Predicting short-term mortality in patients with acute exacerbation of chronic heart failure: The EAHFE-3D scale. / Predicción de la mortalidad a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada: escala EAHFE-3D.

INTRODUCTION AND OBJECTIVES: Prognostic scales are needed in acute exacerbation of chronic heart failure to detect early mortality. The objective of this study is to create a prognostic scale (scale EAHFE-3D) to stratify the risk of death the very short term. PATIENTS AND METHOD: We used the EAHFE database, a multipurpose, multicenter registry with prospective follow-up currently including 6,597 patients with acute heart failure attended at 34 Spanish Emergency Departments from 2007 to 2014. The following variables were collected: demographic, personal history, data of acute episode and 3-day mortality. The derivation cohort included patients recruited during 2009 and 2011 EAHFE registry spots (n=3,640). The classifying variable was all-cause 3-day mortality. A prognostic scale (3D-EAHFE scale) with the results of the multivariate analysis based on the weight of the OR was created. The 3D-EAHFE scale was validated using the cohort of patients included in 2014 spot (n=2,957). RESULTS: A total of 3,640 patients were used in the derivation cohort and 102 (2.8%) died at 3 days. The final scale contained the following variables (maximum 165 points): age≥75 years (30 points), baseline NYHA III-IV (15 points), systolic blood pressure<110mmHg (20 points), room-air oxygen saturation<90% (30 points), hyponatremia (20 points), inotropic or vasopressor treatment (30 points) and need for noninvasive mechanical ventilation (20 points); with a ROC curve of 0.80 (95% CI 0.76-0.84; P<.001). The validation cohort included 2,957 patients (66 died at 3 days, 2.2%), and the scale obtained a ROC curve of 0.76 (95% CI 0.70-0.82; P<.001). The risk groups consisted of very low risk (0-20 points), low risk (21-40 points), intermediate risk (41-60 points), high risk (61-80 points) and very high risk (>80 points), with a mortality (derivation/validation cohorts) of 0/0.5, 0.8/1.0, 2.9/2.8, 5.5/5.8 and 12.7/22.4%, respectively. CONCLUSIONS: EAHFE-3D scale may help to predict the very short term prognosis of patients with acute heart failure in 5 risk groups.

Clinical features, management in the emergency department and mortality of acute heart failure episodes in patients with chronic obstructive pulmonary disease.

OBJECTIVES: This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease (COPD) who present to the emergency department with acute heart failure (AHF). Additionally, it examines mortality rates during such episodes. METHODS: We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD. We compared their baseline characteristics, decompensation episodes, and emergency department management with those of AHF patients without COPD during the same period. We collected data on in-hospital and 30-day all-cause mortality, investigating differences between the two groups using crude and adjusted logistic regression models. RESULTS: A total of 21,694 AHF patients were analysed (median age = 83 years, 56% female), including 4,942 (23%) with COPD. COPD patients were generally younger and more frequently male, with a higher prevalence of comorbidities (excluding valve disease and dementia, which were more common in non-COPD patients). They exhibited a worse respiratory functional class (NYHA) but a better overall functional capacity (Barthel Index). Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia, hypertensive crisis, or acute coronary syndrome. While there were differences in clinical findings in the emergency department, the severity assessed by the MEESSI-AHF Scale was similar across both groups. In terms of emergency department management, a higher proportion of COPD patients received oxygen therapy, non-invasive ventilation, bronchodilators, corticosteroids, and antibiotics, while fewer received intravenous nitroglycerin, and they were hospitalized more frequently. In-hospital mortality rates were 8.1% for patients with COPD and 7.5% for those without (OR = 1.088, 95% CI = 0.968-1.224), with 30-day mortality rates of 11.0% and 10.0%, respectively (OR = 1.111, 95% CI = 1.002-1.231). After adjusting for clinical characteristics, decompensation episodes, and emergency department management, these odds ratios decreased to 1.040 (95% CI = 0.905-1.195) and 1.080 (95% CI = 0.957-1.219), respectively. CONCLUSION: Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization. Although they show higher crude 30-day mortality, this is attributable to their differing clinical profiles rather than the presence of COPD itself.

Human T-cell lymphotropic virus type 1 infection and ocular manifestations in São Paulo, Brazil.

OBJECTIVES: Although human T-cell lymphotropic virus type 1 (HTLV-1)-associated uveitis has been well recognized in Japan, related studies in Brazil are scarce. We performed a serologic survey for HTLV-1 infection among patients with uveitis and investigated the ocular findings in HTLV-1-asymptomatic carriers. METHODS: One hundred ninety serum samples from patients with uveitis of determined (n = 137) and undetermined origins (n = 53) being examined at the Uveitis Service, University of São Paulo, São Paulo, Brazil, underwent testing using HTLV enzyme-linked immunosorbent assay and discriminatory Western blots. One hundred five asymptomatic blood donors and/or their relatives who were seropositive for HTLV-1 (carrier group) and 105 age- and sex-paired blood donors who were seronegative for HTLV-1 (control group) underwent ocular evaluation. For the statistical analysis, chi2 test was used. RESULTS: Only 1 patient with uveitis was seropositive for HTLV- 1, and she belonged to the group with uveitis of undetermined origin. Results of tear films were evaluated in 52 carriers. The prevalence of a decreased tear break-up time was significantly higher in the carrier compared with the control group (P = .02). Two carriers had keratoconjunctivitis sicca. Three of the 105 carriers exhibited mild uveitis (cells in the vitreous, retinal and choroidal infiltrates, retinal vasculitis, and bilateral pars planitis). Retinal pigmentary changes were found in both groups (no statistical difference). CONCLUSIONS: Early tear abnormalities may be present in asymptomatic carriers, and mild uveitis may be found among them. The relatively low seroprevalence of HTLV-1 in the Brazilian population made it difficult to establish the real importance of HTLV-1-associated uveitis among our patients with uveitis.

Negligible prevalence of antibodies against Trypanosoma cruzi among blood donors in the southeastern United States.

Trypanosoma cruzi, a hemoflagellate, causes Chagas' disease and is endemic throughout Latin America. Increasing Latin American immigration to the United States has enhanced concern about transmission of Chagas' disease by infected donor blood. The insect vector and parasites also have been found in the southeastern United States. Autochthonous infection of several species of wild and domesticated mammals suggests that the general human population also may be at risk. To assess the prevalence of antibodies to T cruzi in humans, randomly selected donor blood was screened. Initial screening was performed by indirect hemagglutination (1:4 initial serum dilution) and at least one of three different enzyme immunoassays. All samples testing positive by at least one screening method were tested by radioimmunoprecipitation and indirect immunofluorescence supplemental methods, which were used for confirmation and calculation of specificity. Of the 6,013 serum samples evaluated, 85 tested positive by one screening method. Only 10 of the samples tested positive by more than one method. The percentages of positive screening tests are 0.05% by indirect hemagglutination and 0.06%, 0.91%, 3.97% by Abbott Laboratories (Abbott Park, Ill), Gull (Gull Laboratories, Salt Lake City, Utah), and Polychaco (Polychaco S.A.I.C., Buenos Aires, Argentina) enzyme immunoassays, respectively. All samples were negative by radioimmunoprecipitation and indirect immunofluorescence. These results suggest that although parasite and vector are found in the southeastern United States and both infect mammals, the risk of natural infection to humans in this region seems to be negligible. There was variation in positivity among different screening methods. The highest percentage of positive results was with the enzyme immunoassay, in which the binding of serum antibodies to antigens is amplified by enzymatic reactions.

Human T cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis in Sao Paulo, Brazil: association with blood transfusion.

Human T cell lymphotropic virus type-1 (HTLV-1) associated myelopathy/tropical spastic paraparesis (HAM/TSP) has been epidemiologically linked to prior blood transfusion. The prevalence of transfusion as a risk factor for infection varies among endemic areas. Here we report the relative frequency of reported history of blood transfusion among 52 patients evaluated in Sao Paulo, Brazil. A patient reported history of blood transfusion prior to the onset of symptoms, found in 15 (28.8%) of the patients, was the most important risk factor identified in this group of patients when compared with a history of sexually transmitted diseases, homo/bisexuality, sexual promiscuity (three or more sexual partners a year), and intravenous drug use. The mean time between reported transfusions and the onset of symptoms was longer than previously reported. There was no trend toward a more severe evolution to motor inability among the HAM/TSP patients with a history of previous transfusion.

Spontaneous hepatitis B surface antigen clearance in a long-term follow-up study of patients with chronic type B hepatitis. Lack of correlation with hepatitis C and D virus superinfection.

We investigated the frequency of HBsAg clearance and the possible role of viral superinfection in a long-term follow-up of 184 patients with chronic hepatitis B (CHB). Our subjects were 184 patients with chronic hepatitis B and the follow-up was 12-216 months (mean 66.2 +/- 53.7 months). The investigative methods used were: immunoenzymatic assays for HBV, HCV, HDV, and HIV markers; polymerase chain reaction (PCR) for HBV DNA; and liver biopsy and immunoperoxidase. During the follow-up, 20 of the 184 patients cleared serum HBsAg. A comparison of patients with persistent HBsAg(group I) and of those who cleared this marker (group II) showed a significant difference in mortality (P = 0.002) between the two groups and a tendency to a more severe exacerbation (flare) in group II (P = 0.07). Antibodies to hepatitis C and D virus as well as antibodies to HIV were equally distributed in both groups. Thirteen patients (7.9%) from group I, but none from group II, subsequently developed hepatocellular carcinoma. These results suggest that the frequency of spontaneous clearance of HBsAg during chronic HBV infection is low. No determinant factor for the clearance was found, including the presence of liver cirrhosis. Serum HBV DNA was undetectable by PCR after clearance in 16 out of 17 patients.

HIV infection among Brazilian transvestites in a prison population.

Eighty-two male transvestites imprisoned in Casa de Detenção (São Paulo, Brazil) were tested for HIV antibodies, and completed a questionnaire investigating their demographics, arrest and imprisonment records, sexual practices, and drug use. Data were then analyzed to evaluate the incidence of HIV infection and its association with various behavioral and other factors. Sixty-four of 82 (78%, 95% confidence interval [CI], 67-87%) transvestites were positive for HIV infection. The factors associated with significant differences in positivity among these individuals were the time spent in prison and the number of sexual partners during the previous year. It appears that the high rate of infection in this group obscured the importance of other risk factors and behavioral patterns potentially associated with infection. Given the social environment and the high rate of HIV infection among imprisoned transvestites, their role as "vectors" for dissemination of HIV in urban areas of Brazil may be significant.

Site of peptic ulcer. comparison of hydrochloric acid output, pepsinogen and gastrin serum levels.

BACKGROUND/AIMS: Basal (BAO) and maximum (PAO) hydrochloric acid output after Histalog stimulation, basal pepsinogen (SPL-B), at 60 (SPL-60) and at 90 minutes (SPL-90), and basal gastrin (BG) levels were measured and compared in different gastric (GU) and duodenal (DU) ulcer sites. MATERIAL AND METHODS: Fifty nine patients with peptic ulcer were grouped according to Johnson's classification for gastric ulcers: type I (15), type II (16) type III (12) GU and (16) DU. Fifteen normal subjects were studied as controls. RESULTS: The BAO was greater in the DU than in the control or GU groups. No significant difference was noted in the production of hydrochloric acid after stimulation with Histalog. The SPL-B, at 60 and at 90 minutes was higher in type II GU than in the DU group and controls. The SPL-60 was higher in type II GU patients than in type III GU. Basal gastrin was higher in group DU and types II and III GU compared to the type I GU patients and controls. CONCLUSION: The topographic criteria for differentiating peptic ulcers has low discrimination capacity based on comparison of mean values of HCl acid production, pepsinogen and gastrin serum levels both basal and after stimulation with Histalog due to heterogeneity of these variables in group studies. In these studies, peptic ulcers from different sites should not be grouped as distinct entities except for type II gastric ulcers.

Detection of hepatitis B virus DNA by the polymerase chain reaction in anti-HBe positive chronic hepatitis B patients.

Detection of HBV-DNA by PCR was compared with other serological markers (HBsAG, HBeAg and anti-HBe) in a series of 49 Chronic Hepatitis B patients, including 12 with a spontaneous clearance of HBsAg. None of these HBsAg negative cases were PCR positive, but 33/37 (89.2%) HBsAg positive cases were PCR positive (p < 0.0001). Among HBsAg positive samples, nine cases were HBeAg positive and anti-HBe negative, all of them PCR positive. Other 3 patients were HBeAg and anti-HBe positive and these cases were also found PCR positive. A third group included 21 patients anti-HBe positive and HBeAg negative: 19 of them were PCR positive and 2 were PCR negative. The last 4 cases were HBeAg and anti-HBe negative, two of them were PCR positive. The detection of anti-HBe viremic cases in the present series suggest that preC variants could occur in our country. In conclusion, the integrated phase of chronic hepatitis B seems to be less frequent than it was assumed, when only HBeAg or dot blot hybridization techniques were used. The new term "low replication phase" might favorably replace the former "integrated phase".

[Control of blood transfusion malaria in an endemic and in a non-endemic region in Brazil]. / Controle da malária transfusional em região endêmica e não endêmica do Brasil.

The aim of the present work was to establish appropriate criteria for screening of donor blood from regions with distinct Malaria epidemiological characteristics. Three locations with different screening criteria were studied: São Paulo, SP (with no vectorial transmission), Belém, PA (with low active transmission) and Matupá and Peixoto de Azevedo, MT (with high active transmission). The Malaria parasite--Plasmodium sp--was searched for by "thick film", QBC Test and antigen Immunofluorescence test, and was not detected in any of the samples. There was, however, a great variation in the positivity of anti-plasmodial antibodies, as determined by IIF-IgG anti-P. vivax and -P. falciparum, between accepted donors in the 3 studied locations and between rejected and accepted donors in São Paulo (1.98% accepted, 22.3% rejected--p < 0.01) and Belém (17.2% accepted, 58.3% rejected--p < 0.01). These data endorse the use of the applied clinical and epidemiological screening. In Matupá and Peixoto de Azevedo, where there was no rejected donor, the serological positivity was 80.6%. We, therefore, consider that the Malaria screening in blood banks should follow clinical and epidemiological criteria suitable to each region. The laboratorial screening techniques should then detect either the parasites (thick film/QBC Test or the parasite antigens.

[Dementia and cognitive impairment pattern: its association with epsilon4 allele of apolipoprotein E gene]. / Demencia y patrón de deterioro cognitivo: asociación con el alelo epsilon4 del gen de la apolipoproteína E.

INTRODUCTION: The APOE epsilon4 allele is a well-established risk factor for Alzheimer's disease. This disease is characterized by a typical progressive cognitive impairment pattern, different from that of other primary dementias such as dementia with Lewy bodies or frontotemporal and vascular dementias, for which there are no conclusive results on the influence of the APOE genotype. OBJECTIVE: Our aim is to study how the APOE genotype associates with different dementia types, and the association of this genotype with mild cognitive impairment and age related cognitive decline, which might be stages in a continuum between normality and dementia. PATIENTS AND METHODS: From a group of 1,022 people we selected 733 patients with different dementia diagnosis and 205 controls. APOE genotype for each participant in the study was determined. RESULTS: As it was already known, the epsilon4 allele is associated to senile Alzheimer's disease (OR= 5.6; 95% CI= 3.6-8.9; p< 0.001) and presenile Alzheimer's disease (OR= 5.4; 95% CI= 2.1-13.8; p< 0.001). It is also associated to mild cognitive impairment (OR= 3.7; 95% CI= 2.3-6.0; p< 0.001) and to age related cognitive decline (OR= 3.0; 95% CI= 1.2-7.3; p< 0.01). Female Alzheimer patients with at least one epsilon4 allele present significantly an earlier age at onset (epsilon4+= 73.4 +/- 5.4; epsilon4- = 76.9 +/- 5.5; p< 0.001). CONCLUSION: The APOE genotype is associated to Alzheimer's disease and to its cognitive impairment pattern. This association has a growing value according to the degree of clinical impairment. The APOE genotype could be used in differential diagnostic of cognitive impairment.

[Minor physical abnormalities and clinical features in patients with schizophrenia spectrum disorders]. / Anomalias fisicas menores y caracteristicas clinicas en pacientes con trastornos del espectro de la esquizofrenia.

INTRODUCTION: Minor physical anomalies are nonspecific morphologic variants generated during gestation. They are markers of events (inherited and/or acquired) related with the 'neuroprogression' of the schizophrenia spectrum disorders and may be differentially involved with their symptom profiles. The aim of the study was to explore the relationship of minor physical anomalies with positive syndrome, negative syndrome and general psychopathology in patients with schizophrenia or other functional psychoses. PATIENTS AND METHODS: Cross-sectional study of patients with schizophrenia or other functional psychoses consecutively hospitalized with an acute psychotic episode. Minor physical anomalies were evaluated with the Waldrop scale and clinical characteristics of psychosis were measured with the Positive and Negative Syndrome Scale (PANSS). RESULTS: 41 patients with functional psychoses were evaluated: 32 (78%) with schizophrenia, 9 (21.9%) with psychotic disorder not otherwise specified. There was no relationship between the Waldrop scale score and score on the PANSS, its negative scale and its general psychopathology scale. The positive scale of the PANSS and the Waldrop scale were correlated in the whole sample (Spearman rho = 0.356; p = 0.022). In the group of patients with schizophrenia, the correlation was even greater (Spearman rho = 0.420; p = 0.017). CONCLUSIONS: The path from apparently premorbid stages to specific clinical pictures in patients with schizophrenia spectrum disorders is determined by the neurodevelopment, a dynamic process influenced by genetic inheritance and environmental injuries.

Predicción de la mortalidad a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada: escala EAHFE-3D / Predicting short-term mortality in patients with acute exacerbation of chronic heart failure: The EAHFE-3D scale

INTRODUCCIÓN Y OBJETIVOS: Disponer de escalas pronósticas en la insuficiencia cardiaca crónica agudizada para detectar la mortalidad precoz es fundamental. El objetivo de este estudio es crear una escala pronóstica (escala EAHFE-3D) que estratifique el riesgo de muerte a muy corto plazo. PACIENTES Y MÉTODO: Se utilizó el registro EAHFE, multipropósito y multicéntrico, con seguimiento prospectivo que incluye 6.597 pacientes con insuficiencia cardiaca crónica agudizada atendidos en 34 servicios de urgencias españoles entre 2007 y 2014. Se recogieron variables demográficas, antecedentes personales, datos del episodio agudo, destino final y mortalidad a los 3 días. La cohorte de derivación incluye pacientes seleccionados entre 2009 y 2011 en el registro EAHFE (n = 3.640). La variable a estudio fue la mortalidad a los 3 días. Se creó una escala pronóstica (escala EAHFE-3D) con los resultados del estudio multivariante en función del peso de la OR. La escala fue validada utilizando una cohorte de pacientes incluidos en 2014 (n = 2.957). RESULTADOS: Se analizaron 3.640 pacientes (102 muertos a los 3 días, 2,8%) en la cohorte de derivación. La escala final contiene las siguientes variables (máximo 165 puntos): edad≥ 75 años (30 puntos), NYHA basal III-IV (15 puntos), presión arterial sistólica < 110 mmHg (20 puntos), saturación de O2 < 90% (30 puntos), hiponatremia (20 puntos), tratamiento inotropo o vasopresor (30 puntos) y necesidad de ventilación mecánica no invasiva (20 puntos), con un área bajo la curva ROC de 0,80 (IC 95% 0,76-0,84; p < 0,001). La cohorte de validación incluye 2.957 pacientes (66 muertos a los 3 días, 2,2%) y la escala obtiene un área bajo la curva ROC de 0,76 (IC 95% 0,70-0,82; p < 0,001). Los grupos fueron: muy bajo riesgo (0-20 puntos), bajo riesgo (21-40 puntos), riesgo intermedio (41-60 puntos), alto riesgo (61-80 puntos) y muy alto riesgo (> 80 puntos), con una mortalidad (cohorte de derivación/validación) de 0/0,5, 0,8/1,0%, 2,9/2,8, 5,5/5,8 y 12,7/22,4%, respectivamente. CONCLUSIONES: La escala EAHFE-3D puede ser de ayuda para estratificar el pronóstico a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada en 5 grupos de riesgo

INTRODUCTION AND OBJECTIVES: Prognostic scales are needed in acute exacerbation of chronic heart failure to detect early mortality. The objective of this study is to create a prognostic scale (scale EAHFE-3D) to stratify the risk of death the very short term. PATIENTES AND METHOD: We used the EAHFE database, a multipurpose, multicenter registry with prospective follow-up currently including 6,597 patients with acute heart failure attended at 34 Spanish Emergency Departments from 2007 to 2014. The following variables were collected: demographic, personal history, data of acute episode and 3-day mortality. The derivation cohort included patients recruited during 2009 and 2011 EAHFE registry spots (n=3,640). The classifying variable was all-cause 3-day mortality. A prognostic scale (3D-EAHFE scale) with the results of the multivariate analysis based on the weight of the OR was created. The 3D-EAHFE scale was validated using the cohort of patients included in 2014 spot (n=2,957). RESULTS: A total of 3,640 patients were used in the derivation cohort and 102 (2.8%) died at 3 days. The final scale contained the following variables (maximum 165 points): age≥75 years (30 points), baseline NYHA III-IV (15 points), systolic blood pressure < 110mmHg (20 points), room-air oxygen saturation<90% (30 points), hyponatremia (20 points), inotropic or vasopressor treatment (30 points) and need for noninvasive mechanical ventilation (20 points); with a ROC curve of 0.80 (95% CI 0.76-0.84; P < .001). The validation cohort included 2,957 patients (66 died at 3 days, 2.2%), and the scale obtained a ROC curve of 0.76 (95% CI 0.70-0.82; P < .001). The risk groups consisted of very low risk (0-20 points), low risk (21-40 points), intermediate risk (41-60 points), high risk (61-80 points) and very high risk (>80 points), with a mortality (derivation/validation cohorts) of 0/0.5, 0.8/1.0, 2.9/2.8, 5.5/5.8 and 12.7/22.4%, respectively. CONCLUSIONS: EAHFE-3D scale may help to predict the very short term prognosis of patients with acute heart failure in 5 risk groups