Guideline of the Brazilian Society of Cardiology on Diagnosis and Treatment of Patients with Chagas Disease Cardiomyopathy / Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.

Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz. 

[Implementation of the Choosing Wisely Program in the General Surgery Residency]. / Implementação do Programa Choosing Wisely no Internato de Cirurgia Geral.

INTRODUCTION: The practice of unnecessary conduct and waste in Health is an important topic, not often addressed during undergraduate training. Medical education has a fundamental role in student and doctors' training concerning cost-conscious attitudes for good health care. The aim of this study was to describe and assess the implementation of the Choosing Wisely campaign within a General Surgery residency program. MATERIAL AND METHODS: This was an interventional study involving residency advisors and specialty residents. Recommendations based on three procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients were identified by residency advisors with the use of the Delphi method and were grouped by frequency and by nature according to the Choosing Wisely layout. Educational actions such as workshops and banner advertising in addition to training activities regarding cost-conscious healthcare were carried out. This subject was also included in the theoretical evaluation of the residency program. RESULTS: The leading five recommendations were related to (i) computed tomography overuse (versus ultrasound imaging) in patients with suspected acute appendicitis, (ii) multithreaded computed tomography overuse in patients with low-risk trauma, (iii) longer than recommended antibiotic prophylaxis in surgical patients, (iv) longer than recommended preoperative fasting period and (v) upper gastrointestinal endoscopy overuse in surgical patients without an adequate clinical evidence or without the presence of warning signs. Awareness and reflection among participants were improved, leading to high grades in final evaluation. DISCUSSION: Changes in training regarding quality of care and cost awareness should start throughout undergraduate training, within a learning environment focused on a reflective and evidence-based practice. All the benefits and harms to patients were taken into account in the recommendations that emerged from this study. CONCLUSION: The inclusion of this initiative in the General Surgery residency, involving reflective discussions on campaign recommendations regarding procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients may lead to more cost-conscious procedures.

Introdução: A prática de condutas desnecessárias e os desperdícios na saúde são temas importantes e ainda pouco abordados no curso de Medicina. A educação médica tem um papel fundamental na formação de estudantes e médicos com atitudes custo-conscientes para uma boa atenção à saúde. O objectivo deste estudo foi descrever e avaliar a implementação do programa Choosing Wisely - Escolhas Criteriosas em Saúde, no internato de Cirurgia Geral.Material e Métodos: Estudo de intervenção envolvendo orientadores de formação e internos. Utilizando a técnica Delphi, os orientadores de formação identificaram três intervenções frequentemente observadas na prática clínica sem benefício e com potenciais riscos desnecessários para o doente, que geraram recomendações, agrupadas e adaptadas ao formato do programa Choosing Wisely. O tema foi incluido na avaliação do internato, tendo sido desenvolvidas ações de formação e de divulgação em banners personalizados, a par de atividades de aprendizagem reflexiva sobre o programa e da integração da temática na avaliação teórica do internato.Resultados: As cinco principais recomendações referem-se (i) à utilização excessiva de tomografia axial computorizada na abordagem da suspeita de apendicite aguda e (ii) de tomografia axial computorizada de vários segmentos do corpo em traumatismos de baixo grau de gravidade, (iii) profilaxia antibiótica mais prolongada do que o recomendado no doente cirúrgico, (iv) jejum mais prolongado do que o recomendado no pré-operatório de todas as cirurgias e (v) utilização excessiva da endoscopia digestiva alta em doentes cirúrgicos sem sinais clínicos de alarme. As ações de formação geraram um incremento da sensibilização e reflexão, traduzido globalmente por um elevado aproveitamento na avaliação final.Discussão: A formação em escolhas criteriosas em saúde, promovendo uma utilização de cuidados de saúde consciente e de qualidade, sugere que as mudanças devem ocorrer ao longo do curso de Medicina, num ambiente de aprendizagem centrado numa prática reflexiva e baseada na evidência. As recomendações produzidas no estudo tiveram em consideração a totalidade dos benefícios e riscos para o doente.Conclusão: A integração da iniciativa Choosing Wisely no programa de formação em Cirurgia Geral deu origem a um conhecimento e discussão mais reflexivos sobre as recomendações relativas à utilização racional e criteriosa de cuidados de saúde, podendo resultar numa prática médica mais sustentável e sensível aos custos que gera.

Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP).

INTRODUCTION: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. OBJECTIVE: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. METHODS: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. RESULTS: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain. CONCLUSION: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.

Lack of association between serum syndecan-4, myocardial fibrosis and ventricular dysfunction in subjects with chronic Chagas disease.

BACKGROUND: Syndecan-4 is a transmembrane glycoprotein associated with inflammation and fibrosis. Increased syndecan-4 levels were previously detected after acute myocardial infarction and in subjects with heart failure. However, the levels of syndecan-4 in subjects with Chagas disease have not so far been investigated. The aim of this study was to investigate the potential role of serum sydencan-4 as a novel biomarker for myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. METHODS: This study comprised subjects with Chagas disease (n = 56), being 14 (25%) with the indeterminate form, 16 (29%) with the cardiac form without ventricular dysfunction, and 26 (46%) with the cardiac form with ventricular dysfunction. RESULTS: Syndecan-4 serum concentrations did not correlate with presence or absence of myocardial fibrosis (P = 0.386) nor disease severity in subjects with Chagas disease (P = 0.918). Additionally, no correlation was found either between the degree of myocardial fibrosis and serum syndecan-4 [r = 0.08; P = 0.567] or between left ventricular ejection fraction and syndecan-4 [r = 0.02; P = 0.864]. In contrast, NT-proBNP levels correlated with ejection fraction and myocardial fibrosis. CONCLUSIONS: Our results demonstrate the lack of correlations between serum syndecan-4, myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. Further studies are required to show if syndecan-4 concentrations can be marker for prognosis assessment or disease progression.