent PTCA were divided into a Control Group (CG - no physical exercises) and an Early Ambulation Group (EAG - with physical exercises). Beat-to-beat heart rate was recorded using a heart rate monitor in both groups upon admission and discharge. The linear indices in the time and frequency domains were analyzed, and nonlinear indices were obtained through RP. The Early Ambulation Physical Therapy Protocol began 12-18 hours after PTCA. A two-tailed unpaired t-test was used for comparisons, and p-values < 0.05 were accepted as significant. RESULTS: When comparing both groups, upon discharge, EAG showed an increase in SDNN (23.55 ± 12.05 to 37.29 ± 16.25; p=0.042), Triangular Index (8.99 ± 3.03 to 9.66 ± 3.07; p=0.014), and VLF (694.20 ± 468.20 to 848.37 ± 526.51; p=0.004), but without significant changes in the nonlinear evaluation. In addition, in the qualitative analysis of RP, a more diffuse and less geometric pattern was observed in EAG, indicating greater variability, while in CG, an altered and more geometric pattern was noted. CONCLUSION: The Early Ambulation Protocol promotes an improvement in autonomic behavior as evaluated by HRV and by RP, which can thus be considered a useful procedure for better recovery of patients undergoing PTCA.

FUNDAMENTO: Gráficos de recorrência (GR) permitem uma análise não linear da variabilidade de frequência cardíaca (VFC) e fornecem informações sobre o sistema nervoso autônomo (SNA). OBJETIVOS: Avaliar se a mobilização precoce em pacientes submetidos a angioplastia coronária transluminal percutânea (ACTP) influencia os componentes quantitativos e qualitativos dos GR. MÉTODOS: Um total de 32 participantes que foram submetidos a ACTP foram divididos entre um grupo de controle (GC - sem exercícios físicos) e grupo de mobilização precoce (GMP - com exercícios físicos) A frequência cardíaca batimento a batimento foi registrada utilizando um cardiofrequencímetro em ambos os grupos na admissão e na alta. Os índices lineares nos domínios de tempo e frequência foram analisados, bem como os índices não lineares obtidos pelos GR. O protocolo fisioterapêutico de mobilização precoce começou 12-18 horas após a ACTP. Um teste T não pareado bicaudal foi utilizado para as comparações, e p-valores <0,05 foram aceitos como significativos. RESULTADOS: Ao comparar os dois grupos, na alta, o GMP apresentou um aumento no SDNN (23,55 ± 12,05 a 37,29 ± 16,25; p=0,042), índice triangular (8,99 ± 3,03 a 9,66 ± 3,07; p=0,014) e VLF (694,20 ± 468,20 a 848,37 ± 526,51; p=0,004), mas não apresentou alterações significativas na avaliação não linear. Além disso, na análise qualitativa dos GR, observou-se um padrão mais difuso e menos geométrico no GMP, indicando maior variabilidade, enquanto no GC, notou-se um padrão geométrico mais alterado. CONCLUSÃO: O protocolo de mobilização precoce promove uma melhoria no comportamento autonômico, conforme avaliado por VFC e GR, e pode ser considerado um procedimento útil para a melhor recuperação de pacientes submetidos a ACTP.

Genetic polymorphisms involved in folate metabolism and concentrations of methylmalonic acid and folate on plasma homocysteine and risk of coronary artery disease.

OBJECTIVES: Alterations in the enzymes involved in homocysteine (Hcy) metabolism or vitamin deficiency could play a role in coronary artery disease (CAD) development. This study investigated the influence of MTHFR and MTR gene polymorphisms, plasma folate and MMA on Hcy concentrations and CAD development. MMA and folate concentrations were also investigated according to the polymorphisms. METHODS: Two hundred and eighty-three unrelated Caucasian individuals undergoing coronary angiography (175 with CAD and 108 non-CAD) were assessed in a case-control study. Plasma Hcy and MMA were measured by liquid chromatography/tandem mass spectrometry. Plasma folate was measured by competitive immunoassay. Dietary intake was evaluated using a nutritional questionnaire. Polymorphisms MTHFR and MTR were investigated by polymerase chain reaction (PCR) followed by enzyme digestion or allele-specific PCR. RESULTS: Hcy mean concentrations were higher in CAD patients compared to controls, but below statistical significance (P = 0.246). Increased MMA mean concentrations were frequently observed in the CAD group (P = 0.048). Individuals with MMA concentrations >0.5 micromol/l (vitamin B(12) deficiency) were found only in the CAD group (P = 0.004). A positive correlation between MMA and Hcy mean concentrations was observed in both groups, CAD (P = 0.001) and non-CAD (P = 0.020). MMA mean concentrations were significantly higher in patients with hyperhomocysteinemia in both groups, CAD and non-CAD (P = 0.0063 and P = 0.013, respectively). Folate mean concentration was significantly lower in carriers of the wild-type MTHFR 1298AA genotype (P = 0.010). CONCLUSION: Our results suggest a correlation between the MTHFR A1298C polymorphism and plasma folate concentration. Vitamin B(12) deficiency, reflected by increased MMA concentration, is an important risk factor for the development both of hyperhomocysteinemia and CAD.

Non-linear analysis of the heart rate variability in characterization of manic and euthymic phases of bipolar disorder.

BACKGROUND: - Bipolar Disorder (BD) has been associated with autonomic nervous system (ANS) dysregulation, with a consequent increase in mortality. Recent work highlights the non-linear analysis of ANS function. Our objective was to compare ANS modulation using recurrence plots (RP) and symbolic analysis (SA) in manic and euthymic phases of BD to controls. METHODS: - Eighteen male patients (33.1 ±â€¯12.0 years) were assessed during mania and at discharge in the euthymic phase compared and to a healthy group matched by age (33.9 ±â€¯10.8 years). Electrocardiographic series (1000 RR intervals, at rest, in supine position) were captured using Polar Advantage RS800CX equipment and Heart Rate Variability (HRV) was analysed using RP and SA. Statistical analysis was performed using ANOVA with Tukey's post-test. The threshold for statistical significance was set at P < 0.05 and Cohen's d effect size was also quantified considering d > 0.8 as an important effect. The study was registered into the Clinical Trials Registration (ClinicalTrials.gov: NCT01272518). RESULTS: Manic group presented significantly higher linearity before treatment (P<0.05) compared to controls considering RP variables. Cohen's d values had a large effect size ranging from 0.888 to 1.227. In the manic phase, SA showed predominance of the sympathetic component (OV%) with reduction of the parasympathetic component (2LV% and 2UV%) with reversion post treatment including higher Shannon Entropy (SE) indicating higher complexity. LIMITATIONS: - short follow-up (1 month) and small number of patients. CONCLUSIONS: - Non-linear analyzes may be used as supplementary tools for understanding autonomic function in BD during mania and after drug treatment.

Preoperative nonlinear behavior in heart rate variability predicts morbidity and mortality after coronary artery bypass graft surgery.

BACKGROUND: The aim was to demonstrate that a reduction in the nonlinear behavior of heart rate variability (HRV) in the preoperative period in patients undergoing coronary artery bypass graft (CABG) triggers higher morbidity and mortality rates in the postoperative stay. MATERIAL/METHOD: Seventy patients (59+/-10.3 years) were included. HRV was captured by a Polar Advanced S810 heart rate monitor and analyzed using the nonlinear variables detrended fluctuation analysis (DFA), autocorrelation (tau), Lyapunov exponent (LE), and the Poincaré plot (PP). Based on two scenarios, death vs. non-death (scenario 1) and events vs. their absence (scenario 2), the occurrence of neurological complications, infections, kidney failure, arrhythmia, and death were evaluated. Sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio (95% CI) were recorded. RESULTS: In scenario 1, significant differences were found for DFA, alpha-2, LE, PP[SD1], and PP[SD2], with p-values of 0.0172, 0.0343, 0.0159, 0.0069, and 0.0287, respectively. In scenario 2, differences were found for alpha-1, alfa-2, tau, LE, PP[SD1], and PP[SD2], with p-values of 0.0066, 0.0426, 0.0188, 0.0108, 0.0005, and 0.0158, respectively. The best areas under ROC curve were seen in scenario 1, with values of 0.72 (tau), 0.77 (LE), and 0.78 (PP[SD1]). CONCLUSIONS: Analysis of HRV in the nonlinear domain in the preoperative period in patients undergoing elective CABG surgery may detect subgroups with a high risk for postoperative complications, at least with the assistance of some of the variables, and it can become a new prognostic tool for assessing patients scheduled to undergo other major surgeries.

[MTHFR genetic variability on coronary artery disease development]. / Variabilidade genética MTHFR no desenvolvimento da doença arterial coronária.

OBJECTIVE: Increased homocysteine (Hcy) concentration is considered a risk factor for coronary artery disease (CAD). Genetic alterations of the metylenetetrahydrofolate reductase (MTHFR) enzyme could reduce its thermolability and alter the Hcy metabolism, contributing to development of atherosclerotic lesions. Objective of this study was to investigate the relation between MTHFR C677T and A1298C polymorphisms and presence, extension, and severity of CAD. METHODS: One hundred seventy-five patients with CAD confirmed by angiography, and 108 individuals without CAD (control group) were evaluated. MTHFR C677T polymorphism was investigated by polymerase chain reaction (PCR) followed by enzyme digestion. The genotyping of the MTHFR A1298C polymorphism was performed by PCR allele-specific method. RESULTS: Frequency of the altered allele MTHFR 677C was 0.38 in the CAD group and 0.37 in the control group. Regarding the polymorphic allele MTHFR 1298C, frequency was 0.22 and 0.27, respectively. The genotype distribution MTHFR C677T and A1298C did not differ regarding number of affected vessels (P > 0.05). Also, relation between MTHFR C677T polymorphism and degree of arterial obstruction was not observed (P > 0.05), as well as the MTHFR A1298C polymorphism (P > 0.05). CONCLUSION: Results did not show association between MTHFR A1298C and MTHFR C677T polymorphisms and presence, extension or severity of CAD.

Reparação da parede abdominal com membranas acelulares de pericárdio bovino - Parte II - Análises histológicas e morfométricas / Repair of the abdominal wall with acellular bovine pericardial membranes - Part II - Histological and morphometric analyses

Introdução: Análise histológica é a principal ferramenta de avaliação de biopróteses acelulares, em sua maioria em caráter experimental. O objetivo é analisar histologicamente a matriz acelular de pericárdio bovino em reparações de parede abdominal implantada em humanos. Método: De uma série de 30 reparações com a membrana, 3 pacientes foram submetidas a revisão cirúrgica não relacionada aos implantes, aos 13, 22 e 23 meses de pós-operatório, obtendo-se biópsias das áreas previamente implantadas. Além da avaliação dos aspectos básicos de biocompatibilidade e neoformação tecidual, as lâminas foram digitalizadas e submetidas a análise computadorizada com o software ImageJ para quantificação da cinética de degradação das membranas, associada à análise da dimensão fractal das amostras. Os valores obtidos para porcentagens de membrana residual tiveram suas médias comparadas por análise de variância (ANOVA) e pelo teste T de Student não pareado, também utilizado para os valores da quantificação da dimensão fractal. Resultados: Foi demonstrada a biocompatibilidade do material, com neoformação tecidual, deposição de colágeno e tecido celularizado de aspecto normal, sem reações locais importantes. Fragmentos residuais da membrana foram quantificados em 40%±7% aos 13 meses, em 20%±6% aos 22 meses e em 17%±6% aos 23 meses de pós-operatório, com a análise da dimensão fractal indicando uma progressiva degradação dos implantes, com significância estatística entre 13 meses e as amostras tardias. Conclusão: Os resultados atestaram a funcionalidade do pericárdio bovino acelular sob diferentes níveis de estresse mecânico nas reparações da parede abdominal em humanos.

Introduction: Histological analysis is the main tool for evaluating acellular bioprostheses, mostly on an experimental basis. The objective is to histologically analyze the acellular matrix of bovine pericardium in abdominal wall repairs implanted in humans. Method: From a series of 30 repairs with the membrane, 3 patients underwent surgical revision unrelated to the implants at 13, 22, and 23 months postoperatively, obtaining biopsies of the previously implanted areas. In addition to evaluating the basic aspects of biocompatibility and tissue neoformation, the slides were digitalized and subjected to computerized analysis with the ImageJ software to quantify the kinetics of membrane degradation associated with the analysis of the fractal dimension of the samples. The values obtained for percentages of residual membrane had their means compared by analysis of variance (ANOVA) and the unpaired Student's T test, also used for the fractal dimension quantification values. Results: The biocompatibility of the material was demonstrated, with tissue neoformation, collagen deposition, and cellularized tissue with a normal appearance without important local reactions. Residual fragments of the membrane were quantified at 40%±7% at 13 months, at 20%±6% at 22 months, and at 17%±6% at 23 months postoperatively, with the analysis of the fractal dimension indicating a progressive degradation of implants, with statistical significance between 13 months and late samples. Conclusion: The results confirmed the functionality of the acellular bovine pericardium under different levels of mechanical stress in abdominal wall repairs in humans.

Evaluation of Cardiac Autonomic Modulation Using Symbolic Dynamics After Cardiac Transplantation.

OBJECTIVE: To characterize the behavior of cardiac autonomic modulation in individuals with different times after orthotopic heart transplantation (HTx) using symbolic dynamics analysis. METHODS: Sixty patients were evaluated after HTx. We recorded their instantaneous R-R intervals (RRi) by cardiac monitor Polar® RS800CX™ (Polar Electro Oy, Kempele, Finland) for 10 minutes. The same sequence of RRi with 256 consecutive beats was used to perform spectral analysis and symbolic dynamics analysis. We used hierarchical clustering to form groups. One-way analysis of variance (ANOVA) (with Holm-Sidak method) or one-way Kruskal-Wallis test (with Dunn´s post-hoc test) was used to analyze the difference between groups. Linear correlation analysis between variables was performed using Pearson's or Spearman's tests. P-value < 0.05 was considered statistically significant. RESULTS: The 0V% index increased, the 2UV% index and the normalized complexity index decreased with an increase of HTx postoperative time. There were a negative correlation between complexity indexes and 0V% and a positive correlation between complexity indexes and 2UV%. CONCLUSION: Symbolic dynamics indexes were able to show a specific cardiac autonomic modulation pattern for HTx recipients with different postoperative times.

Effect of Preoperative Creatinine Levels on Mortality after Coronary Artery Bypass Grafting Surgery: an Observational Study.

INTRODUCTION: Renal function is an independent risk factor for mortality among on-pump coronary bypass grafting (ONCABG) patients. This association is well known in the international literature, but there is a lack of knowledge of how admission creatinine (AC) levels modulate each cardiovascular risk factor. OBJECTIVE: The aim of this paper was to assess the effect of different AC levels on mortality among ONCABG patients. METHODS: 1,599 patients who underwent ONCABG between December 1999 and February 2006 at Hospital de Base in São José do Rio Preto/SP-Brazil were included. They were divided into quartiles according to their AC levels (QI: 0.2 ≤AC < 1.0 mg/dL; QII: 1.0 ≤ AC < 1.2 mg/dL; QIII: 1.2 ≤ AC < 1.4 mg/dL; and QIV: 1.4 ≤ AC ≤ 2.6 mg/dL). Seven risk factors were then evaluated in each stratum. RESULTS: Mortality was higher in the QIV group than QI or QII groups. Factors such as age (≥ 65 years) and cardiopulmonary bypass (CPB) time (≥ 115 minutes) in QIV, as well preoperative hospital stay (≥ 5 days) in QIII, were associated with higher mortality rates. Creatinine variation greater than or equal to 0.4 mg/dL increased mortality rates in all groups. The use of intra-aortic balloon pump and dialysis increased mortality rates in all groups except for QII. Type I neurological dysfunction increased the mortality rate in the QII and III groups. CONCLUSION: Creatinine levels play an important role in ONCABG mortality. The combination of selected risk factors and higher AC values leads to a worse prognosis. On the other hand, lower AC values were associated with a protective effect, even among elderly patients and those with a high CPB time.

Surgical Treatment for Congenital Heart Defects in Down Syndrome Patients.

OBJECTIVE: To analyze data related to surgical treatment in patients with congenital heart defects (CHD) and Down syndrome (DS) based on information from International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). METHODS: Between July 1, 2010 and December 31, 2017, 139 patients with CHD and DS underwent surgery at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME)/Faculdade de Medicina de São José do Rio Preto - SP (FAMERP). A quantitative, observational and cross-sectional study was performed in which the pre, intra and postoperative data were analyzed in an IQIC database. The data included gender, age, prematurity, weight, preoperative procedures, diagnosis, associated cardiac and non-cardiac anomalies, Risk Adjustment for Congenital Heart Surgery (RACHS-1), type of surgery, cardiopulmonary bypass (CPB), perfusion time, aortic clamping time and CPB temperature, bacterial sepsis, surgical site infection and other infections, length of stay in intensive care unit (ICU), length of hospital stay and in-hospital mortality. RESULTS: The most prevalent procedures were complete atrioventricular septal defect repair (58 - 39.45%), followed by closure of ventricular septal defect (36 - 24.49%). The RACHS-1 categories 1, 2, 3 and 4 were distributed as 22 (15%); 49 (33.3%); 72 (49%) and 4 (2.7%), respectively. There were no procedures classified as categories 5 or 6. Bacterial sepsis occurred in 10.2% of cases, surgical site infection in 6.1%, other infections in 14.3%. The median length of ICU stay was 5 days and the median length of hospital stay was 11 days. In-hospital mortality was 6.8%. CONCLUSION: Surgical treatment in patients with CHD and DS usually does not require highly complex surgical procedures, but are affected by infectious complications, resulting in a longer ICU and hospital length of stay with considerable mortality.