Trasplante cardíaco en miocardiopatía chagásica: 23 años de experiencia en un centro de referencia / Heart Transplantation in Chagas Cardiomyopathy: 23-Year Follow-Up in a Referral Center

RESUMEN Introducción: La enfermedad de Chagas afecta aproximadamente a 6 millones de personas en América Latina. El 25 a 35% evoluciona hacia la Miocardiopatía Chagásica (MCh). Una opción terapéutica en sus estadios avanzados es el trasplante cardíaco (TxC). Objetivos: Comparar la supervivencia de pacientes con TxC por MCh frente a otras etiologías. Analizar la incidencia de la reactivación (Ra) de enfermedad de Chagas y su impacto en la supervivencia en este subgrupo de pacientes. Material y métodos: Se evaluaron retrospectivamente pacientes con TxC entre agosto 1998 y marzo 2021. Se analizó la supervivencia mediante curvas de Kaplan-Meier y log rank test. El diagnóstico de Ra se realizó mediante métodos moleculares, prueba de Strout en sangre periférica, tejido miocárdico y/o cutáneo. Resultados: De 606 pacientes con TxC, 39 (6,4%) presentaban MCh. Seguimiento medio 4,4 años (Rango Intercuartilo 1,2-8,6). Edad subgrupo MCh 51 años (RIC 45-60). Hombres 28 (72%). Se documentó Ra en el 38,5% de los pacientes. Supervivencia a 1, 5 y 10 años en TxC por MCh con Ra versus no Ra: 85%, 76% y 61% versus 72%, 55% y 44% (p = 0,3). Supervivencia a 1, 5 y 10 años en TxC por MCh versus TxC por otras causas: 79%, 65% y 50% versus 79%, 62% y 47% (p = 0,5). Conclusión: En nuestra serie no se encontró diferencia estadísticamente significativa en la supervivencia de los pacientes trasplantados cardíacos por MCh en comparación con aquellos trasplantados por otras causas; así como tampoco entre los pacientes que reactivaron la enfermedad de Chagas y los que no lo hicieron.

ABSTRACT Background: Chagas disease affects about 6 million people in Latin America, and 25 to 35% progress to Chagas cardiomyopathy (ChCM). Heart transplantation (HTx) is a therapeutic option in advanced stages. Objectives: The aim of this study is to compare survival of patients with HTx due to ChCM versus those transplanted for other etiologies and to analyze the incidence of Chagas disease reactivation (Ra) and its impact on survival in this group of patients. Methods: Patients undergoing HTx between August 1998 and March 2021 were retrospectively evaluated. Survival was analyzed using Kaplan-Meier curves and the log-rank test. The diagnosis of Ra was performed by molecular methods, Strout's test in peripheral blood, myocardial tissue or skin tissue. Results: Of 606 patients with Htx, 39(6,4%) presented ChCM. Median follow up was 4.4 years (interquartile range 1.2-8.6). Median age of the subgroup with ChCM was 51 years (IQR 45-60) and 28 were men (72%). Reactivation was documented in 38.5% of the patients. Survival at 1, 5 and 10 years in HTx recipients due to ChCM and Ra versus no Ra was 85%, 76% and 61% versus 72%, 55% and 44%, respectively (p = 0.3). Survival at 1, 5 and 10 years in HTx recipients due to ChCM versus HTx for other causes was 79%, 65% and 50% versus 79%, 62% and 47%, respectively (p = 0.5). Conclusion: In our series we did not find statistically significant differences in survival of heart transplant recipients due to ChCM versus those transplanted due to other reasons. Survival in patients with Chagas disease reactivation and those without reactivation was also similar.

A cross-country qualitative study on contraceptive method mix: contraceptive decisionmaking among youth.

BACKGROUND: Youth ages 15 to 24, who comprise a large portion of sub-Saharan Africa, face a higher burden of unmet contraceptive need than adults. Despite increased international and national commitments to improving young people's access to contraception, significant barriers impede their access to a full range of methods. To further explore these barriers among youth in Kenya, Nigeria, and Uganda, we conducted a qualitative study to capture the challenges that affect contraceptive method decisionmaking and complicate youth access to the full method mix. METHODS: To understand factors that impact young people's contraceptive decisionmaking process across all three countries, we conducted a total of 35 focus group discussions with 171 youth ages 15 to 24 and 130 in-depth interviews with key stakeholders working in youth family planning. Questionnaires aligned with the High Impact Practices in Family Planning's elements of adolescent-friendly contraceptive services. Data were coded with MAXQDA and analyzed using a framework for contraceptive decisionmaking to identify relevant patterns and themes. RESULTS: In all three countries, youth reported that condoms are the most commonly sought contraceptive method because they are easiest to access and because youth have limited knowledge of other methods. Youth from diverse settings shared uncertainty and concern about the safety and side effects of many methods other than condoms, complicating their ability to take full advantage of other available methods. While most youth in Kenya, Nigeria, and Uganda reported at least moderate confidence in obtaining the information needed to help choose a method, and only a few youth reported that they are completely unable to access contraceptives, other barriers still present a major deterrent for youth, including cost, inconvenient facility hours and long wait times, and stigma from family, community members, and providers. CONCLUSIONS: Young people's ability to fully exercise their method choice remains limited despite availability of services, leading them to take the path of least resistance. Program implementers and policymakers should consider the diverse and often interconnected barriers that youth face in attempting to enjoy the benefits of a full spectrum of contraceptive methods and design multi-level interventions to mitigate such barriers.

Despite increased international and national commitments to improving young people's access to contraception, youth ages 15 to 24 face significant barriers to accessing a full range of contraceptive methods. This study conducted in-depth interviews with key stakeholders and focus group discussions with youth in Kenya, Nigeria, and Uganda to understand what factors impact youth's decision to use or not use certain contraceptive methods. In all three countries, youth reported that condoms are the most commonly sought contraceptive method because they are easiest to access and because youth have limited knowledge of other methods. Youth from diverse settings shared uncertainty and concern about the safety and side effects of many methods other than condoms. While most youth in Kenya, Nigeria, and Uganda reported at least moderate confidence in obtaining the information needed to help choose a method, other barriers like cost, inconvenient facility hours and long wait times, and stigma from family, community members, and providers still present a major deterrent for youth who want information on contraceptive methods. Program implementers and policymakers should consider the diverse and often interconnected barriers that youth face in attempting to enjoy the benefits of a full spectrum of contraceptive methods and design multi-level interventions to mitigate such barriers.

Tracking changes in states of contraceptive use over time in sub-Saharan Africa through cohort and period analyses.

It is difficult to gauge the success of programmatic efforts to reduce unmet need for contraception without knowing whether individual women have had their need met and adopted contraception. However, the number of true longitudinal datasets tracking the transition of panels of individual women in and out of states of contraceptive use is limited. This study analyses changes in contraceptive use states using Demographic and Health Survey data for 22 sub-Saharan African countries. A cohort approach, tracking representative samples of five-year age groups longitudinally across surveys, as well as period-based techniques, are applied to indicate whether new users of contraception have been drawn from women who previously had no need and/or those who had unmet need for family planning. The results suggest that a greater proportion of increases in contraceptive use in recent years can be attributed to decreases in the percentage of women with no need, especially among younger women, than to decreases in the proportion with unmet need.

Defining motivational intensity of need for family planning in Africa.

Non-users of contraception differ greatly in their likely motivation to adopt a method or resume use. This study presents a new approach to defining high and low motivation groups by stated intention to use, past use, and unmet need, to determine how these groups differ in characteristics and in region of residence. Data come from 23 DHS surveys in sub-Saharan countries, with representation from the eastern/southern region and western/central region. The low motivation non-users, with less past use and less intention to use in the future, are more rural, less educated, and closer to poverty. Motivational intensity is lower in the western/central region, which contains far fewer intenders than the eastern/southern region and where many more report no past use and no unmet need. When used to guide planning, unmet need should be augmented with motivation, since the two classifications do not entirely overlap. Between 10 and 17% of current non-users of family planning are likely highly motivated to use, but are not captured in the unmet need classification. Program implications for these non-using groups are discussed.

Pandemic influenza A/H1N1 virus infection in solid organ transplant recipients: a multicenter study.

BACKGROUND: The 2009 novel influenza A/H1N1 virus pandemic did not spare solid organ transplant (SOT) recipients. We aimed to describe the behavior of pandemic influenza infection in a group of SOT recipients in Argentina. METHODS: Data from 10 transplant (Tx) centers were retrospectively collected for SOT that presented with a respiratory illness compatible with pandemic influenza A infection, between May and September 2009. Cases were defined as suspected, probable, or confirmed according to diagnostic method. RESULTS: Seventy-seven cases were included. No significant differences in presenting symptoms, pulmonary infiltrates, and graft involvement were found among 35 suspected, 19 probable, and 23 confirmed cases. The 33 ambulatory cases had significantly more sore throat and headache when compared with 34 cases admitted to medical ward (MW) and 10 admitted to intensive care unit (ICU), 9 of whom required ventilatory support. MW and ICU cases had significantly more dyspnea, hypoxemia, pulmonary infiltrates, and graft dysfunction. Time from onset of symptoms to first visit and to treatment was significantly longer in MW and ICU cases (P=0.008). Coinfections were found in six cases. Most cases received oseltamivir for 5 to 10 days. Six patients (7.8%) died from viral infection at a median of 15 days from admission. No differences in outcome were seen related to the transplanted organ, the immunosuppressive regimen, time from Tx, or confirmation of diagnosis. CONCLUSIONS: Mortality is higher in Tx recipients than in the general population. Poor outcome seems to be related to a delay in the beginning of treatment.