In vitro Evaluation of Fungal Susceptibility and Inhibition of Virulence by Diosgenin.

Fungal infections are a public health problem that mainly affects immunosuppressed people, Candida spp. have been responsible for most sources of contamination and invasive fungal infections described around the world. The need arises to find new therapeutic approaches to combat growing infections. Plants and natural products have been considered a valuable source for discovering new molecules with active ingredients. Diosgenin is a sapogenin found in the families of Leguminosae and Dioscoreaceae, it is obtained mainly from the dioscin saponin through the hydrolysis method, it is a phytochemical that has been highlighted in the treatment of various diseases, as well as in combating microbial resistance. The present study aimed to evaluate the susceptibility of fungal strains to diosgenin, as well as verify the association with the reference drug and evaluate the inhibition of the virulence factor through morphological changes in the yeast state to the filamentous form of hyphae and pseudohyphae in strains of Candida albicans, Candida tropicalis and Candida krusei using the broth microdilution method and microculture technique. Antifungal assays revealed that diosgenin was not able to inhibit the growth of the tested strains. However, it was able to inhibit the fungal dimorphism of the strains evaluated, however further studies are recommended to verify its effectiveness against other virulence factors.

Health condition, income loss, food insecurity and other social inequities among migrants and refugees during the COVID-19 pandemic in Brazil.

BACKGROUND: Brazil is the destination of many international migrants and refugees and, given the circumstances of their entry into the country, many face difficulties due to the absence of targeted policies. Thus, the objective of this study was to survey the social impact of COVID-19 on international migrants and refugees regarding income loss, food insecurity and other social inequities, and to identify explanatory factors on these aspects. METHODS: This is a cross-sectional, analytical study. We used a validated instrument applied by trained interviewers. Descriptive analysis and binary logistic regression were performed to identify factors associated with income loss and food insecurity. RESULTS: A total of 360 individuals from sub-Saharan African and South American countries participated in the study. Individuals who were white, black/brown, yellow, had an occupation/employment, and earned less than one minimum wage were more likely to lose income. Those who reported no income, received less than one minimum wage, and were diagnosed with COVID-19 were more likely to be food insecure. CONCLUSIONS: The study advances knowledge by identifying factors associated with income loss, food insecurity, and individuals' difficulty in accessing health services and social support measures in Brazil.

Drosophila nasuta (Diptera, Drosophilidae) in Brazil: a decade of invasion and occupation of more than half of the country.

As a result of human activities and natural dispersal, exotic species can be brought to new areas, where they become established and spread, becoming invaders. These species are responsible for the loss of biodiversity and cause ecosystemic harm throughout the world. In this paper, we report the rapid, broad geographic expansion of the invasive fly Drosophila nasuta in Brazil. An 84% increase was found in its area of occupation in the country compared to previous studies. The present data reveal its arrival to the Pantanal wetlands in a location more than one thousand kilometers from the closest previous record in the Cerrado biome. We present the first record of D. nasuta in the Atlantic Forest in the states of Paraíba and Bahia. We report its introduction in the Amazon Forest in the state of Amazonas approximately 700 kilometers from previous records. The relative abundance of D. nasuta in this biome increased fivefold in comparison to a previous study. In the first decade of invasion in Brazil, D. nasuta has already colonized more than half of the country. The present data reveal its invasive potential and underscore the importance of following up the possible negative effects of this biological invasion.

Translation, cross-cultural adaptation, reliability, and construct validity of the Brazilian Portuguese version of the Basic Psychological Needs in Exercise Scale.

RESULTS: 59 patients were included (61% with COPD and 39% with ILD). BPNES factor scores were not significantly different between raters' assessments (p > 0.05). The internal consistency was 0.70 for autonomy, 0.76 for competence, and 0.80 for relatedness. Inter-rater and test-retest reliability were good to very good for autonomy (ICC = 0.78, 95%CI 0.62-0.87; ICC = 0.75, 95%CI 0.57-0.86, respectively), competence (ICC = 0.81, 95%CI 0.68-0.89; ICC = 0.65, 95%CI 0.43-0.80, respectively), and relatedness (ICC = 0.79, 95%CI 0.65-0.88; ICC = 0.70, 95%CI 0.50-0.83, respectively). Significant correlations were observed between BPNES factors and quality of life, anxiety, depression, and functional status. In conclusion, this study confirmed the reliability and construct validity of the Brazilian Portuguese version of the BPNES in patients with COPD and ILD.

Diversity and dynamics of bacterial communities in the drinking water distribution network of a mid-sized city in Brazil.

This study assessed the bacterial community composition of a drinking water system (DWS) serving a mid-sized city (120,000 inhabitants) in Brazil. Water samples, including raw and treated water, were collected at seven points throughout the DWS. DNA was extracted and analysed using high-throughput sequencing (Ion Torrent). Free chlorine and turbidity were measured in situ. Results showed that the highest relative abundance of 16S rRNA genes was from phyla Proteobacteria, followed by Bacteroidetes and Actinobacteria. The next most abundant phylum was Cyanobacteria, represented by Arthronema, Calothrix, and Synechococcus. An interesting observation was that the DNA-based analysis suggested a bacterial community change in the distribution network, with treated reservoir water being very different from the network samples. This suggests active microbiology within the distribution network and a tendency for bacterial diversity to decrease after chlorine disinfection but increase after pipeline distribution. In raw water, a predominance of Proteobacteria was observed with reduced Cyanobacteria, showing a negative correlation. In treated water, Proteobacteria were negatively correlated with Bacteroidetes. Finally, 16S rRNA genes from Firmicutes (especially Staphylococcus) had a high abundance in the chlorinated water, which may indicate the phylum's resistance to chlorine residuals. Opportunistic pathogens, e.g., Mycobacteria, Legionella, and Staphylococcus, were also observed.

Reliability and validity of the Glittre-ADL test to assess the functional status of patients with interstitial lung disease.

The study objective was to investigated the reliability and validity of the ADL-Glittre test (TGlittre) to assess the functional status of patients with interstitial lung disease (ILD). Twenty-one individuals with ILD participated (age: 63 ± 11 years; DLCO: 51.0 ± 12.6%predicted), evaluated with body plethysmography, Saint George Respiratory Questionnaire, modified Medical Research Council dyspnea scale, six-minute walk test (6MWT) and monitoring of physical activity of daily living. Two TGlittre were performed, with an interval of 30 minutes between them. The TGlittre demonstrated high test-retest reliability, with an intraclass correlation coefficient of 0.90 (95%CI: 0.75-0.96; p < 0.001). Nineteen patients (90.5%) performed better on the second test (mean difference between TGlittre 1 and 2: -0.57 ± 0.96 minute; p = 0.001), with a learning effect of 11.6%. The time in TGlittre correlated with 6MWT (r = -0.70; p = 0.002) and with the total energy expenditure in physical activity of daily living (r = -0.52; p = 0.02). In %predicted, TGlittre and 6MWT also correlated (r = -0.50; p = 0.04). Correlations were observed between TGlittre and pulmonary function variables (r = -0.47 to -0.57; p = 0.01 to p = 0.04). There was no difference in the physiological response between TGlittre 1 and 2, and between TGlittre and 6MWT (p > 0.05). In conclusion, the TGlittre is reliable and valid for assessing functional status of patients with ILD.

Assessing XMT-Measurement Variability of Air-Water Interfacial Areas in Natural Porous Media.

This study investigates the accuracy and reproducibility of air-water interfacial areas measured with high-resolution synchrotron x-ray microtomography (XMT). Columns packed with one of two relatively coarse-grained monodisperse granular media, glass beads or a well-sorted quartz sand, were imaged over several years, encompassing changes in acquisition equipment, improved image quality, and enhancements to image acquisition and processing software. For the glass beads, the specific solid surface area (SSSA-XMT) of 31.6 ±1 cm-1 determined from direct analysis of the segmented solid-phase image data is statistically identical to the independently calculated geometric specific solid surface area (GSSA, 32 ±1 cm-1) and to the measured SSSA (28 ±3 cm-1) obtained with the N2BET method (NBET). The maximum specific air-water interfacial area (Amax) is 27.4 (±2) cm-1, which compares very well to the SSSA-XMT, GSSA, and SSSA-NBET values. For the sand, the SSSA-XMT (111 ±2 cm-1) and GSSA (113 ±1 cm-1) are similar. The mean Amax is 96 ±5 cm-1, which compares well to both the SSSA and the GSSA values. The XMT-SSSA values deviated from the GSSA values by 7-16% for the first four experiments, but were essentially identical for the later experiments. This indicates that enhancements in image acquisition and processing improved data accuracy. The Amax values ranged from 74 cm-1 to 101 cm-1, with a coefficient of variation (COV) of 9%. The maximum capillary interfacial area ranged from 12 cm-1 to 19 cm-1, for a COV of 10%. The COVs for both decreased to 5-6% for the latter five experiments. These results demonstrate that XMT imaging provides accurate and reproducible measurements of total and capillary interfacial areas.

Echocardiography Learning by Pediatricians While Screening Congenital Heart Disease with the Aid of Telemedicine.

Background: Congenital heart disease (CHD) affects 1% of all newborns and is a major public health problem. Most children with CHD benefit from early diagnosis to optimize management. However, in many places there are no specialized professionals to do so. Introduction: A screening method for CHD was developed between two states in Northeast Brazil. It was based upon the performance of an echocardiogram by local pediatricians with support of pediatric cardiologists through telemedicine. Objective: To determine if the continuous performance of examinations together with online supervision increased the level of understanding of the pediatricians about the echocardiograms. Methods: Pediatricians received online support to perform echocardiograms for 7 years (2012-2018). Although the project aimed to teach them to acquire images and send to the cardiologists for analysis and interpretation, they were encouraged to describe their own diagnostic impressions. The level of agreement between pediatricians and cardiologists was calculated. Results: A large number (n = 3,951) echocardiograms was analyzed. From them, 2,818 were classified as abnormal, inconclusive, or normal by both the pediatricians and the cardiologists. The 7-year analysis demonstrated an overall agreement of 63.7%. As for the final diagnosis, it was possible to compare 1,457 echocardiograms. The combined analysis of the 7 years demonstrated agreement in 62.2%. Discussion: The screening of CHD under online support led to more in-depth learning of echocardiography by the pediatricians. This approach potentialized the accuracy of the screening through the years. Conclusion: By enrolling in a telemedicine-based screening program, the pediatricians' degree of understanding of echocardiography increased considerably.

Bacterial community dynamics in tropical soil after sewage sludge amendment.

Although the widespread use of sewage sludge in developing countries is common, little is known about how sludge disposal can affect the microbial composition and diversity of tropical soils. We evaluated the effects of the sewage sludges of two types of anaerobic digestors differing, by the biological treatment they have undergone (uplow anaerobic sludge blanket and activated sludge digester), and two different disposal methods (surface and incorporated) on tropical soils. Samples were taken from topsoil (0-10 cm) and analyzed by amplifying the 16S rRNA genes to study the microbial community, and physicochemical analysis was performed concomitantly. The results indicated that, in general, sewage sludge amendment (SSA) significantly changed the tropical soil bacterial community by the sludge type and by application method. Moreover, the redundancy analysis diagram indicates that changes in soil chemical parameters over time due to SSA resulted in changes in the bacterial community's composition, increasing the population responsible for recycling nutrients in the soil.

The rates and players of denitrification, dissimilatory nitrate reduction to ammonia (DNRA) and anaerobic ammonia oxidation (anammox) in mangrove soils.

Mangroves are ecosystems located in the transition zone between land and sea, characterized by periodic flooding that confer to its unique characteristics. Little is known about the transformation of nutrients that occur during the organic matter degradation in this system. In this study, we monitor the nitrogen transformations in soils from three mangroves with distinct levels of contamination using labeled 15NO3-. We also screened the mangroves metagenomes for the presence of genes that encode enzymes involved in denitrification (nirS, nirK, nosZ, norB and narG), anaerobic oxidation of ammonia (anammox) (hh, hao and hzo) and dissimilatory nitrate reduction to ammonium (DNRA) (nrfA). The transformations of 15NO3- indicated the balance of denitrification over anammox and DNRA in all three mangroves, with lower rates of processes in the mangrove affected by oil contamination. The metagenomic analysis detected 56 sequences related to denitrification, 19 with anammox and 6 with DNRA. Genes related with denitrification were phylogenetically distributed among several groups of bacteria (mainly Gammaproteobacteria). Anammox and DNRA related sequences were affiliated with Planctomycetes and Gammaproteobacteria, respectively. Thus, metagenomic and functional approaches supported the description of denitrification, anammox and DNRA rates in mangrove soils, and identified the major bacterial groups involved in these processes.

Nitrogen removal from food waste digestate using partial nitritation-anammox process: Effect of different aeration strategies on performance and microbial community dynamics.

The feasibility of employing anammox and partial nitritation-anammox (PN/A) processes for nitrogen removal from food waste (FW) digestate was investigated in this study. The effects of different aeration strategies on the microbial community were also investigated. To achieve this, after anammox enrichment (Phase 1), the reactor was fed with digestate supplemented with nitrite (Phase 2), and subsequently different aeration strategies were evaluated to establish PN/A. Aeration strategies with high anoxic periods (30 and 45 min) in relation to aerobic periods (15 min) coupled with low air flow rates (0.026 L  min-1. Lreator-1) were found to be better for establishing PN/A, as coefficients of produced nitrate/removed ammonium were closer to those reported previously (0.17 and 0.21). Aeration conditions considerably altered the microbial community. Candidatus Brocadia was replaced by Candidatus Jettenia, after the first aeration strategies. These results support the feasibility of FW digestate treatment using anammox and PN/A processes and provide a better understanding of the effect of aeration on microbial dynamics in PN/A reactors.

Effects of Resistance Training on Fatigue-Related Domains of Quality of Life and Mood During Pregnancy: A Randomized Trial in Pregnant Women With Increased Risk of Back Pain.

OBJECTIVE: The aim of the study was to test whether the adoption of twice weekly, low-to-moderate intensity resistance training during weeks 22 to 34 of pregnancy can improve quality of life and mood. METHODS: A parallel-group trial was conducted. Women in their second trimester (N = 134) were randomly assigned to 12 weeks of wait list, bimonthly pregnancy education classes, or twice weekly low-to-moderate intensity resistance training. Resistance training involved one abdominal exercise with no external load and five exercises (leg extension, leg press, arm lat pull, leg curl, and lumbar extension) with an external load that gradually progressed, and the total active exercise time during each exercise session was approximately 17 minutes. Quality of life and mood were measured before and after the interventions using the 36-item Short Form Health Survey and Profile of Mood States. Intent-to-treat mixed-model analyses of variance (3 groups by 2 times, pre- and postintervention) tested the hypothesis that outcomes would worsen for the controls and not change or improve for the resistance training group. RESULTS: The group by time interaction (F(2,131) = 3.144, η = .046, p = .046) for 36-item Short Form Health Survey vitality and subsequent simple main effects showed that scores were unchanged across time after resistance training (-1.8 (14.8)) but significantly decreased for the education (-6.44 (12.69), t = 3.408, df = 44, p = .001) and wait list (-9.11 (14.78), t = 4.135, df = 44, p < .001) groups, whereas posttest vitality scores for the pregnancy group (45.9 (16.9)) were significantly higher than the wait list (40.1 (16.3), t = 1.989, df = 87, p = .05) but not the education group (42.1 (15.4), p = .27). Profile of mood states fatigue scores showed a similar pattern. CONCLUSIONS: Adverse changes in symptoms of energy and fatigue during pregnancy are attenuated by adopting low-to-moderate intensity resistance training. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT02557893.

Reduction of bovine strongilides in naturally contaminated pastures in the southeast region of Brazil.

Biological control through the use of nematophagous fungi is a sustainable alternative for combatting helminthes in domestic animals and allows a reduction in the use of anthelmintics. The objective of this research was to evaluate the efficacy of the Arthrobotrys cladodes var macroides fungus in a pelleted formulation, based on sodium alginate and administered twice a week orally, as an alternative for the biological control of nematodes in field-grown young cattle. The experiment was conducted in a farm located in the municipality of Viçosa, MG, where 12 cattle, seven to nine months old, were allocated in two groups (treated group and control group) and distributed in pickets of Brachiaria decumbens, naturally infested with nematode larvae. The animals in the treated group received 1g of sodium alginate matrix pellets for every 10 kg of animal live weight, containing the nematophagous fungus Arthrobotrys cladodes var macroides and administered twice a week in conjunction with commercial feed. In the control group, each animal received 1 g of pellets for every 10 kg of animal live weight, without fungal mycelium added to the feed. Samples of feces and pastures were collected fortnightly for 12 months. The results showed that the most prevalent nematode genera in the coprocultures were Haemonchus sp., Cooperia sp. and Oesophagostomum sp., reflecting the results found in forage. The pasture that contained the animals that received feed with the fungus presented a reduction of 59% and 52% of larvae recovered at distances of 20 cm and 40 cm from the fecal pats, respectively. The mean number of eggs per gram of feces each month and animal body weight did not differ (p > 0.05) between the treated and control groups. Stool and soil samples from both groups were colonized by A. cladodes fungus and other fungi. Administration of Arthrobotrys cladodes var macroides mycelium by means of a sodium alginate matrix twice weekly reduced larval infestation of the surrounding pasture, indicating that this fungus may be a promising biological control of infecting forms of nematodes present in the environment.

Duddingtonia flagrans formulated in rice bran in the control of Oesophagostomum spp. intestinal parasite of swine.

Three experimental assays with Duddingtonia flagrans (isolated AC001) were carried out. The growth of the genus Duddingtonia present in formulation of rice bran, its predatory capability on Oesophagostomum spp. infective larvae (L3) in petri dishes (assay 1), its action in faecal cultures with eggs of that parasite (assay 2) and isolate's capability of predation after passing through gastrointestinal tract of swine (assay 3) was evaluated. At assay 3, feces were collected at time intervals of 12, 24, 36, 48, and 60 h after feed animals with the formulation. Assays 1 and 2 showed a statistical difference (p < 0.01) by the F test when comparing the treated group with the control group. At the both assays, was observed in the treated group a reduction percentage of 74.18% and 88.38%, respectively. In assay 3, there was a statistical difference between the treated group and the control group at all collection times (p < 0.01). Regarding the collection periods, there was no statistical difference over time in the treatment group (p > 0.05). The results demonstrate that the fungal isolate AC001 formulated in rice bran can prey on L3 of Oesophagostomum spp., in vitro and after passing through the gastrointestinal tract, without loss of viability. This isolate may be an alternative in the control of Oesophagostomum spp. in swine.

Using the fungus Arthrobotrys cladodes var. macroides as a sustainable strategy to reduce numbers of infective larvae of bovine gastrointestinal parasitic nematodes.

Research in the area of sanitation in ruminant production has focused on discovery of potential agents for biological control of helminths with nematophagous fungi and has provided evidence of success. The antagonistic potential of the fungus Arthrobotrys cladodes var. macroides on infective larvae of bovine gastrointestinal parasitic nematodes was evaluated by scanning electron microscopy. Additionally, an in vivo test of the resistance to digestive processes and viability of the fungus was carried out using a formulation based on sodium alginate administered orally in cattle. Production of conidia and chlamydospores was high. In in vitro tests, the number of infective nematode larvae was reduced 68.7% by the fungus in the treated group compared to the control group. The interaction between the fungus and the nematodes was confirmed by scanning electron microscopy. Plates containing fecal samples collected after oral administration of 100 g of pellets containing the A. cladodes fungus showed that the fungus survived passage through the gastrointestinal tract of ruminants, grew on agar, formed traps and preyed on L3 larvae of gastrointestinal parasites. The results of the present study provide a new opportunity for alternative, environmentally safe control of ruminant nematodes.

The Gas-absorption/Chemical-reaction Method for Measuring Air-water Interfacial Area in Natural Porous Media.

The gas-absorption/chemical-reaction (GACR) method used in Chemical Engineering to quantify gas-liquid interfacial area in reactor systems is adapted for the first time to measure the effective air-water interfacial area of natural porous media. Experiments were conducted with the GACR method, and two standard methods (x-ray microtomographic imaging and interfacial partitioning tracer tests) for comparison, using model glass beads and a natural sand. The results of a series of experiments conducted under identical conditions demonstrated that the GACR method exhibited excellent repeatability for maintaining constant water saturation and for measurement of interfacial area (Aia). Coefficients of variation for Aia were 3.5% for the glass beads and 11% for the sand. Estimated maximum interfacial areas (Am) obtained with the GACR method were statistically identical to independent measures of the specific solid surface areas of the media. For example, the Am for the glass beads is 29 (±1) cm-1, compared to 32 (±3), 30 (±2), and 31 (±2) cm-1 determined from geometric calculation, N2/BET measurement, and microtomographic measurement, respectively. This indicates that the method produced accurate measures of interfacial area. Interfacial areas determined with the GACR method were similar to those obtained with the standard methods. For example, Aias of 47 and 44 cm-1 were measured with the GACR and XMT methods, respectively, for the sand at a water saturation of 0.57. The results of the study indicate that the GACR method is a viable alternative for measuring air-water interfacial areas. The method is relatively quick, inexpensive, and requires no specialized instrumentation compared to the standard methods.

Microcephaly in north-east Brazil: a retrospective study on neonates born between 2012 and 2015.

OBJECTIVE: To assess the number of children born with microcephaly in the State of Paraíba, north-east Brazil. METHODS: We contacted 21 maternity centres belonging to a paediatric cardiology network, with access to information regarding more than 100 000 neonates born between 1 January 2012 and 31 December 2015. For 10% of these neonates, nurses were requested to retrieve head circumference measurements data from delivery-room books. We used three separate criteria to classify whether a neonate had microcephaly: (i) the Brazilian Ministry of Health proposed criterion: term neonates (gestational age ≥ 37 weeks) with a head circumference of less than 32 cm; (ii) Fenton curves: neonates with a head circumference of less than -3 standard deviation for age and gender; or (iii) the proportionality criterion: neonates with a head circumference of less than ((height/2))+10) ± 2. FINDINGS: Between 1 and 31 December 2015, nurses obtained data for 16 208 neonates. Depending on which criterion we used, the number of neonates with microcephaly varied from 678 to 1272 (4.2-8.2%). Two per cent (316) of the neonates fulfilled all three criteria. We observed temporal fluctuations of microcephaly prevalence from late 2012. CONCLUSION: The numbers of microcephaly reported here are much higher than the 6.4 per 10 000 live births reported by the Brazilian live birth information system. The results raise questions about the notification system, the appropriateness of the diagnostic criteria and future implications for the affected children and their families. More studies are needed to understand the epidemiology and the implications for the Brazilian health system.

Impact of Telemedicine in the Screening for Congenital Heart Disease in a Center from Northeast Brazil.

OBJECTIVES: To describe the incidence of congenital heart disease before and after the establishment of a telemedicine screening program, in a reference center from Northeast Brazil. METHODS: This is a descriptive, retrospective and comparative study based on the institutional data from a reference center in perinatology for a period of 16 years. Institutional data were collected from a 16-year period (2001-15). Data were divided into two periods: prior to (2001-11) and after (2012-15) the establishment of a telemedicine screening program. RESULTS: After the implementation of the screening process, almost all kinds of heart disease showed a significant increase in their incidence (p < 0.05). With this, the incidence of major heart diseases approached those specified in developed regions. CONCLUSION: The implementation of a screening process model for congenital heart diseases can change the context of patients with congenital heart diseases in poor regions.

The use of novel packing material for improving methane oxidation in biofilters.

The use of biofilters (working bed volume of 7.85 L) for the oxidation of CH4 at low concentrations (from 0.17%v/v to 3.63%v/v, typically in waste gas from anaerobic sewage treatment) was investigated and four empty bed residence times were tested (in min): 42.8, 29.5, 19.6, and 7.4. Mixtures of organic (composted leaves) and three non-organic materials (sponge-based material - SBM, blast furnace slag - BFS, and expanded vermiculite - ExpV) were used as packing media. Along 188 operational days after the steady state was reached (95 days for start-up), the CH4 mineralization decreased while the inlet loads gradually increased from 3.0 ± 0.8 gCH4 m(-3) h(-1) to 148.8 ± 4.4 gCH4 m(-3) h(-1). The biofilter packed with ExpV showed the best results, since the CH4 conversions decreased from 95.0 ± 5.0% to 12.7 ± 3.7% as a function of inlet concentration, compared to the other two biofilters (SBM and BFS) which showed CH4 conversions decreasing from 56.0 ± 5.4% to 3.5 ± 1.2% as a function of inlet concentration. The methanotrophic activity of biomass taken from ExpV biofilter was three times higher than the activity of biomass from the other two biofilters. Taken together, these results suggested that ExpV provides an attractive environment for microbial growth, besides the mechanical resistance provided to the whole packing media, showing the potential to its use in biofiltration of diffuse CH4 emissions.

A telemedicine network for remote paediatric cardiology services in north-east Brazil.

PROBLEM: Providing health care for children with congenital heart diseases remains a major challenge in low- and middle-income countries. APPROACH: In October 2011, the Government of Paraíba, Brazil, established a paediatric cardiology network in partnership with the nongovernmental organization Círculo do Coração. A cardiology team supervised all network activities, using the Internet to keep in contact with remote health facilities. The network developed protocols for screening heart defects. Echocardiograms were performed by physicians under direct online supervision of a cardiologist; alternatively, a video recording of the examination was subsequently reviewed by a cardiologist. Cardiovascular surgeons came to a paediatric hospital in the state capital once a week to perform heart surgeries. LOCAL SETTING: Until 2011, the State of Paraíba had no structured programme to care for children with heart disease. This often resulted in missed or late diagnosis, with adverse health consequences for the children. RELEVANT CHANGES: From 2012 to 2014, 73,751 babies were screened for heart defects and 857 abnormalities were identified. Detection of congenital heart diseases increased from 4.09 to 11.62 per 1000 live births (P < 0.001). Over 6000 consultations and echocardiograms were supervised via the Internet. Time to diagnosis, transfers and hospital stays were greatly reduced. A total of 330 operations were carried out with 6.7% (22/330) mortality. LESSONS LEARNT: Access to an echocardiography machine with remote supervision by a cardiologist improves the detection of congenital heart disease by neonatologists; virtual outpatient clinics facilitate clinical management; the use of Internet technology with simple screening techniques allows resources to be allocated more efficiently.