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Background and Methods: In order to study fractal HR dynamics in Chagas disease, we performed detrended fluctuation analysis (DFA)-along with analysis of power-law beta slope (beta index) and standard deviation of N-N intervals (SDNN)-in edited and unedited (with ventricular premature beats - VPBs, only in DFA analysis) series of R-R intervals from Holter monitoring of healthy controls (Group 0, n = 27) and Chagas disease patients with left ventricular (LV) ejection fraction >50% (Group 1, n = 137) and with LV ejection fraction <50% (Group 2, n = 23).Results: When analyzed from the edited R-R interval data, the long-term scaling exponent alpha(2) is altered both among the Chagas patients with and without LV dysfunction. The short-term scaling exponent alpha(1) was higher in Group 1 Chagas patients as compared to controls (P < 0.01) and did not differ between Group 2 and controls. In unedited R-R interval series, alpha(1) was significantly reduced in Group 2 Chagas patients (0.55 +/- 0.002) as compared to controls (0.90 +/- 0.002) and Group 1 (0.91 +/- 0.003) (P < 0.001), but did not differ between Group 1 and controls. Similarly alpha(2) was lower in Group 2 compared to other groups (P < 0.001). SDNN did not differ between the groups, but the beta index derived from 1/f model was reduced both in Group 1 and 2 Chagas patients as compared to controls (P < 0.01). There was strong correlation (rs = 0.82; P < 0.001) between the beta and alpha(2) index from edited series. There was an inverse correlation (rs =-0.63, P < 0.01) between the number of VPBs and alpha(1) index of unedited series.Conclusions: The long-term fractal HR dynamics altered in chagasic patients with and without LV dysfunction could be an early sign of autonomic dysfunction. Patients with impaired LV function show marked alterations in short-term fractal HR dynamics toward more random behavior, mainly due to frequent ectopy. Prospective studies are necessary to define the value of these indices as predictors of death in Chagas disease. [ABSTRACT FROM AUTHOR]

Background: Clinical reasoning is at the core of medical practice and entangled in a conceptual confusion. The duality theory in probability allows to evaluate its objective and subjective aspects., Objectives: To conduct a systematic review of the literature about clinical reasoning in decision making in medical education and to propose a "reasoning based on the Bayesian rule" (RBBR)., Methods: A systematic review on PubMed was conducted (until February 27, 2022), following a strict methodology, by a researcher experienced in systematic review. The RBBR, presented in the discussion section, was constructed in his undergraduate dissertation in Philosophy at Minas Gerais Federal University. Heart failure was used as example., Results: Of 3,340 articles retrieved, 154 were included: 24 discussing the uncertainty condition, 87 on vague concepts (case discussion, heuristics, list of cognitive biases, choosing wisely) subsumed under the term "art", and 43 discussing the general idea of inductive or deductive reasoning. RBBR provides coherence and reproducibility rules, inference under uncertainty, and learning rule, and can incorporate those vague terms classified as "art", arguments and evidence, from a subjective perspective about probability., Conclusions: This systematic review shows that reasoning is grounded in uncertainty, predominantly probabilistic, and reviews possible errors of the hypothetico-deductive reasoning. RBBR is a two-step probabilistic reasoning that can be taught. The Bayes theorem is a linguistic tool, a general rule of reasoning, diagnosis, scientific communication and review of medical knowledge according to new evidence.

The HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is the most common neurological manifestation associated with human T-cell lymphotropic virus type-1 (HTLV-1) infection. Although cognitive impairment has been highlighted in the spectrum of HTLV-1 neurological manifestations, it may go unnoticed in those who do not spontaneously report it. We aimed at evaluating the applicability of a self-perceived memory score (SMS) and the cognitive event-related potential (P300) for early detection of cognitive impairment in HTLV-1-infected people. The SMS was measured by a 0-10 point numeric scale combined with a sad-happy face rating scale. The higher the number, the better was the SMS. The P300 was obtained through an oddball paradigm with a mental counting task. The participants were 15 (21.4%) individuals with HAM/TSP, 20 (28.6%) HTLV-1 asymptomatic carriers, and 35 (50%) seronegative controls. We found that SMS (p < 0.001) and P300 latency (p < 0.001) got progressively worse from the seronegative controls to the asymptomatic carriers and then to the HAM/TSP. The results that indicated cognitive impairment were SMS < 7.2 points and P300 latency > 369.0 ms. The HAM/TSP group showed the highest prevalence of altered P300 (80%) and SMS (87%). Interestingly, the asymptomatic group also presented significantly higher prevalence of altered SMS (60%) and P300 (35%) when compared to controls (< 10%). The frequency of cognitive impairment was 16 times higher in the HTLV-1 asymptomatic group and 69 times higher in the HAM/TSP group when compared to controls. The use of SMS in the medical consultation was a useful and easy-to-apply method to screen HTLV-1-infected subjects for everyday memory complaints., (© 2022. Journal of NeuroVirology, Inc.)

Current guidelines recommend at least one attempt of defibrillator antitachycardia pacing (ATP) therapy, showing preference for burst therapy. The objective of this study is to compare ramp versus burst ATP therapy proportion of success and acceleration in treating spontaneous or induced ventricular tachycardia (VT). The review protocol was previously published in PROSPERO. Data synthesis and measures of heterogeneity (I 2 ) was performed by CMA® software v.3 comparing proportions in both groups. Sensitivity analysis was performed as subgroup or meta-regression according to quality, clinical characteristics, and differences in design. Thirteen studies including 30,117 VT episodes in 1672 patients were analyzed. There was no significant difference in the proportion of success between burst and ramp therapy in spontaneous VT (odds ratio = 1.116; 95% confidence interval [CI] = 0.788-1.579; I 2  = 89%). There was no significant difference in the proportion of success between burst and ramp therapy in induced VT (odds ratio = 0.820; 95% CI = 0.468-1.437; I 2  = 93%). No significant difference was found in the proportion of acceleration between burst and ramp in spontaneous VT (odds ratio = 0.792; 95% CI = 0.476-1.317; I 2  = 83%). No significant difference was found in the proportion of acceleration between burst and ramp in induced VT (odds ratio = 1.234; 95% CI = 0.802-1.898; I 2  = 55%). Sensitivity analysis did not change main results. There is no difference in success or in acceleration proportion between burst or ramp ATP therapy irrespective if the VT was spontaneous or induced. Future implantable cardioverter defibrillator programming guidelines should offer both ATP therapies without preference in one of them., (© 2021 Wiley Periodicals LLC.)

Aims: To compare the blood pressure (BP)-lowering efficacy of a chlorthalidone/amiloride combination pill with losartan, during initial management of JNC 7 Stage I hypertension in patients with type 2 diabetes mellitus., Methods: In an a priori subgroup analysis of a randomized, double-blind, controlled trial, volunteers aged 30-70 years, with stage I hypertension and diabetes mellitus, were randomized to 12.5/2.5 mg of chlorthalidone/amiloride (N = 47) or 50 mg of losartan (N = 50), and followed for 18 months in 21 clinical centers. If BP remained uncontrolled after three months, study medication dose was doubled, and if uncontrolled after six months, amlodipine (5 and 10 mg) and propranolol (40 and 80 mg BID) were added as open label drugs in a progressive fashion., Results: Systolic BP decreased to a greater extent in participants allocated to diuretics compared to losartan (P < 0.001). After 18 months of follow-up, systolic BP was 128.4 ± 10.3 mmHg in the diuretic group versus 133.5 ± 8.0 in the losartan group (P < 0.01). In the diuretic group, 36 out of 43 participants (83.7%) had a JNC 7 normal BP, compared to 31/47 (66%) in the losartan group (P = 0.089). Serum cholesterol was higher in the diuretic arm at the end of the trial. Other biochemical parameters and reports of adverse events did not differ by treatment., Conclusions: Treatment of hypertension based on a combination of chlorthalidone and amiloride is more effective for BP lowering compared to losartan in patients with diabetes mellitus and hypertension., Trial Registration: Clinical trials registration number: NCT00971165.

Background: Expert nurses must provide both physical and emotional care to patients with diabetic foot syndrome (DFS) who require an amputation. This includes helping patients and families to cope with this situation, while ensuring the maximum level of comfort., Purpose: The aim of this study was to explore the perspective of expert nurses on the needs and hospital care of people requiring an amputation due to DFS., Method: This was a qualitative multicenter study involving 8 hospitals in Spain and Portugal. In-depth interviews with expert nurses were transcribed verbatim to enable content analysis., Results: Twenty-four expert nurses were interviewed about their knowledge and experience of treating patients with diabetic foot disease. Two themes emerged from the qualitative analysis: (1) poor self-care and the disease trajectory, and (2) effective hospital care., Conclusions: The results of this study highlight the key role that expert nurses play in the care of patients with DFS. Expert nurses considered that amputation leaves the individual physically and psychologically vulnerable, especially upon discharge from hospital. It is therefore essential to provide these patients with comprehensive and multidisciplinary care that includes emotional support.

Objective: To evaluate the effects of an implementation intention intervention on adherence to an oral anti-diabetic medication regime, diabetes-related distress and on glycemic control in patients with type 2 diabetes mellitus., Methods: A randomized, parallel-group, single-center controlled trial was conducted among adults with type 2 diabetes being managed at the primary care level. The intervention group (IG, n = 45) received an 'implementation intention' intervention; the control group (CG, n = 45) received standard care. Primary outcomes were the taking of oral anti-diabetic medication, global adherence and level of glycated hemoglobin. The secondary outcome was diabetes-related distress. Data were gathered at baseline and after 15 weeks., Results: The IG showed improvements in adherence to an oral anti-diabetic medication regime (p < 0.0001), glycemic control (p < 0.0001) and diabetes-related distress (p < 0.0001) relative to the CG., Conclusions: The implementation intention intervention enhanced adherence to an oral anti-diabetic medication regime, which had positive effects on blood glucose levels and diabetes-related distress., Practice Implications: Adherence to an oral anti-diabetic medication regime can decrease blood glucose levels and diabetes-related distress and thus reduce complications of type 2 diabetes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: In patients with Chagas cardiomyopathy (ChCM), sudden cardiac death (SCD) is the leading cause of mortality. Implantable cardioverter-defibrillator (ICD) is a well-established therapy for secondary prevention in patients with structural heart disease, but there are conflicting opinions regarding its efficacy and safety in patients with ChCM. The aim of this meta-analysis was to assess the efficacy of the ICD for secondary prevention in patients with ChCM, comparing mortality as the primary outcome of patients treated with ICD with those treated with amiodarone., Methods: We systematically searched five databases for studies assessing mortality outcomes in patients with ChCM and sustained ventricular tachycardia (VT) treated with ICD implantation or with amiodarone. The results of studies were pooled using random-effects modeling., Results: There was no randomized clinical trial comparing efficacy of ICD versus medical treatment in patients with ChCM. Six observational studies were included, totalizing 115 patients in amiodarone group and 483 patients in ICD group. The mortality outcome in the ICD population was 9.7 per 100 patient-years of follow-up (95%CI 5.7-13.7) and 9.6 per 100 patient-years in the amiodarone group (95%CI 6.7-12.4) (p = 0.95). Meta-regression did not show any association with LV ejection fraction (p = 0.32), age (p = 0.44), beta-blocker (p = 0.33) or angiotensin-converting enzyme inhibitors (p = 0.096) usage., Conclusion: The best available evidence derived from small observational studies suggests that ICD therapy in secondary prevention of sudden death (VT or resuscitated SCD) is not associated with lower rate of all-cause mortality in patients with ChCM. Randomized controlled trials are needed to answer this question., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Autonomic dysregulation is one of the recognized pathophysiological mechanisms in sepsis, generating the hypothesis that heart rate variability (HRV) can be used to predict mortality in sepsis., Methods: This was a systematic review of studies evaluating HRV as a predictor of death in patients with sepsis. The search was performed by independent researchers in PubMed, LILACS and Cochrane, including papers in English, Portuguese or Spanish, indexed until August 20th, 2017 with at least 10 patients. Study quality was assessed by Newcastle-Ottawa Scale. To analyze the results, we divided the articles between those who measured HRV for short-term recordings (≤ 1 hour), and those who did long-term recordings (≥ 24 hours)., Results: Nine studies were included with a total of 536 patients. All of them were observational studies. Studies quality varied from 4 to 7 stars in Newcastle-Ottawa Scale. The mortality rate in the studies ranged from 8 to 61%. Seven studies performed HRV analysis in short-term recordings. With the exception of one study that did not explain which group had the lowest results, all other studies showed reduction of several HRV parameters in the non-survivors in relation to the surviving septic patients. SDNN (Standard deviation of the Normal to Normal interval), TP (Total Power), VLF (Very Low Frequency Power), LF (Low Frequency Power), LF/HF (Low Frequency Power / High Frequency Power), nLF (Normalized Low Frequency Power), α1/α2 (short-term and long-term fractal scaling coefficients from DFA) and r-MSSD (Square root of the squared mean of the difference of successive NN-intervals) of the non-survivor group were reduced in relation to the survivors in at least one study. Two studies found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors. Three studies performed HRV analysis using long-term recordings. Only one of these studies found difference between surviving and non-surviving groups, and even so, in only one HRV parameter: LogHF., Conclusions: Several HRV parameters are reduced in nonsurviving septic patients in short-term recording. Two studies have found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors., Competing Interests: The authors have declared that no competing interests exist.

Background: To determine the effectiveness of low-dose diuretic therapy to achieve an optimal level of blood pressure (BP) in adults with prehypertension., Methods: The PREVER-prevention trial was a randomized, parallel, double-blinded, placebo-controlled trial, with 18 months of follow-up, conducted at 21 academic medical centers in Brazil. Of 1772 individuals evaluated for eligibility, 730 volunteers with prehypertension who were aged 30-70 years, and who did not reach optimal blood pressure after 3 months of lifestyle intervention, were randomized to a fixed association of chlorthalidone 12.5 mg and amiloride 2.5 mg or placebo once a day. The main outcomes were the percentage of participants who achieved an optimal level of BP., Results: A total of 372 participants were randomly allocated to diuretics and 358 to placebo. After 18 months of treatment, optimal BP was noted in 25.6% of the diuretic group and 19.3% in the placebo group (P < 0.05). The mean net reduction in SBP and DBP for the diuretic group compared with placebo was 2.8 mmHg (95% CI 1.1 to 4.5) and 1.1 mmHg (95% CI -0.09 to 2.4), respectively. Most participants in the active treatment group (74.5%) and in the placebo group (80.7%) continued to have BP in the prehypertension range or progressed to hypertension., Conclusion: Low-dose diuretic therapy increased the probability of individuals with prehypertension to achieve optimal BP but most of those treated continued to have a BP in the prehypertension range or progressed to having overt hypertension.

Background: Visceral leishmaniasis (VL) affecting HIV-infected patients is considered a challenging condition because of its high mortality and relapse rates. The approach of this condition is still surrounded by many uncertainties, especially regarding the criteria to institute and discontinue secondary prophylaxis for VL. The aim of this study was to evaluate the Leishmania parasitism kinetic assessed by polymerase chain reaction (PCR) as a possible tool in the prognostic assessment in a context in which patients are receiving highly active antiretroviral therapy and secondary prophylaxis., Methods: A prospective observation of Leishmania-HIV-co infected patients was performed and two groups with distinct clinical prognosis unpredicted by their CD4 count at the moment of VL diagnosis and not related to their HIV load control were confirmed., Results: Relapsing (R) and non-relapsing (NR) patients had similar antiviral therapy use rates, CD4 lymphocyte count medians and HIV load levels at VL-diagnosis. At the 12-month follow-up, R-patients presented a significantly lower CD4 lymphocyte count than NR-patients, without difference in HIV load control. The time between HIV and VL diagnoses was longer in the R than NR-group. Comparison between Kaplan-Meier relapse-free survival curves (time to relapse) using a log rank test showed that patients presenting circulating Leishmania DNA had a significantly higher risk of clinical VL relapse within 4 months after a positive test (p=0.001)., Conclusions: These results reinforce that a negative PCR could be a useful tool to support prophylaxis interruption among patients with CD4 counts above 200cells/mm 3 and that a positive PCR suggests imminent VL relapse., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Sepsis is a serious medical condition with increasing prevalence and high mortality. The role of the autonomic nervous system in pathophysiology of sepsis has been increasingly researched. The objective of this study is to evaluate the Heart rate variability (HRV) as a predictor of mortality in septic patients., Methods: This was a prospective cohort of patients diagnosed with sepsis. Patient recruitment was carried out at ICU in tertiary university hospital between March 2012 and February 2014. Clinical data and laboratory exams were collected at admission. Each patient underwent a 20-minute Holter and a 24-hour Holter on the first day of enrollment. The primary outcome was the 28-day all-cause mortality., Results: A total of 63 patients were included. Patients were categorized into nonsurvivor group (n = 16) or survivor group (n = 47) depending on this endpoint. Survivors were younger (48.6 years vs. 63.0 years), had better renal function and lower values in severity scores (APACHE II and SOFA) compared to nonsurvivors. In the 20-minute Holter, SDNN, Total Power, VLF Power, LF Power and LF/HF of nonsurvivors were significantly lower than those of survivors (p = <0.001, p = 0.003, p = 0.002, p = 0.006, p = 0.009 respectively). ROC curve of SDNN was built, showing area under the curve of 0.772 (0.638-0.906) for mortality. The value of 17ms was chosen as best SDNN cutoff to discriminate survivors and nonsurvivors. In the Cox proportional regression, adjusted for SOFA score and for APACHE II, a SDNN ≤ 17ms was associated with a greater risk of death, with hazard ratios of 6.3 (1.4-28.0; p = 0.015) and 5.5 (1,2-24,8; p = 0.027), respectively. The addition of the dichotomized SDNN to the SOFA model reduced AIC and increased the concordance statistic and the R2, indicating that predictive power of the SDNN + SOFA model is better than predictive power of SOFA only., Conclusions: Several HRV parameters are reduced in nonsurviving septic patients. SDNN ≤17 is a risk factor for death in septic patients, even after adjusting for severity scores.

Background: Prehypertension is associated with higher cardiovascular risk, target organ damage, and incidence of hypertension. The Prevention of Hypertension in Patients with PreHypertension (PREVER-Prevention) trial aimed to evaluate the efficacy and safety of a low-dose diuretic for the prevention of hypertension and end-organ damage., Methods and Results: This randomized, parallel, double-blind, placebo-controlled trial was conducted in 21 Brazilian academic medical centers. Participants with prehypertension who were aged 30 to 70 years and who did not reach optimal blood pressure after 3 months of lifestyle intervention were randomized to a chlorthalidone/amiloride combination pill or placebo and were evaluated every 3 months during 18 months of treatment. The primary outcome was incidence of hypertension. Development or worsening of microalbuminuria, new-onset diabetes mellitus, and reduction of left ventricular mass were secondary outcomes. Participant characteristics were evenly distributed by trial arms. The incidence of hypertension was significantly lower in 372 study participants allocated to diuretics compared with 358 allocated to placebo (hazard ratio 0.56, 95% CI 0.38-0.82), resulting in a cumulative incidence of 11.7% in the diuretic arm versus 19.5% in the placebo arm (P=0.004). Adverse events; levels of blood glucose, glycosylated hemoglobin, creatinine, and microalbuminuria; and incidence of diabetes mellitus were no different between the 2 arms. Left ventricular mass assessed through Sokolow-Lyon voltage and voltage-duration product decreased to a greater extent in participants allocated to diuretic therapy compared with placebo (P=0.02)., Conclusions: A combination of low-dose chlorthalidone and amiloride effectively reduces the risk of incident hypertension and beneficially affects left ventricular mass in patients with prehypertension., Clinical Trial Registration: URL: http://www.ClinicalTrials.gov, www.ensaiosclinicos.gov. Unique identifiers: NCT00970931, RBR-74rr6s., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

The purpose of this case series is to report eight patients with giant prolactinomas emphasizing presentations and a treatment complication. The study group included six men and two women. The median age was 29 years (18-54 years); median serum prolactin level was 4,562 ng/ml (1,543-18,690 ng/ml); three patients (37.5%) had panhypopituitarism; median tumor diameter was 50 mm (41-60 mm). Five patients (62.5%) had visual field defects and three had improvement during treatment; six patients (75%) reached prolactin normalization, with a median time of 10.5 months (7-84 months) and median dose of 2.0 mg/week (1.0 to 3.0 mg/week). One patient presented as a true incidentaloma. One patient presented a cerebrospinal fluid leakage during medical treatment and refused surgery, however this resolved with conservative measures. This case series illustrate a rare subtype of macroprolactinomas, the importance of considering unusual presentations at the diagnosis, the effectiveness of pharmacological treatment and its possible complications.

Objectives: To compare the blood pressure (BP)-lowering efficacy of a chlorthalidone/amiloride combination pill with losartan, during initial management of stage I hypertension., Methods: In a randomized, double-blind, controlled trial, 655 participants were followed for 18 months in 21 Brazilian academic centers. Trial participants were adult volunteers aged 30-70 years with stage I hypertension (BP 140-159 or 90-99 mmHg) following 3 months of a lifestyle intervention. Participants were randomized to 12.5/2.5 mg of chlorthalidone/amiloride (N = 333) or 50 mg of losartan (N = 322). If BP remained uncontrolled after 3 months, study medication dose was doubled, and if uncontrolled after 6 months, amlodipine (5 and 10 mg) and propranolol (40 and 80 mg twice daily) were added as open-label drugs in a progressive fashion. At the end of follow-up, 609 (93%) participants were evaluated., Results: The difference in SBP during 18 months of follow-up was 2.3 (95% confidence interval: 1.2 to 3.3) mmHg favoring chlorthalidone/amiloride. Compared with those randomized to diuretic, more participants allocated to losartan had their initial dose doubled and more of them used add-on antihypertensive medication. Levels of blood glucose, glycosilated hemoglobin, and incidence of diabetes were no different between the two treatment groups. Serum potassium was lower and serum cholesterol was higher in the diuretic arm. Microalbuminuria tended to be higher in patients with diabetes allocated to losartan (28.5 ± 40.4 versus 16.2 ± 26.7 mg, P = 0.09)., Conclusion: Treatment with a combination of chlorthalidone and amiloride compared with losartan yielded a greater reduction in BP., Clinical Trials Registration Number: NCT00971165.

Introduction: There are few drugs with proven efficacy in cutaneous leishmaniasis (CL), and pentavalent antimonial derivatives are still the main first-line therapeutic agents worldwide, despite their recognized high toxicities. Randomized controlled clinical trials assessing the efficacy and safety of new therapeutic modalities are of high priority, and the definition of the design of such trials raises debate about the use of placebo as a comparator. To support the use of placebo as a comparator, two main points need to be addressed: 1--the cure rate without any therapeutic intervention and 2--the damage caused by CL and its impact on patients., Objective: The aim of this study was to systematically assess the spontaneous cure rate for American CL and to broaden the discussion about placebo use in CL trials., Methods: The PRISMA guidelines for systematic reviews and the Cochrane manual were followed. The sources used were the PubMed and LILACS databases. Studies were included if they reported cure rates using placebo or no treatment in American CL., Results: Thirteen studies of a total of 352 patients were ultimately included in this review. The summarized global cure rates for all Leishmania species according to the intention-to-treat analyses performed at approximately three ("initial cure") and nine ("definitive cure") months after "no treatment" or placebo use were 26% (CI95%: 16 to 40%) and 26% (CI95%:16 to 38%), respectively. Notably, a significantly lower cure rate was observed for L. braziliensis infection (6.4%, CI95%:0.2 to 20%) than for L. mexicana infection (44%, CI95%:19 to 72%), p = 0.002. Of note, relapse occurred in 20% of patients with initial healing (CI95%:9.2 to 38.9%)., Conclusion: These results clearly demonstrate a low spontaneous cure rate following no-treatment or placebo use, confirming that this strategy for the control group in CL studies expose patients to greater morbidity, especially for CL caused by L. braziliensis. Therefore, from this point, the crucial question to consider regarding placebo use is the seriousness of the suffering caused by this disease.

Objectives: To evaluate the epidemiology of and surgical results from treating elbow fracture-dislocations, including only the cases in which dislocation is associated with fracture of the coronoid process and the radial head (terrible triad)., Methods: Nineteen patients were evaluated: 12 males and 7 females. The medical records were analyzed to gather data about the mechanism of injury, fracture pattern, time elapsed until surgery and type of procedure applied. A clinical assessment was made to measure elbow range of motion, and the MEPS questionnaire was applied., Results: The most common mechanism of injury in our sample was a fall from a height (12 patients). All the patients underwent surgical treatment and the mean time elapsed between the date of the injury and the surgery was 16.1 days. The mean follow-up was 50.3 months. The mean range of flexion-extension obtained was 112° and the mean range of pronation-supination obtained was 127.9°. The mean score from the MEPS questionnaire was 86 points, and excellent and good results were obtained for 15 patients (79%). The time elapsed until surgery, final flexion-extension range greater than 100° and flexion contracture of less than 30° were shown to have a statistically significant relationship with a good final clinical result. Five patients had complications, of which three cases related to peripheral nerves, one case to pseudarthrosis and one case to recurrent instability., Conclusions: Despite the severity of the injuries found in the terrible triad of the elbow, most of the patients evaluated here achieved elbow stability with good clinical results. The factors that led to better clinical results were surgery not more than 14 days after the injury, flexion-extension range greater than 100° and flexion contracture less than 30°.

Objective: To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation., Methods: Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I(2) ) and publication bias were both evaluated., Results: Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI 1.0-3.3) in the group receiving OAC, 2.2% (95% CI 0.9-5.3) in the OAC + UFH group, and 5.5% (95% CI 2.9-10.4) in the OAC + LMWH group (P = 0.042). The thromboembolic event rate was 2.1% (95% CI 1.5-2.9) in the group receiving OAC, as compared with 1.1% (95% CI 0.7-1.8) when the bridging therapy groups were combined as follows: OAC + UFH and OAC + LMWH (P = 0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias., Conclusions: Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH., (© 2015 International Society on Thrombosis and Haemostasis.)

Introduction: Although intravascular ultrasound minimal luminal area (IVUS-MLA) is one of many anatomic determinants of lesion severity, it has been proposed as an alternative to fractional flow reserve (FFR) to assess severity of coronary artery disease., Objective: Pool the diagnostic performance of IVUS-MLA and determine its overall accuracy to predict the functional significance of coronary disease using FFR (0.75 or 0.80) as the gold standard., Methods: Studies comparing IVUS and FFR to establish the best MLA cutoff value that correlates with significant coronary stenosis were reviewed from a Medline search using the terms "fractional flow reserve" and "ultrasound." DerSimonian Laird method was applied to obtain pooled accuracy., Results: Eleven clinical trials, including two left main (LM) trials (total N = 1,759 patients, 1,953 lesions) were included. The weighted overall mean MLA cutoff was 2.61 mm(2) in non-LM trials and 5.35 mm(2) in LM trials. For non-LM lesions, the pooled sensitivity of MLA was 0.79 (95% CI = 0.76-0.83) and specificity was 0.65 (95% CI = 0.62-0.67). Positive likelihood ratio (LR) was 2.26 (95% CI = 1.98-2.57) and LR- was 0.32 (95% CI = 0.24-0.44). Area under the summary receiver operator curve for all trials was 0.848. Pooled LM trials had better accuracy: sensitivity = 0.90, specificity = 0.90, LR+ = 8.79, and LR- = 0.120., Conclusion: Given its limited pooled accuracy, IVUS-MLA's impact on clinical decision in this scenario is low and may lead to misclassification in up to 20% of the lesions. Pooled analysis points toward lower MLA cutoffs than the ones used in current practice., (© 2013 Wiley Periodicals, Inc.)

Background: Prosthetic heart valve thrombosis is a life-threatening condition for which treatment has not been evaluated by randomized trials., Objectives: To compare surgery with thrombolytic therapy for the treatment of prosthetic valve thrombosis., Methods: A comprehensive systematic review was carried out by independent researchers using PubMed, Web of Knowledge, HINARI, LILACS and EMBASE, including papers indexed up to 23 October 2013 with at least 10 patients, evaluating one or both treatment options. Outcomes of interest were death, stroke, bleeding, embolic events and success. Study quality was assessed by the Newcastle-Ottawa Scale (ranges from 0 to 9). Comprehensive Meta Analysis Software was used to pool study results, for publication bias analysis and for meta-regression., Results: Forty-eight studies were included (2302 patients). No randomized study was identified, and all were observational in design. Study quality varied from 4 to 6 stars using the Newcastle-Ottawa Scale. Mortality for surgery was 18.1% (95%CI, 14.6-22.1; I(2) , 62% [42-75]), while mortality for thrombolytic therapy was 6.6% (95% CI, 4.8-8.9; I(2) , 0% [0-13]). Surgical mortality appeared to increase with NYHA-class, according to meta-regression. Other results related to surgery and thrombolytic therapy, respectively, were: embolic events, 4.6% (2.9-7.3) and 12.8% (10.8-15.2); stroke, 4.3%,(2.7-6.6%) and 5.6%,(4.3-7.4%); success rate, 81.9% (77.2-85.8) and 80.7% (75.6-85.0); bleeding, 4.6% (2.9-7.1) and 6.8% (5.4-8.6); and death or stroke, 19.0% (14.8-24.2) and 11.4% (8.7-14.7)., Conclusion: Mortality in patients treated by thrombolytic therapy for valve prosthesis thrombosis is significantly lower than in patients treated surgically. As we cannot yet ascertain whether this difference is due to the treatment alone, more studies are now necessary to further clarify these findings., (© 2014 International Society on Thrombosis and Haemostasis.)

Background: Visceral leishmaniasis (VL) is an emerging condition affecting HIV-infected patients living in Latin America, particularly in Brazil. Leishmania-HIV coinfection represents a challenging diagnosis because the clinical picture of VL is similar to that of other disseminated opportunistic diseases. Additionally, coinfection is related to treatment failure, relapse and high mortality., Objective: To assess the clinical-laboratory profile and outcomes of VL-HIV-coinfected patients using a group of non HIV-infected patients diagnosed with VL during the same period as a comparator., Methods: The study was conducted at a reference center for infectious diseases in Brazil. All patients with suspected VL were evaluated in an ongoing cohort study. Confirmed cases were divided into two groups: with and without HIV coinfection. Patients were treated according to the current guidelines of the Ministry of Health of Brazil, which considers antimony as the first-choice therapy for non HIV-infected patients and recommends amphotericin B for HIV-infected patients. After treatment, all patients with CD4 counts below 350 cells/mm3 received secondary prophylaxis with amphotericin B., Results: Between 2011 and 2013, 168 patients with suspected VL were evaluated, of whom 90 were confirmed to have VL. In total, 51% were HIV coinfected patients (46 patients). HIV-infected patients had a lower rate of fever and splenomegaly compared with immunocompetent patients. The VL relapse rate in 6 months was 37% among HIV-infected patients, despite receiving secondary prophylaxis. The overall case-fatality rate was 6.6% (4 deaths in the HIV-infected group versus 2 deaths in the non HIV-infected group). The main risk factors for a poor outcome at 6 months after the end of treatment were HIV infection, bleeding and a previous VL episode., Conclusion: Although VL mortality rates among HIV-infected individuals are close to those observed among immunocompetent patients treated with amphotericin B, HIV coinfection is related to a low clinical response and high relapse rates within 6 months.

Objectives. Assess the impact of associating thrombolytics, anticoagulants, antiplatelets, and primary angioplasty (PA) on death, reinfarction (AMI), and major bleeding (MB) in STEMI therapy. Methods. Medline search was performed to identify randomized trials comparing these classes in STEMI treatment, at least 500 patients, providing death, AMI, and MB rates. Similar arms were grouped. Correlation between number of drugs and PA and the outcomes was evaluated, as well as correlation between the year of the study and the outcomes. Results. Fifty-nine papers remained after exclusions. 404.556 patients were divided into 35 groups of arms. There was correlation between the number of drugs and rates of death (r = -0.466, P = 0.005) and MB (r = 0.403, P = 0.016), confirmed by multivariate regression. This model also showed that PA is associated with lower mortality and increased MB. Year and period of publication correlated with the outcomes: death (r = -0.380, P < 0.001), MB (r = 0.212, P = 0.014), and AMI (r = -0.231, P = 0.009). Conclusion. The increasing complexity of STEMI treatment has resulted in significant reduction in mortality along with increased rates of MB. Overall, however, the benefits of treatment outweigh the associated risks of MB.

The aim of this study was to evaluate the accuracy of invasive and non-invasive tests for diagnosis of visceral leishmaniasis (VL) in a large series of human immunodeficiency virus (HIV)-infected patients. In this delayed-type cross-sectional study, 113 HIV-infected symptomatic patients were evaluated by an adjudication committee after clinical follow-up to establish the presence or absence of VL as the target condition (reference test). The index tests were recombinant K39 antigen-based immunochromatographic test (rK39), indirect fluorescent antibody test (IFAT), prototype kit of direct agglutination test (DAT-LPC), and real-time polymerase chain reaction (qPCR) in peripheral blood. Compared with parasitological test and adjudication committee diagnosis or latent class model analyses, IFAT and rk39 dipstick test presented the lowest sensitivity. DAT-LPC exhibited good overall performance, and there was no statistical difference between DAT-LPC and qPCR diagnosis accuracy. Real-time PCR emerges as a less invasive alternative to parasitological examination for confirmation of cases not identified by DAT.

Objective: We conducted a systematic literature review with indirect comparison of studies evaluating therapeutic efficacy and toxicity associated to visceral leishmaniasis (VL) therapy among HIV infected individuals., Main Outcome Measurements: The outcomes of interest were clinical and parasitological cure, mortality, and adverse events., Methods: PRISMA guidelines for systematic reviews and Cochrane manual were followed. Sources were MEDLINE, LILACS, EMBASE, Web of Knowledge databases and manual search of references from evaluated studies. We included all studies reporting outcomes after VL treatment, regardless of their design. Study quality was evaluated systematically by using the Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Comprehensive Meta-Analysis software v.2.2.048 was used to perform one-group meta-analysis of study arms with the same drug to estimate global rates of success and adverse events with each drug. These estimates were used, when possible, to indirectly compare treatment options, adjusted for CD4 count. Direct comparison was pooled when available., Results: Seventeen studies reporting five treatment regimens and outcome of 920 VL episodes occurring in HIV infected individuals were included. The main outstanding difference in outcome among the treatment regimens was observed in mortality rate: it was around 3 times higher with high-dose antimony use (18.4%, CI 95% 13.3-25%), indirectly compared to lipid formulations of amphotericin B treatment (6.1%, CI 95% 3.9-9.4%). It was observed, also by indirect comparison, higher rates of clinical improvement in study arms using amphotericin B than in study arms using pentavalent antimonial therapy (Sb(v)). The parasitological cure, an outcome that presented some degree of risk of selection and verification bias, had rates that varied widely within the same treatment arm, with high heterogeneity, hampering any formal comparison among drugs. One direct comparison of amphotericin and antimoniate was possible combining results of two studies and confirming the superiority of amphotericin., Conclusions: Available evidence suggests that amphotericin is superior to antimony treatment. Death rate using antimoniate high dose is unacceptably high. Randomized controlled trials are necessary to compare different formulations and doses of amphotericin, alternative therapies and drug combinations.

Background: The cause of collagenous colitis (CC) and lymphocytic colitis (LC) is unknown and epidemiological risk factors for CC and LC are not well studied. The aim was to evaluate in a case-control study epidemiological risk factors for CC and LC., Methods: In all, 120 patients with CC, 70 with CL, and 128 controls were included. For all cases and controls information was prospectively recorded. A binary logistic regression analysis was performed separately for CC and LC., Results: Independent associations observed with the diagnosis of CC were: current smoking (odds ratio [OR], 2.4), history of polyarthritis (OR, 20.8), and consumption of lansoprazole (OR, 6.4), low-dose aspirin (OR, 3.8), beta-blockers (OR, 3.6), and angiotensin II receptor antagonists (OR 0.20). In the case of LC they were: current smoking (OR, 3.8), associated autoimmune diseases (OR, 8), and consumption of sertraline (OR, 17.5), omeprazole (OR 2.7), low-dose aspirin (OR, 4.7), and oral antidiabetic drugs (OR, 0.14)., Conclusions: The consumption of drugs, current smoking, and associated autoimmune diseases were independently associated with the risk of microscopic colitis.

This cross-sectional and quantitative study analyzed the knowledge of nursing professionals regarding Adverse Events (AE) in a hemodialysis unit of a teaching hospital. Data collection was performed between February and April 2011, based on interviews with 25 professionals. Data analysis identified 517 reports of 32 types of adverse events, of which the most commonly cited were: obstructed catheter, accidental withdrawal of the needle; and clotting of the extracorporeal system. Patient-related causes were mentioned in 42.8% of the reports. The main measures adopted were the implementation/ change of protocols and continuing education; the latter is the main suggestion for prevention. The results can contribute to a critical analysis of the quality of care in hemodialysis units, resulting in the development of interventions that help promote patient safety.

The presence of microbialite structures in a freshwater, dimictic mid-latitudelake and their establishment after the last ice age about 10,000 years ago is puzzling.Freshwater calcite microbialites at Pavilion Lake, British Columbia, Canada, consist of acomplex community of microorganisms that collectively form large, ordered structuredaggregates. This distinctive assemblage of freshwater calcite microbialites was studied through standard microbial methods, morphological observations, phospholipid fatty acid(PLFA) analysis, DNA sequencing and the identification of quorum sensing molecules.Our results suggest that the microbialites may represent a transitional form from theexclusively prokaryotic colonial precursors of stromatolites to the multicellular organismicaggregates that give rise to coral reefs.

Background: The role of intravascular ultrasound (IVUS) in percutaneous coronary interventions (PCI) is still controversial despite several previously published meta-analyses. A meta-analysis to evaluate the controversial role of IVUS-guided PCI with bare-metal stenting was performed and a previous published meta-analysis was re-evaluated in order to clarify the discrepancy between results of these studies., Methods: A systematic review was performed by an electronic search of the PubMed, Embase and Web of Knowledge databases and by a manual search of reference lists for randomized controlled trials published until April 2011, with clinical outcomes and, at least, six months of clinical follow-up. A meta-analysis based on the intention to treat was performed with the selected studies., Results: Five studies and 1,754 patients were included. There were no differences in death (OR = 1.86; 95% CI = 0.88-3.95; p = 0.10), non-fatal myocardial infarction (OR = 0.65; 95% CI = 0.27-1.58; p = 0.35) and major adverse cardiac events (OR = 0.74; 95% CI = 0.49-1.13; p = 0.16). An analysis of the previous published meta-analysis strongly suggested the presence of publication bias., Conclusions: There is no evidence to recommend routine IVUS-guided PCI with bare-metal stent implantation. This may be explained by the paucity and heterogeneity of the studies published so far.

Background: Human visceral leishmaniasis (VL), a potentially fatal disease, has emerged as an important opportunistic condition in HIV infected patients. In immunocompromised patients, serological investigation is considered not an accurate diagnostic method for VL diagnosis and molecular techniques seem especially promising., Objective: This work is a comprehensive systematic review and meta-analysis to evaluate the accuracy of serologic and molecular tests for VL diagnosis specifically in HIV-infected patients., Methods: Two independent reviewers searched PubMed and LILACS databases. The quality of studies was assessed by QUADAS score. Sensitivity and specificity were pooled separately and compared with overall accuracy measures: diagnostic odds ratio (DOR) and symmetric summary receiver operating characteristic (sROC)., Results: Thirty three studies recruiting 1,489 patients were included. The following tests were evaluated: Immunofluorescence Antibody Test (IFAT), Enzyme linked immunosorbent assay (ELISA), immunoblotting (Blot), direct agglutination test (DAT) and polimerase chain reaction (PCR) in whole blood and bone marrow. Most studies were carried out in Europe. Serological tests varied widely in performance, but with overall limited sensitivity. IFAT had poor sensitivity ranging from 11% to 82%. DOR (95% confidence interval) was higher for DAT 36.01 (9.95-130.29) and Blot 27.51 (9.27-81.66) than for IFAT 7.43 (3.08-1791) and ELISA 3.06 (0.71-13.10). PCR in whole blood had the highest DOR: 400.35 (58.47-2741.42). The accuracy of PCR based on Q-point was 0.95; 95%CI 0.92-0.97, which means good overall performance., Conclusion: Based mainly on evidence gained by infection with Leishmania infantum chagasi, serological tests should not be used to rule out a diagnosis of VL among the HIV-infected, but a positive test at even low titers has diagnostic value when combined with the clinical case definition. Considering the available evidence, tests based on DNA detection are highly sensitive and may contribute to a diagnostic workup.

In the next few years, the number of catalogued exoplanets will be counted in the thousands. This will vastly expand the number of potentially habitable worlds and lead to a systematic assessment of their astrobiological potential. Here, we suggest a two-tiered classification scheme of exoplanet habitability. The first tier consists of an Earth Similarity Index (ESI), which allows worlds to be screened with regard to their similarity to Earth, the only known inhabited planet at this time. The ESI is based on data available or potentially available for most exoplanets such as mass, radius, and temperature. For the second tier of the classification scheme we propose a Planetary Habitability Index (PHI) based on the presence of a stable substrate, available energy, appropriate chemistry, and the potential for holding a liquid solvent. The PHI has been designed to minimize the biased search for life as we know it and to take into account life that might exist under more exotic conditions. As such, the PHI requires more detailed knowledge than is available for any exoplanet at this time. However, future missions such as the Terrestrial Planet Finder will collect this information and advance the PHI. Both indices are formulated in a way that enables their values to be updated as technology and our knowledge about habitable planets, moons, and life advances. Applying the proposed metrics to bodies within our Solar System for comparison reveals two planets in the Gliese 581 system, GJ 581 c and d, with an ESI comparable to that of Mars and a PHI between that of Europa and Enceladus.

The structural properties of twin-plane superlattices in InP nanowires are systematically analyzed. First, we employ molecular dynamics simulations to determine the strain fields in nanowires grown in the [111] direction. These fields are produced by the formation of twin-planes and by surface effects. By using the stress tensor obtained from molecular dynamics simulations, we are able to describe changes on the electronic structure of these nanowires. On the basis of the resulting electronic structure, we confirm that a one-dimensional superlattice is indeed formed. Furthermore, we describe the transport properties of both electrons and holes in the twin-plane superlattices. In contrast to the predicted transparency of Γ-electrons in heterolayered III-V semiconductor superlattices, we verify that surface effects in 1D systems open up possibilities of electronic structure engineering and the modulation of their transport and optical responses.

Background and Objectives: Visceral leishmaniasis (VL) is a common complication in AIDS patients living in Leishmania-endemic areas. Although antiretroviral therapy has changed the clinical course of HIV infection and its associated illnesses, the prevention of VL relapses remains a challenge for the care of HIV and Leishmania co-infected patients. This work is a systematic review of previous studies that have described predictors of VL relapse in HIV-infected patients., Review Methods: We searched the electronic databases of MEDLINE, LILACS, and the Cochrane Central Register of Controlled Trials. Studies were selected if they included HIV-infected individuals with a VL diagnosis and patient follow-up after the leishmaniasis treatment with an analysis of the clearly defined outcome of prediction of relapse., Results: Eighteen out 178 studies satisfied the specified inclusion criteria. Most patients were males between 30 and 40 years of age, and HIV transmission was primarily via intravenous drug use. Previous VL episodes were identified as risk factors for relapse in 3 studies. Two studies found that baseline CD4+ T cell count above 100 cells/mL was associated with a decreased relapse rate. The observation of an increase in CD4+ T cells at patient follow-up was associated with protection from relapse in 5 of 7 studies. Meta-analysis of all studies assessing secondary prophylaxis showed significant reduction of VL relapse rate following prophylaxis. None of the five observational studies evaluating the impact of highly active antiretroviral therapy use found a reduction in the risk of VL relapse upon patient follow-up., Conclusion: SOME PREDICTORS OF VL RELAPSE COULD BE IDENTIFIED: a) the absence of an increase in CD4+ cells at follow-up; b) lack of secondary prophylaxis; and c) previous history of VL relapse. CD4+ counts below 100 cells/mL at the time of primary VL diagnosis may also be a predictive factor for VL relapse.

Background: Blood pressure (BP) within pre-hypertensive levels confers higher cardiovascular risk and is an intermediate stage for full hypertension, which develops in an annual rate of 7 out of 100 individuals with 40 to 50 years of age. Non-drug interventions to prevent hypertension have had low effectiveness. In individuals with previous cardiovascular disease or diabetes, the use of BP-lowering agents reduces the incidence of major cardiovascular events. In the absence of higher baseline risk, the use of BP agents reduces the incidence of hypertension. The PREVER-prevention trial aims to investigate the efficacy, safety and feasibility of a population-based intervention to prevent the incidence of hypertension and the development of target-organ damage., Methods: This is a randomized, double-blind, placebo-controlled clinical trial, with participants aged 30 to 70 years, with pre-hypertension. The trial arms will be chlorthalidone 12.5 mg plus amiloride 2.5 mg or identical placebo. The primary outcomes will be the incidence of hypertension, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new sub-clinical atherosclerosis, and sudden death. The study will last 18 months. The sample size was calculated on the basis of an incidence of hypertension of 14% in the control group, a size effect of 40%, power of 85% and P alpha of 5%, resulting in 625 participants per group. The project was approved by the Ethics committee of each participating institution., Discussion: The early use of blood pressure-lowering drugs, particularly diuretics, which act on the main mechanism of blood pressure rising with age, may prevent cardiovascular events and the incidence of hypertension in individuals with hypertension. If this intervention shows to be effective and safe in a population-based perspective, it could be the basis for an innovative public health program to prevent hypertension in Brazil., Trial Registration: Clinical Trials NCT00970931.

Background: Cardiovascular disease is the leading cause of death in Brazil, and hypertension is its major risk factor. The benefit of its drug treatment to prevent major cardiovascular events was consistently demonstrated. Angiotensin-receptor blockers (ARB) have been the preferential drugs in the management of hypertension worldwide, despite the absence of any consistent evidence of advantage over older agents, and the concern that they may be associated with lower renal protection and risk for cancer. Diuretics are as efficacious as other agents, are well tolerated, have longer duration of action and low cost, but have been scarcely compared with ARBs. A study comparing diuretic and ARB is therefore warranted., Methods/design: This is a randomized, double-blind, clinical trial, comparing the association of chlorthalidone and amiloride with losartan as first drug option in patients aged 30 to 70 years, with stage I hypertension. The primary outcomes will be variation of blood pressure by time, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new subclinical atherosclerosis and sudden death. The study will last 18 months. The sample size will be of 1200 participants for group in order to confer enough power to test for all primary outcomes. The project was approved by the Ethics committee of each participating institution., Discussion: The putative pleiotropic effects of ARB agents, particularly renal protection, have been disputed, and they have been scarcely compared with diuretics in large clinical trials, despite that they have been at least as efficacious as newer agents in managing hypertension. Even if the null hypothesis is not rejected, the information will be useful for health care policy to treat hypertension in Brazil., Clinical Trials Registration Number: ClinicalTrials.gov: NCT00971165.

Minimum accuracy of HIV diagnostic tests is considered the pillar on which testing strategies for all settings must be based. Systematic reviews and meta-analyses have shown that performance of the same test in different settings may vary according to several factors, resulting in different confidence intervals for sensitivity and specificity. Prevalence of HIV infection may influence observed test accuracy. The purpose of this article is to use the knowledge from meta-analyses of general diagnostic tests to inform the specific field of HIV diagnostic strategies. We propose the 'Bayesian' thinking: considering the pretest probability (i.e., prevalence, risk factors) and understanding test limitations to estimate a post-test probability of HIV diagnosis. Cost-effectiveness analysis, patient preferences and ethical issues must also be considered in HIV testing strategies.

Objectives: To perform a meta-analysis of studies using the Valsalva ratio (VR) in Chagas disease (ChD) patients without cardiopathy in comparison to control subjects in order to determine if vagal heart modulation is impaired in early forms of ChD., Methods: The medical literature was systematically searched and reviewed for cross-sectional studies in humans in which the Valsalva maneuver was used to evaluate the autonomic modulation of the heart in ChD patients without cardiopathy. The Hedges g statistic (software Medcalc v.9.4.0.0) was used to combine the results of all studies through the calculation of the summary standardized mean difference (SMD): the mean VR in controls minus the mean VR in ChD patients, divided by the pooled and adjusted standard deviation. The sample size necessary to detect this SMD with 80% of power was calculated using the G*Power software v.3.0., Results: The meta-analysis included 396 patients in 7 studies. Summary mean VRs were 1.87 +/- 0.39 ms in controls versus 1.74 +/- 0.40 ms in ChD without cardiopathy, leading to a statistically significant summary SMD of -0.310 (95% CI -0.513 to -0.106). Considering the summary SMD of -0.31, an alpha error of 0.05 and a 1:1 ratio of ChD and control patients, the estimated total sample size for a study with 80% power was 330 patients., Interpretation: ChD patients without cardiopathy have reduced VR values compared to healthy controls, indicating early vagal dysfunction. Most previous studies could not detect this impairment due to small study samples and insufficient statistical power.

Purpose: To study morphologic and histochemical alterations arising at the ileocystoplasty site., Methods: Sixteen Wistar female rats were subjected to ileocystoplasty and sacrificed after eight weeks. Material collected was divided into four groups for histological and histochemical studies: Group I (control) - isolated ileum segment removed during ileocystoplasty; Group II - ileoileal anastomosis; Group III - ileovesical anastomosis and Group IV - ileal segment from the neobladder. Histological and histochemical study assessed dysplasia, metaplasia, acute and chronic inflammation, fibrosis, atrophy, hypertrophy, total mucins, sialomucins and sulfomucins. The non-parametric Wilcoxon and Mann-Whitney tests were employed in statistical analysis., Results: None of the groups presented dysplasia. Acute inflammation and atrophy occurred in Groups II, III and IV, not reaching statistical significance. Metaplasia was significant only in Group III (p=0.012). Chronic inflammation, fibrosis and hypertrophy were significant in Groups II, III and IV. There was a significant increase in total mucin content in Group IV (p=0.014) and a reduction in Group III (p=0.016). Increases in sialomucins were observed in samples for Groups III (p=0.003) and IV (p=0.002) along with reduced sulfomucins in samples from Groups III (p=0.013) and IV (p=0.008)., Conclusion: Ileocystoplasty in female rats caused squamous metaplasia, chronic inflammatory infiltration, fibrosis, hypertrophy, increase in sialomucin content, reduction in sulfomucins, and alterations in total mucin content with statistical significance, as well acute inflammatory infiltration and muscular atrophy with less intensity.

Objectives: To analyze histopathological patterns of placental bed arteries in pregnancies complicated by chronic arterial hypertension. Alterations were considered according to clinical classification of the hypertensive disorders as mild (MG); moderate (MoG) and severe (SG) for comparison with uncomplicated pregnancies, control group (CG)., Methods: Placental bed biopsy was performed in 60 pregnant women; the study group was comprised of pregnant women with hypertension, subdivided in 13 with severe chronic hypertension (CH), 11 with moderate CH and 11 with mild CH, and results were compared to 25 placental bed biopsies from uncomplicated pregnancies. All the pregnant women had a gestational age of at least 28 weeks of gestation with a live fetus and were submitted to cesarean section. Hypertension was considered mild with diastolic blood pressure (DBP) 90 I? 100 mmHg, moderate DBP 100 I? 110 mmHg and severe DBP=110 mmHg. Placental bed variables selected for histological analysis were: unaltered patterns, physiological changes, medial layer disorganization, medial and intimal hyperplasic changes, acute necrosis and atherosis., Results: In cases with SG and MoG there was predominance of abnormal histophysiological findings: medial layer disorganization and hyperplasic changes, with a statistically significant difference when compared to MG and CG. Alteration in the medial layer was observed in these cases. The normal pattern, unaltered patterns and physiologic changes were more frequent in CG and MG. Physiological changes were the most usual finding, further, there was no acute necrosis or atherosis., Conclusion: 1. Abnormal histophysiological findings were predominant in hypertensive pregnant women compared to the normotensive ones; 2. These patterns were more frequent, according to the severity of the hypertensive disorders: Severe, Moderate and Mild; 3. More significant abnormal findings were a change in the medial layer, mainly in the group with severe hypertensive disorders; 4. The groups with moderate and severe hypertensive disorders when compared had similar results; 5. The normal histological pattern was higher in the control group and patients with mild hypertensive disorders and disclosed a similarity between them 6. The most usual pattern was physiologic changes, which was more frequent in the control group.

Background: Identifying patients at risk of sudden cardiac death (SCD) remains a challenge., Aim: To evaluate the performance of non-sustained ventricular tachycardia (NSVT) from 24 hour ambulatory electrocardiography as a predictor of SCD in patients with heart failure or non-ischaemic dilated cardiomyopathy with left ventricular systolic dysfunction (LVSD)., Methods and Results: Study search and selection were performed by independent reviewers using a validated strategy. Eleven prognostic studies with >100 patients with good quality data and multivariate analysis of predictors of SCD were included. Publication bias was evaluated by funnel plot with Kendall's tau b test. A summary ROC (sROC) curve was built to evaluate predictive performance of NSVT. There was threshold effect (Spearman's correlation between sensitivity and specificity=-0.818, p<0.01) which indicates that combining sensitivity and specificity was not appropriate. The area of 0.68+/-0.02 under the sROC curve indicates a statistically significant contribution of NSVT in the prediction of SCD. The true negative rate varied from 89 to 97%. Multivariate analysis and meta-regression suggested that the contribution of NSVT to risk stratification is independent of ejection fraction., Conclusions: Absence of NSVT indicated a low probability of SCD in patients with LVSD. A risk score including NSVT should be evaluated in prospective studies.

Background: The pathophysiology of cardiovascular disease (CVD) in chronic kidney disease (CKD) remains uncertain, but autonomic dysfunction seems to be involved. The aim of the study is to investigate the cardiac dysautonomia in uremic pediatric individuals through iodine 123 metaiodobenzylguanidine (MIBG) scintigraphy and heart rate variability (HRV) analysis., Methods and Results: We divided 40 CKD patients (aged 5-21 years) into 4 groups according to the treatment for CKD: conservative (n = 7), continuous ambulatory peritoneal dialysis (n = 5), hemodialysis (n = 13), and kidney transplantation (n = 15). Planar and tomographic I-123 MIBG images were acquired, and early and late cardiac uptake, cardiac and lung washout, and regional I-123 MIBG uptake were evaluated. Hemodialysis patients showed increased cardiac washout (P = .002), a heterogeneous pattern of I-123 MIBG distribution (P = .036), and lower values of the low-frequency (LF) component of HRV (P = .040). Subjects undergoing continuous ambulatory peritoneal dialysis had reduced lung washout (P = .030). The cardiac washout correlated positively with parathyroid hormone levels and negatively with creatinine clearance. There was a significant negative association between the LF component and cardiac washout., Conclusions: Uremic cardiac dysautonomia may be characterized by a decreased LF component of HRV, increased I-123 MIBG washout, and a heterogeneous distribution pattern in the left ventricular walls; these abnormalities were not present after kidney transplantation.

Acute myocardial infarction (AMI) is a rare, potentially fatal and often unrecognized complication of blunt thoracic trauma (BTT). Heart injury is diagnosed in less than 10% of all cases of blunt thoracic trauma. Medical literature is scarce in publications about AMI caused by BTT (AMI-BTT). There is no specific protocol on this issue. We describe two cases of AMI-BTT in young patients who were previously healthy and with no risk factors for coronary artery disease. The diagnostic tools and therapeutic approach are discussed based on a literature review. We conclude that the emergency physician should be alert for the possibility of AMI in victims of BTT, regardless of the intensity of the trauma.

Objective: To determine the value of the radiological study of the thorax for diagnosing left ventricular dilation and left ventricular systolic dysfunction in patients with Chagas' disease., Methods: A cross-sectional study of 166 consecutive patients with Chagas' disease and no other associated diseases. The patients underwent cardiac assessment with chest radiography and Doppler echocardiography. Sensitivity, specificity, and positive and negative predictive values of chest radiography were calculated to detect left ventricular dysfunction and the accuracy of the cardiothoracic ratio in the diagnosis of left ventricular dysfunction with the area below the ROC curve. The cardiothoracic ratio was correlated with the left ventricular ejection fraction and the left ventricular diastolic diameter., Results: The abnormal chest radiogram had a sensitivity of 50%, specificity of 80.5%, and positive and negative predictive values of 51.2% and 79.8%, respectively, in the diagnosis of left ventricular dysfunction. The cardiothoracic ratio showed a weak correlation with left ventricular ejection fraction (r=-0.23) and left ventricular diastolic diameter (r=0.30). The area calculated under the ROC curve was 0.734., Conclusion: The radiological study of the thorax is not an accurate indicator of left ventricular dysfunction; its use as a screening method to initially approach the patient with Chagas' disease should be reevaluated.

Left ventricular dysfunction in Chagas' disease is common but can be difficult to detect. We investigated whether measurement of plasma brain natriuretic peptide (BNP) could identify patients with left ventricular dysfunction who need further investigation or treatment. Among patients with an abnormal electrocardiogram or chest radiograph, a BNP concentration of 60.7 pmol/L or higher has a sensitivity and positive predictive value of 80%, and specificity and negative predictive value of 97%. Measurement of plasma BNP concentration could be a useful method to screen patients with Chagas' disease.