Accuracy and reliability of focused echocardiography in patients with Chagas disease from endemic areas: SaMi-Trop cohort study.

BACKGROUND: Chagas disease remains a major cause of cardiovascular death in endemic areas. Focused echocardiography (FoCUS) is a point-of-care means of assessing cardiac function which can be useful for the diagnosis of cardiac involvement. OBJECTIVE: This study aims evaluating the characteristics of validity and reliability of FoCUS applied on Chagas disease patients. METHODS: Patients with Chagas disease coming from an endemic area were selected from a large cohort (SaMi-Trop). A simplified echocardiogram with only three images was extracted from the conventional echocardiogram performed in this cohort. The images were evaluated by an observer who was blinded to the clinical and echocardiographic data, to determine the accuracy and reliability of FoCUS for cardiac assessment. The analysis constituted of 5 prespecified variables, dichotomized in absence or presence: left ventricular (LV) size and systolic function, right ventricular (RV) size and systolic function, and LV aneurysm. RESULTS: We included 725 patients with a mean age of 63.4 ± 12.3 years, 483 (67%) female. Abnormal electrocardiogram was observed in 81.5% of the patients. Left and right ventricular dysfunctions were found in 103 (14%) and 49 (7%) of the patients, respectively. Sensitivity, specificity, positive predictive value and negative predictive value were 84%, 94%, 70% and 97% for LV enlargement and 81%, 93%, 68% and 97% for LV systolic dysfunction, respectively, and 46%, 99%, 60% and 98% for RV dilatation, and 37%, 100%, 100% and 96% for RV dysfunction, respectively. Inter and intraobserver agreement were 61% and 87% for LV enlargement and 63% and 92% for LV dysfunction, respectively, and 50% and 49% for RV size and 46% and 79% for RV dysfunction, respectively. LV apical aneurysm was found in 45 patients (6.2%) with the lowest sensitivity of FoCUS study (11%; 95% CI 2-28%). CONCLUSIONS: FoCUS showed satisfactory values of validity and reliability for assessment of cardiac chambers in patients with Chagas disease, except for apical aneurysm. This tool can identify heart disease with potential impact on patient management in the limited-resource setting.

Risk Score for Predicting 2-Year Mortality in Patients With Chagas Cardiomyopathy From Endemic Areas: SaMi-Trop Cohort Study.

Background Risk stratification of Chagas disease patients in the limited-resource setting would be helpful in crafting management strategies. We developed a score to predict 2-year mortality in patients with Chagas cardiomyopathy from remote endemic areas. Methods and Results This study enrolled 1551 patients with Chagas cardiomyopathy from Minas Gerais State, Brazil, from the SaMi-Trop cohort (The São Paulo-Minas Gerais Tropical Medicine Research Center). Clinical evaluation, ECG, and NT-proBNP (N-terminal pro-B-type natriuretic peptide) were performed. A Cox proportional hazards model was used to develop a prediction model based on the key predictors. The end point was all-cause mortality. The patients were classified into 3 risk categories at baseline (low, <2%; intermediate, ≥2% to 10%; high, ≥10%). External validation was performed by applying the score to an independent population with Chagas disease. After 2 years of follow-up, 110 patients died, with an overall mortality rate of 3.505 deaths per 100 person-years. Based on the nomogram, the independent predictors of mortality were assigned points: age (10 points per decade), New York Heart Association functional class higher than I (15 points), heart rate ≥80 beats/min (20 points), QRS duration ≥150 ms (15 points), and abnormal NT-proBNP adjusted by age (55 points). The observed mortality rates in the low-, intermediate-, and high-risk groups were 0%, 3.6%, and 32.7%, respectively, in the derivation cohort and 3.2%, 8.7%, and 19.1%, respectively, in the validation cohort. The discrimination of the score was good in the development cohort (C statistic: 0.82), and validation cohort (C statistic: 0.71). Conclusions In a large population of patients with Chagas cardiomyopathy, a combination of risk factors accurately predicted early mortality. This helpful simple score could be used in remote areas with limited technological resources.

Challenges and lessons from a primary care intervention in a Brazilian municipality.

OBJECTIVE: To address the implementation of the Lab for Innovation in Chronic Conditions in Santo Antonio do Monte, indicating the main challenges and lessons of a new chronic condition model. METHODS: This is an observational study based on two sources of data: 1) two cross-sectional household surveys, 2013 (2012 as reference year) and 2015 (2014 as reference year), representative for the entire population and four target groups (pregnant women; children under two years old; individuals with hypertension and diabetes); medical records of individuals who self-reported having hypertension or diabetes in the household survey of 2013. A descriptive statistics analysis was performed. RESULTS: The main findings showed that the public health system is the main provider of health services, mainly primary care, in Santo Antonio do Monte. Besides, the implementation of Lab for Innovation in Chronic Conditions showed the importance of building a Primary Health Care network in small municipalities. CONCLUSIONS: Community health agents and health managers played a fundamental role in the Primary Health Care network. The case study of Santo Antonio do Monte poses some challenges and lessons that clarify future interventions on building a Primary Health Care network that is essential to provide an adequate and longitudinal care to chronic conditions.

Challenges and lessons from a primary care intervention in a Brazilian municipality

ABSTRACT OBJECTIVE To address the implementation of the Lab for Innovation in Chronic Conditions in Santo Antonio do Monte, indicating the main challenges and lessons of a new chronic condition model. METHODS This is an observational study based on two sources of data: 1) two cross-sectional household surveys, 2013 (2012 as reference year) and 2015 (2014 as reference year), representative for the entire population and four target groups (pregnant women; children under two years old; individuals with hypertension and diabetes); medical records of individuals who self-reported having hypertension or diabetes in the household survey of 2013. A descriptive statistics analysis was performed. RESULTS The main findings showed that the public health system is the main provider of health services, mainly primary care, in Santo Antonio do Monte. Besides, the implementation of Lab for Innovation in Chronic Conditions showed the importance of building a Primary Health Care network in small municipalities. CONCLUSIONS Community health agents and health managers played a fundamental role in the Primary Health Care network. The case study of Santo Antonio do Monte poses some challenges and lessons that clarify future interventions on building a Primary Health Care network that is essential to provide an adequate and longitudinal care to chronic conditions.

Implementation of a text message intervention to promote behavioural change and weight loss among overweight and obese Brazilian primary care patients.

INTRODUCTION: Mobile-technology-based interventions are promising strategies for promoting behavioural change in obese patients. The aims of this study were to evaluate the feasibility of implementing a text message intervention, and to assess the effects of the intervention on body mass index (BMI) and self-reported behavioural change. METHODS: TELEFIT was a three-phase feasibility study comprising the following stages: (a) the development of text messages; (b) testing; and (c) a quasi-experimental pilot study in which patients who were engaged in obesity/overweight educational groups in public primary care centres in Belo Horizonte, Brazil, were recruited. A bank of text messages was drafted and reviewed by an expert panel, text message delivery software was developed and tested, and a pilot study assessed patients before and after receiving the intervention using validated questionnaires and body measures. The data were analysed using the Wilcoxon test. RESULTS: A total of 46 patients completed the follow-up; 93.5% were women and the median age was 42 years (interquartile range (IQR) 34-52 years). At four months, participants had a significant reduction in BMI (median 31.3 (IQR 28.2-34.6) vs. 29.9 (IQR 27.2-34.6) kg/m2, p < 0.001), systolic (median 125 (IQR 120-132) vs. 120 (IQR 110-130) mmHg, p = 0.013) and diastolic blood pressure (median 80 (IQR 70-100) vs. 80 (IQR 70-80) mmHg, p = 0.006), when compared to baseline. All patients reported to be satisfied and willing to continue receiving the intervention, and 93.3% felt that the intervention helped them change their behaviours. DISCUSSION: This study has shown that a text message intervention to promote behavioural change and weight loss was feasible and effective in a short-term period. Participants were satisfied and willing to continue receiving the SMS messages.

Interview-based assessment of cognition is a strong predictor of quality of life in patients with schizophrenia and severe negative symptoms

Objective: To analyze the correlation between quality of life, symptoms, and cognition assessed by the interview-based Schizophrenia Cognition Rating Scale (SCoRS). Methods: Seventy-nine outpatients diagnosed with schizophrenia were evaluated with the Quality of Life Scale – Brazilian version (QLS-BR), the SCoRS, and symptoms scales (Positive and Negative Syndrome Scale [PANSS]). After determining the potential explanatory variables using Spearman’s correlation and Student’s t test results, we ran simple, multivariate, and decision-tree regression analyses to assess the impact of SCoRS and PANSS ratings on mean overall quality of life. Results: Cognitive deficits and negative symptoms were the best predictors of quality of life. A low degree of negative symptoms (PANSS negative < 11) was a strong predictor of better quality of life (QLS ∼ 75), regardless of SCoRS rating. Among participants with more severe negative symptoms, elevated cognitive impairment (interviewer SCoRS ∼ 44) was a predictor of worse quality of life (QLS ∼ 44). Conclusions: Cognitive impairment determined by interview-based assessment seems to be a strong predictor of quality of life in subjects with severe negative symptoms. These results support the usefulness of SCoRS for cognitive assessment that is relevant to the everyday life of patients with schizophrenia.

Interview-based assessment of cognition is a strong predictor of quality of life in patients with schizophrenia and severe negative symptoms.

OBJECTIVE: To analyze the correlation between quality of life, symptoms, and cognition assessed by the interview-based Schizophrenia Cognition Rating Scale (SCoRS). METHODS: Seventy-nine outpatients diagnosed with schizophrenia were evaluated with the Quality of Life Scale - Brazilian version (QLS-BR), the SCoRS, and symptoms scales (Positive and Negative Syndrome Scale [PANSS]). After determining the potential explanatory variables using Spearman's correlation and Student's t test results, we ran simple, multivariate, and decision-tree regression analyses to assess the impact of SCoRS and PANSS ratings on mean overall quality of life. RESULTS: Cognitive deficits and negative symptoms were the best predictors of quality of life. A low degree of negative symptoms (PANSS negative < 11) was a strong predictor of better quality of life (QLS ∼ 75), regardless of SCoRS rating. Among participants with more severe negative symptoms, elevated cognitive impairment (interviewer SCoRS ∼ 44) was a predictor of worse quality of life (QLS ∼ 44). CONCLUSIONS: Cognitive impairment determined by interview-based assessment seems to be a strong predictor of quality of life in subjects with severe negative symptoms. These results support the usefulness of SCoRS for cognitive assessment that is relevant to the everyday life of patients with schizophrenia.

Factors associated with the use of a teleconsultation system in Brazilian primary care.

BACKGROUND: The Telehealth Network of Minas Gerais (TNMG) is a public telehealth service that provides support to primary healthcare in Minas Gerais, Brazil, performing teleconsultation and tele-electrocardiography. The aim of this study was to assess teleconsultation requests received by the TNMG and to investigate the factors associated with low teleconsultation utilization in most municipalities. MATERIALS AND METHODS: A cross-sectional study was carried out including 214 municipalities. Indicators were defined to analyze teleconsultation requests. A structured questionnaire was used to investigate factors associated with teleconsultation utilization, which were analyzed by multivariate analysis through a decision tree algorithm (chi-squared automatic interaction detector) to the entire population of the study and logistic regression for municipalities that had used the system during the analyzed period. RESULTS: From May to September 2009, 1,954 teleconsultations were performed. The average number (±standard deviation) of teleconsultations per municipality was 1.71 (±1.50) per month. The majority of the users were located in remote regions with a low Human Development Index. The decision tree showed "conduction of sufficient training" (p=0.0015) as the factor with the greatest positive impact on teleconsultation utilization, followed by "ability to discuss clinical cases outside the teleconsultation system" (p=0.0192). Logistic regression analysis revealed two factors associated with increased use of the system: "complexity of the system" (odds ratio=3.35; 95% confidence interval [CI], 1.58-7.09) and whether they considered that the "service helps to solve everyday problems" (odds ratio=4.37; 95% CI, 1.14-16.69). CONCLUSIONS: The study of factors associated with the low use of the teleconsultation system of the TNMG may help policy makers define strategies to improve the use of teleconsultation services.

Doença falciforme e qualidade de vida: um estudo da percepção subjetiva dos pacientes da Fundação Hemominas, Minas Gerais, Brasil / Sickle cell disease and quality of life: a study on the subjective perception of patients from the Fundação Hemominas, Minas Gerais, Brazil

Na presente investigação, buscou-se pesquisar se o conceito de qualidade de vida, preconizado pela Organização Mundial de Saúde (OMS) poderia ser utilizado para pacientes com doença falciforme (DF), uma vez que se apresenta como um problema de saúde pública no país. Utilizou-se uma abordagem qualitativa com a seguinte questão norteadora na entrevista: "Para você o que é QV?". De acordo com o relato dos pacientes, procurou-se identificar a presença dos domínios físico, psicológico, nível de independência, relações sociais, meio ambiente e espiritualidade/crenças pessoais na representação da QV. Participaram do estudo 25 pacientes, dos quais 80% eram portadores da hemoglobina SS (HbSS) e 20% com hemoglobina SC (HbSC). A médiada idade encontrada foi de 33,3 anos, 56% eram do sexo feminino e 44% eram casados(as). Em relação à escolaridade, 44% atingiram até 11 anos de estudo e 56% até 8 anos. A DF representou, para 72%, impedimento para o trabalho, o que revela seu impacto negativo no desenvolvimento das habilidades laborais. Todos os domínios de QV preconizados pela OMS foram detectados no relato dos participantes: domínio físico em 84%, psicológico e relações sociais em 76%, nível de independência em 60%,meio ambiente em 52% e espiritualidade/crenças pessoais em 4% deles. Os aspectos referentes à multidimensionalidade e à subjetividade, apresentados no conceito de QV preconizado pela OMS, e representados pelos seus domínios, podem ser tomadoscomo norteadores de estudos que envolvam o conceito de QV em pacientes com DF.

This study aimed at investigating whether the concept of quality of life advocated by the World Health Organization can be applied to sickle cell patients, as this disease is an important public health problem in the country. A qualitative approach was utilized with the following guide question in the interview: "What is quality of life for you?" According to the patients' replies, the following domains were identified: physical, psychological, level of independence, social relationships, environment and spirituality/personal beliefs. Twentyfivepatients took part in the study, 80% had hemoglobin SS and 20% hemoglobin SC. The average age was 33.3 years old, 56% of the patients were women and 44% were married. In relation to schooling, 12% had concluded the 4th grade of elementary school and 24% completed high school. Sickle cell disease represented a barrier in respect to work for 72% of the patients, which demonstrates its negative impact on the development of the work capabilities ofthe individuals. All quality of life domains advocated by the WHO were present in the patients' replies: physical domain in 84%, psychological and social relationships in 76%, level of independence in 60%, environment in 52% and spirituality/personal believes in 4%. To conclude, the aspects referring to multidimensionality andsubjectivity, presented in the quality of life concept advocated by the WHO and represented by their domains, can be taken as a guide for studies which involve the quality of life in sickle cell patients.