From Psoriasis to Psoriatic Arthritis: Ultrasound Insights Connecting Psoriasis with Subclinical Musculoskeletal Inflammation and the Path to Psoriatic Arthritis

PURPOSE OF REVIEW

This review summarizes the literature about the transition from psoriasis to psoriatic arthritis (PsA), focusing on musculoskeletal ultrasound (MSUS) for detecting subclinical inflammation and its role in diagnosis and triage of high-risk patients.

RECENT FINDINGS

MSUS effectively detects subclinical musculoskeletal inflammation in patients with psoriasis; however, some of these lesions are non-specific and can be found in healthy individuals. Preliminary evidence suggest that subclinical sonographic findings may predict progression to PsA in psoriasis patients. MSUS can also improve referrals' accuracy and its integration in the PsA classification criteria may improve early PsA detection. MSUS is a valuable tool for detecting subclinical abnormalities in psoriasis patients, which indicate an increased likelihood of progressing to PsA. Its integration into referral protocols and clinical use could improve PsA diagnosis. We propose an MSUS-inclusive algorithm for PsA referrals and triage, which requires validation. The potential of early intervention in reducing PsA progression in psoriasis patients with subclinical inflammation remains to be established.

Clinical characteristics and in-hospital outcomes of patients coinfected with Chagas disease and SARS-CoV-2

Background

Underlying comorbidities have been widely associated with a worse prognosis for COVID-19 patients, since viral infections could act as triggers for worsening of chronic diseases.

Although Chagas disease (CD) is endemic in Latin America, it has been recognized that the disease is now a worldwide concern. Information on the interplay between COVID-19 and CDis lacking.

Purpose

To assess clinical characteristics and in-hospital outcomes of patients with CD and COVID-19, and to compare it to non-CD patients.

Methods

Patients with COVID-19 diagnosis were selected from the Brazilian COVID-19 Registry, a prospective multicenter cohort, from March to September, 2020. CD diagnosis was based on hospital record at the time of admission. Study data were collected by trained hospital staff using Research Electronic Data Capture (REDCap) tools. Genetic matching for sex, age, hypertension, DM and hospital was performed in a 4:1 ratio.

Results

Of the 7,018 patients who had confirmed infection with SARS-CoV-2 in the registry, 31 patients with CD and 124 matched controls were included. Overall, the median age was 72 (64.-80) years-old and 44.5% were male. At baseline, heart failure (25.8% vs. 9.7%) and atrial fibrillation (29.0% vs. 5.6%) were more frequent in CD patients than in the controls (p<0.05 for both). C-reactive protein levels were lower in CD patients compared with the controls (55.5 [35.7, 85.0] vs. 94.3 [50.7, 167.5] mg/dL). Seventy-two (46.5%) patients required admission to the intensive care unit. In-hospital management, outcomes and complications were similar between the groups (Table 1).

Conclusions

In this large Brazilian COVID-19 Registry, CD patients had a higher prevalence of atrial fibrillation and chronic heart failure compared with non-CD controls, with no differences in-hospital outcomes. The lower C-reactive protein levels in CD patients require further investigation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported in part by Minas Gerais State Agency for Research and Development (Fundação de Amparo à Pesquisa do Estado de Minas Gerais - FAPEMIG) [grant number APQ-00208-20], National Institute of Science and Technology for Health Technology Assessment (Instituto de Avaliação de Tecnologias em Saúde – IATS)/ National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnolόgico - CNPq) [grant number 465518/2014-1], Table 1. Clinical outcomes

Level of literacy and clinical outcomes in patients with Chagas disease: SaMi-Trop project

Background

Chagas disease (CD) is a neglected tropical disease that affects mainly vulnerable population, whose majority has low ability to understand health information. This study aimed to assess the prevalence of health literacy (HL) and its association with sociodemographic, quality of life, health care aspects and worse clinical outcomes.

Methods

This is a cross-sectional study developed inside a cohort study (SaMi-Trop) including 1959 patients. It has been conducted in an endemic region to CD in Brazil. The eligible criteria for HL evaluation was the ability to read. The HL was assessed with SALPHA-18 scale and literacy was categorized in inadequate HL; adequate HL and; illiterate. Multiple models were adjusted using binary logistic regression, multinomial and beta regression models using the gamlss framework.

Results

Of the patients included, 1136 (74.1%) are illiterate. For HL assessment, only 397 managed to complete the HL evaluation. The prevalence of inadequate HL was 85.1% (338), only 59 patients (14.9%) had adequate HL. Our results are as following: 1) being illiterate increases the chance of using more drugs when compared to individuals with adequate HL - 1 or 2 drugs (OR: 1.96; CI: 1.06-3.62) and 3 to 4 medications (OR: 3.06; CI:1.44-6.52), to have hypertension (OR: 2.24; CI: 1.29-3.90), report an average self-perceived health (OR: 2.97; IC: 1.63-5.42) and report poor self-perceived health (OR: 3.67; CI: 1.71-7.89); 2) inadequate literacy increases the chance of using 3 to 4 medications (OR: 2.26; CI: 1.04-4.93) and report an average self-perceived health (OR: 2.48; CI: 1.34-4.62); 3) Illiterate patients present worst quality of life scores in Physical (OR: 0,730; CI: 0,583-0,914), Psychological (OR: 0,671; CI: 0,544-0,828) and Environmental (OR: 0,727; CI: 0,601-0,880) domains.

Conclusions

We found a high prevalence of inadequate HL; it was associated with worse clinical outcomes and poor self-perceived health.

Key messages

Our findings reinforce the importance of improving health communication in CD patients seeking to avoid unfavorable outcomes. A high prevalence of inadequate health literacy was observed in our study, which can impact the self-care ability of patients with CD.

P5520Evaluation of the impact of the implementation of a pre-hospital ambulance system on acute myocardial infarction mortality in a developing country

Background

Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. The effective management of patients with AMI is directly linked to time, and approximately one-half of the deaths attributed to AMI occur from cardiac arrest in the out-of-hospital setting, reinforcing the importance of the prehospital care. Contemporary data remain particularly lacking about the use of prehospital care in the setting of AMI, particularly from the more generalizable perspective of a community-based investigation, as well as information about the hospital outcomes of patients transported by ambulance.

Purpose

To assess the impact the implementation of a nationwide ambulance service (Serviço de Atendimento Médico de Urgência, SAMU) on AMI mortality and number of hospitalizations, in the state of Minas Gerais, Brazil.

Methods

Retrospective, ecological study, which assessed data from the Brazilian Universal Health System (SUS), from all 853 municipalities of Minas Gerais, from 2008 to 2016. SAMU implementation dates were obtained from the state government and SAMU local coordinators. Data on the population of each municipality was obtained from Instituto Brasileiro de Geografia e Estatística (IBGE), the Brazilian official demographic institute. Excessive skewness of general and in-hospital mortality rates were smoothed using the Empirical Bayes method The relationship between SAMU care in each municipality and the mortality due to AMI in the general population, in-hospital mortality and number of hospitalizations for AMI was assessed using the Poisson hierarchical model, and the analyzed rates were corrected by the age structure and detrended by seasonal influences.

Results

AMI mortality rates showed a decreasing tendency throughout the study, on average 2% per year, and seasonal variation, being higher during winter months. Age-corrected AMI in-hospital mortality also showed a decreasing trend, from 13.81% in 2008 to 11.43% in 2016. SAMU implementation was associated with decreased AMI mortality (odds ratio [OR]=0.967, 95% confidence interval [CI] 0.936–0.998) and AMI in-hospital mortality (OR=0.914, 95% CI 0.845–0.986) with no relation with the number of hospitalizations (OR 1.003, 95% CI 0.927–1.083). There was no seasonal variation in the number of AMI hospitalizations.

Conclusion

SAMU implementation was related to a modest but significant decrease in AMI in-hospital mortality. This finding reinforces the main role of prehospital care in AMI care and reinforces the need for investment in improving the service throughout the country.

Abstract P1-11-02: Meta-regression and meta-analysis of dexrazoxane for cardioprotection in all breast cancer stages in patients treated with anthracyclines

Background: Anthracyclines continue to be a valuable option in chemotherapy for breast cancer (BC), in spite of their well-documented cardiotoxicity. Anthracycline-induced cardiotoxicity depends on cumulative dose, and it actually begins with the first dose. Clinical studies have suggested that dexrazoxane could reduce this toxicity. Dexrazoxane is frequently used when higher anthracycline cumulative doses are needed, but is often omitted in the adjuvant setting. We aimed to analyse by an updated meta-analysis the cardioprotective effect of dexrazoxane in all BC stages in patients receiving anthracycline-based chemotherapy. In addition, we perfomed subgroup analyses and meta-regression to assess if the average anthracycline dose and the studies publication date would interfere in the cardiac event outcome.

Methods: We performed a systematic review and meta-analysis. The review was registered in PROSPERO database (CRD42017077462). We searched data from 1990 to August 2017 in Cochrane Central Register of Controlled Trials, Google Scholar, MEDLINE/Pubmed, LILACS, Web of Science, articles references and ASCO proceedings. Studies assessing congestive heart failure and cardiac event (cardiac function alterations without cardiac symptoms or hospitalization for cardiac reasons) as primary endpoints were included. Two reviewers independently performed the studies selection, risk of bias assessment and data extraction. Meta-analysis was done using random effect model for estimation of treatment effect. Heterogeneity was assessed by visual inspection of forest plots and by Q test. Subgroup analyses were carried out, according with the chemotherapy regimen (use of anthracycline in previous chemotherapy). In the meta-regression we used the random effects model.

Results: Our search resulted in 1603 articles, from which we included 7 studies providing 1545 participants. Meta-analysis showed an overall beneficial effect of dexrazoxane on reducing the risk of cardiac events (OR 0.262, CI 95%:0.169-0.407, p < 0.0001). In two of the seven studies which evaluated the cardiac event outcome, the patients were previously exposed to anthracyclines. In this patients' subgroup, we found an odds ratio of 0,244 (CI 95%, 0,102 to 0,584). In the study subgroup that the patients didn't report previous exposure to anthracycline, the odds ratio was 0,266 (CI 95%, 0,149 to 0,478). The Q test to evaluate the difference between the subgroups showed a value of 0,026 with p = 0,871 suggesting there was no difference between the subgroups. The multiple meta-regression was performed, adding to the model the average dose and studies age variables, for a combined analysis. The statistical analysis of the impact of the two combined cofactors didn't show significative association (Q test = 2,36, df = 2 and p = 0,30).

Conclusions: Dexrazoxane reduced the occurrence of cardiac events when added to anthracycline based chemotherapy regimen. There was no evidence that the benefit of the reduction of cardiac events with the use of dexrazoxane was different according to the use of anthracycline in previous chemotherapy or by the used average dose of anthracycline. These findings may have significant implications for clinical practice.

Citation Format: Macedo AV, Rodrigues AN, Brant RC, Ribeiro AL. Meta-regression and meta-analysis of dexrazoxane for cardioprotection in all breast cancer stages in patients treated with anthracyclines [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-02.

Incidence of cardiovascular risk factors in female patients with systemic lupus erythematosus: a 3-year follow-up cohort

Objectives

To evaluate the incidence and variability of traditional coronary artery disease (CAD) risk factors in a cohort of lupus patients and to investigate if prednisone use predicts an increase in the number of risk factors.

Methods

A total of 151 women, 37.8 ± 11.1 (mean ± SD) years old at baseline, were reevaluated after a median period of 39 (interquartile range 36.5–42.0) months. The cumulative incidence of traditional risk factors, the incidence rate (with 95% confidence interval) of hypertension, diabetes, dyslipidemia and hypertriglyceridemia, and the frequency of the risk factors’ disappearance were calculated. Metabolic syndrome (MetS) and Framingham risk score (FRS) were computed. Logistic regression was used to investigate if maximum or cumulative prednisone dose used during follow-up predicted an increase in the cardiometabolic risk factors’ number.

Results

The cumulative incidence of risk factors varied from 39.1% (abdominal obesity) to zero (smoking), and the incidence rate varied from 133.2 (87.8–178.6) per 1000 person-years (dyslipidemia) to 10.4 (1.3–19.5) per 1000 person-years (diabetes). The cumulative incidence for MetS was 18.8%, and 11.7% of 143 patients with low FRS at baseline (T1) were classified in the high-risk category at the end of the study (T2). Dyslipidemia was the most variable risk factor, with 43.5% disappearance at T2. The maximum prednisone dose used during follow-up was borderline ( p = 0.050) for prediction of an increase in the number of cardiometabolic risk factors in an adjusted model for antimalarial use, modified Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and age.

Conclusion

The authors described high incidence and variability of CAD risk factors in female lupus patients, with higher prednisone dose being borderline for an increase in the number of cardiometabolic risk factors.

Characterization of a promiscuous cadmium and arsenic resistance mechanism in Thermus thermophilus HB27 and potential application of a novel bioreporter system

Background

The characterization of the molecular determinants of metal resistance has potential biotechnological application in biosensing and bioremediation. In this context, the bacterium Thermus thermophilus HB27 is a metal tolerant thermophile containing a set of genes involved in arsenic resistance which, differently from other microbes, are not organized into a single operon. They encode the proteins: arsenate reductase, TtArsC, arsenic efflux membrane transporter, TtArsX, and transcriptional repressor, TtSmtB.

Results

In this work we show that the arsenic efflux protein TtArsX and the arsenic responsive transcriptional repressor TtSmtB are required to provide resistance to cadmium. We analyzed the sensitivity to Cd(II) of mutants lacking TtArsX, finding that they are more sensitive to this metal than the wild type strain. In addition, using promoter probe reporter plasmids, we show that the transcription of TtarsX is also stimulated by the presence of Cd(II) in a TtSmtB-dependent way. Actually, a regulatory circuit composed of TtSmtB and a reporter gene expressed from the TtarsX promoter responds to variation in Cd(II), As(III) and As(V) concentrations.

Conclusions

Our results demonstrate that the system composed by TtSmtB and TtArsX is responsible for both the arsenic and cadmium resistance in T. thermophilus. The data also support the use of T. thermophilus as a suitable chassis for the design and development of As-Cd biosensors.

Electronic supplementary material

The online version of this article (10.1186/s12934-018-0918-7) contains supplementary material, which is available to authorized users.

An ArsR/SmtB family member regulates arsenic resistance genes unusually arranged in Thermus thermophilus HB27

Arsenic resistance is commonly clustered in ars operons in bacteria; main ars operon components encode an arsenate reductase, a membrane extrusion protein, and an As‐sensitive transcription factor. In the As‐resistant thermophile Thermus thermophilus HB27, genes encoding homologues of these proteins are interspersed in the chromosome. In this article, we show that two adjacent genes, TtsmtB, encoding an ArsR/SmtB transcriptional repressor and, TTC0354, encoding a Zn²⁺/Cd²⁺‐dependent membrane ATPase are involved in As resistance; differently from characterized ars operons, the two genes are transcribed from dedicated promoters upstream of their respective genes, whose expression is differentially regulated at transcriptional level. Mutants defective in TtsmtB or TTC0354 are more sensitive to As than the wild type, proving their role in arsenic resistance. Recombinant dimeric TtSmtB binds in vitro to both promoters, but its binding capability decreases upon interaction with arsenate and, less efficiently, with arsenite. In vivo and in vitro experiments also demonstrate that the arsenate reductase (TtArsC) is subjected to regulation by TtSmtB. We propose a model for the regulation of As resistance in T. thermophilus in which TtSmtB is the arsenate sensor responsible for the induction of TtArsC which generates arsenite exported by TTC0354 efflux protein to detoxify cells.

The Effects of Weight and Waist Change on the Risk of Long-Term Mortality in Older Adults- The Bambuí (Brazil) Cohort Study of Aging

OBJECTIVE

We aimed to investigate the risk of long-term mortality associated with weight and waist circumference (WC) change among older adults, particularly the overweight and obese ones.

DESIGN

Cohort Study.

SETTING

The Bambuí (Brazil) Cohort Study of Aging.

PARTICIPANTS

Community-dwelling elderly (n=1138).

MEASUREMENTS

Weight and WC were reassessed three years after baseline. Mortality risk associated with a 5% weight/WC loss and gain was compared to that of weight/WC stability by Cox models adjusted for clinical, behavioral and social known risk factors for death (age, gender, BMI, smoking, diabetes, total cholesterol, hypertension, Chagas disease, major electrocardiographic changes, physical activity, B-type natriuretic peptide, C-reactive protein, creatinine, education and household income).

RESULTS

Female sex was predominant (718; 63.1%). Mean age was 68 (6.7) years. Weight stability (696; 61.1%) was more common than weight loss (251; 22.1%) or gain (191; 16.8%). WC remained stable in 422 (37.3%), decreased in 418 (37.0%) and increased in 291 (25.7%) participants. There were 334 (29.3%) deaths over a median follow-up time of 8.0 (6.4-8.0) years from weight/WC reassessment. Weight loss (HR 1.69; 95% CI 1.30-2.21) and gain (HR 1.37; 95% CI 1.01-1.85) were associated with increased mortality, except in those who were physically active in which weight gain was associated with decreased mortality. Results were similar for participants who were overweight/obese or with abdominal obesity at baseline (HR 1.41; 95%CI 1.02-1.97 and HR 2.01; 95%CI 1.29-3.12, for weight loss and gain, respectively). WC change was not significantly associated with mortality.

CONCLUSION

Although weight loss has been recommended for adults with excessive weight regardless of age, weight change might be detrimental in older adults. Rather than weight loss, clinical interventions should target healthy lifestyle behaviors that contribute to weight stability, particularly physical activity in overweight and obese older adults.

Naa50/San-dependent N-terminal acetylation of Scc1 is potentially important for sister chromatid cohesion

The gene separation anxiety (san) encodes Naa50/San, a N-terminal acetyltransferase required for chromosome segregation during mitosis. Although highly conserved among higher eukaryotes, the mitotic function of this enzyme is still poorly understood. Naa50/San was originally proposed to be required for centromeric sister chromatid cohesion in Drosophila and human cells, yet, more recently, it was also suggested to be a negative regulator of microtubule polymerization through internal acetylation of beta Tubulin. We used genetic and biochemical approaches to clarify the function of Naa50/San during development. Our work suggests that Naa50/San is required during tissue proliferation for the correct interaction between the cohesin subunits Scc1 and Smc3. Our results also suggest a working model where Naa50/San N-terminally acetylates the nascent Scc1 polypeptide, and that this co-translational modification is subsequently required for the establishment and/or maintenance of sister chromatid cohesion.

Adipokines, tumor necrosis factor and its receptors in female patients with systemic lupus erythematosus

OBJECTIVES

To analyze the association of adipokines and tumor necrosis factor α (TNFα) and its receptors with characteristics of systemic lupus erythematosus (SLE) and to investigate the correlation between adipokines and the TNF system.

METHODS

One hundred and thirty-six SLE women, aged ≥18 years old, were assessed. TNFα, soluble TNFα receptors 1 (sTNFR1) and 2 (sTNFR2) and adipokines were analyzed by ELISA kits.

RESULTS

The median (IQR) of age was 41.5 (33.0-49.7) years old and of disease duration 11.3 (7.8-15.8) years. The median (IQR) of disease activity was 0 (0-4) and of damage index was 2 (1-3). Higher levels of sTNFR1 and sTNFR2 were associated with nephritis (p < 0.001 for both), and sTNFR1 (p = 0.025) and TNFα (p = 0.014) were positively associated with arthritis. Higher sTNFR1 levels were found in participants that were not using antimalarial drugs (p = 0.04). Independent correlation was found between sTNFR1 (β = 0.253; p = 0.003) and sTNFR2 (β = 0.297; p < 0.001) levels and disease activity and damage index (sTNFR1: β = 0.367; p < 0.001; sTNFR2: β = 0.335; p < 0.001). Higher adiponectin levels were independently associated with nephritis (p = 0.009) and antimalarial drugs use (p = 0.015). There was a positive correlation between leptin and sTNFR2 levels (p = 0.002) and between resistin levels and sTNFR1 (p < 0.001) and sTNFR2 (p < 0.001).

CONCLUSION

The correlation between adipokines and TNF system allows a better understanding of the role of adipokines in the inflammatory response in SLE patients.

Detection of Trypanosoma cruzi DNA in blood by PCR is associated with Chagas cardiomyopathy and disease severity

BACKGROUND

The significance of detection of Trypanosoma cruzi DNA in blood of antibody-positive patients for risk of development of Chagas heart disease is not well established. The objective of this study was to compare detection of T. cruzi DNA with known clinical and laboratory markers of Chagas cardiomyopathy (CC) severity.

METHODS

This is a case-control study nested within a retrospective cohort developed in Brazil to understand the natural history of Chagas disease. The study enrolled 499 T. cruzi seropositive blood donors (SP-BD) and 488 frequency matched seronegative control donors (SN-BD) who had donated between 1996 and 2002, and 101 patients with clinically diagnosed CC. In 2008-2010 all enrolled subjects underwent a health questionnaire, medical examination, electrocardiograms and echocardiograms and polymerase chain reaction (PCR) analyses. A blinded panel of three cardiologists adjudicated the outcome of CC. Trypanosoma cruzi kinetoplast minicircle sequences were amplified by real-time PCR using an assay with a sensitivity of one parasite per 20 mL of blood. All testing was performed on coded samples.

RESULTS

Rates of PCR detection of T. cruzi DNA were significantly (P = 0.003) higher in CC patients and SP-BD diagnosed with CC (79/105 [75.2 %]) compared with SP-BD without CC (143/279 [51.3%]). The presence of parasitaemia was significantly associated with known markers of disease progression such as QRS and QT interval duration, lower left ventricular ejection fraction, higher left ventricular index mass, and elevated troponin and NTpro-BNP levels.

CONCLUSION

Trypanosoma cruzi PCR positivity is associated with presence and severity of cardiomyopathy, suggesting a direct role of parasite persistence in disease pathogenesis.

Drug metabolism and transport under hypoxia

Tumour progression is characterized by a rapid cell growth accompanied by changes in the microenvironment, largely due to hypoxia. The angiogenic switch involves changes in the expression of genes that play key roles in tumour progression, invasion, metastasis and therapeutic response, contributing to tumour aggressiveness. The effect of hypoxia on the cellular concentrations of drug metabolizing enzymes and transporters is much less understood. A brief summary of the signaling mechanisms triggered by hypoxia is presented, followed by a review of the known effects of hypoxia on drug metabolism and transport. Most of the studies available have focused on Cytochromes P450 and ATP-binding cassette transporters, while influx transporters of the SLC family have been less investigated. Given its potential to contribute both to the understanding of the pathogenesis of disease and to the optimization of therapeutics, it is rather surprising that this area of research is still underdeveloped. An increasing number of studies focusing on this subject are bound to provide key information for drug development and optimization of therapeutics.

Imatinib treatment duration is related to decreased estimated glomerular filtration rate in chronic myeloid leukemia patients

BACKGROUND

We analyzed the incidence of acute kidney injury and chronic renal failure in chronic myeloid leukemia (CML) patients using imatinib and investigated whether there is a relation between duration of imatinib therapy and decrease in estimated glomerular filtration rate (GFR).

PATIENTS AND METHODS

One hundred five CML patients on imatinib therapy were enrolled. Creatinine, urea, uric acid, and potassium measurements from imatinib treatment onset until the end of follow-up (median 4.5 years) were included in the analysis. GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation.

RESULTS

During follow-up, 7% of patients developed acute kidney injury; creatinine levels returned to baseline in only one of them. According to the regression equation, the mean baseline value of the estimated GFR was 88.9 ml/min/1.73 m(2). Estimated GFR decreased significantly with imatinib treatment duration; the mean decrease per year was 2.77 ml/min/1.73 m(2) (P < 0.001); 12% of patients developed chronic renal failure. Age, hypertension, and a history of chronic renal failure or interferon usage were not significantly related to the mean decrease in the estimated GFR over time.

CONCLUSION

The introduction of imatinib therapy in nonclinical trial CML patients is associated with potentially irreversible acute renal injury, and the long-term treatment may cause a clinically relevant decrease in the estimated GFR.

Is total abolishment of great saphenous reflux in the invasive treatment of superficial chronic venous insufficiency always necessary?

Chronic venous insufficiency ranges from mild telangiectasias to skin ulceration with poor prognosis regarding healing and quality of life. Varicose veins are the most frequent clinical presentation, affecting 75% of such patients and 71% are due to primary reflux of great saphenous vein, which is the most compromised vein in chronic venous insufficiency. However, about 75% of these veins are not dilated. The standard treatment has been stripping of the saphenous vein, because it has 85% of good results at long term. However, saphenous vein is the main arterial substitute and should be spared whenever possible. The development of non-invasive diagnostic methods showed that hemodynamic worsening correlates with clinical severity and that the majority of patients did not have a dilated saphenous vein. Thus, several selective operations proposed to spare the saphenous vein have reported good results. Minimally invasive techniques (eco-guided foam, radiofrequency and laser) have also emerged aiming to obliterate the vein and abolishing reflux and have also reported good results, but they do not spare the vessel. Measurement of saphenous diameter has been shown to correlate with clinical and hemodynamic worsening, thus allowing planning the invasive treatment of chronic venous insufficiency. Dilated diameters (>7.2 mm) correlate with severe disease and poor prognosis, being an indication for total abolishment of saphenous vein reflux. All other presentations must be individualized, sparing saphenous vein whenever possible and and a standardized approach is not indicated for all patients.

Can we measure the ankle-brachial index using only a stethoscope? A pilot study

BACKGROUND

Ankle-brachial index (ABI) is an excellent method for the diagnosis of peripheral arterial disease (PAD) when it is performed with Doppler. However, this device is not always available for primary care physicians. The ABI measured with stethoscope is an easy alternative approach, but have not been proved to be useful.

OBJECTIVE

To assess the accuracy of the ABI measured using a stethoscope comparatively to that of the current eligible method for the diagnosis of PAD, the Doppler ABI, and describe the characteristics of this new approach.

METHODS

We conducted a diagnostic study of ABI measured with a stethoscope and a Doppler probe and compared the results. Eighty-eight patients were accessed by both methods.

RESULTS

Mean stethoscope ABI, 1.01 +/- 0.15, and mean Doppler ABI, 1.03 +/- 0.20, (P = 0.047) displayed a good correlation. Measurements of stethoscope ABI diagnostic accuracy in recognizing a Doppler ABI are described. The comparison of this data with the current gold standard method results gave a sensitivity of 71.4% [95% confidence interval (CI), 41.9-91.6] and specificity of 91.0% (95% CI, 81.5-96.6), with predictive positive value of 62.5% (95% CI, 38.6-81.5) and negative predictive value of 93.8% (95% CI, 85.2-97.6). The study accuracy was 87.7%. The area under the ROC curve was 0.895 (95% CI, 0.804-0.986, P < 0.0001).

CONCLUSIONS

According to our study, the stethoscope ABI is a useful method to detect PAD and it may be suitable for its screening in the primary care setting.

Carotid atherosclerotic alterations in systemic lupus erythematosus patients treated at a Brazilian university setting

To determine the frequency of carotid plaque and intima-media thickness (IMT) in patients with systemic lupus erythematosus (SLE) and their association with risk factors in a Brazilian university setting. Carotid plaque and IMT were identified and measured by ultrasonography. Traditional risk factors and lupus-related factors were analysed. One hundred and seventy-two patients (women = 96%, age = 38 ± 11 years) were evaluated. The frequency of carotid plaque was 9.3%. The median (IR) IMT was 0.60 mm (0.54—0.71 mm). Age, family history (FH) of premature coronary disease, low-density cholesterol (LDL-c) >100 mg/dL, hypertriglyceridemia, diabetes, hypertension, smoking, postmenopause, number of risk factors, Framingham risk score, age at diagnosis, duration of lupus, mucocutaneous manifestations and duration of prednisone use were associated with plaque ( P < 0.05), univariate analysis. Nephritis, immunosuppressive therapy, intravenous methylprednisolone and a higher average daily dose of prednisone were associated with the absence of plaque. Independent predictors of plaque were smoking ( P = 0.004), LDL-c >100 mg/dL ( P = 0.044), Framingham score ( P = 0.006) and absence of immunosuppressive therapy ( P = 0.032). There was an independent correlation between IMT and age ( P < 0.001) and duration of prednisone use ( P = 0.020). Subclinical atherosclerosis was associated with traditional risk and SLE-related factors, especially the absence of immunosuppressive therapy. The present study suggests that the levels of LDL-c should be kept under 100mg/dL in lupus. Lupus (2008) 17, 105—113.

Preoperative plasma levels of soluble tumor necrosis factor receptor type I (sTNF-RI) predicts adverse events in cardiac surgery

OBJECTIVE

The objective was to estimate the sTNF-RI preoperative measure in the identification of patients with bad outcome and death.

METHODS

We assessed prospectively sixty-two patients submitted electively to myocardial revascularization with ECC or heart valve surgery. The sTNF-RI levels were determined by the Sandwich-Type ELISA method before anesthetic induction. Clinical, surgical characteristics and sTNF-RI levels were compared among patients with good (group I, n=46) or bad outcome (group II, n=16--length of stay in the ICU for over 72 h or death).

RESULTS

No difference was found between the verified mortality (6.4%) and the predicted by EuroSCORE (3.0%), p=0.48. The sTNF-RI levels were higher in group II (1322) than group I (748) p=0.009 (levels >954, 69% sensitivity and 70% specificity for good outcome, 44% positive predicted value and 85% negative). The sTNF-RI levels were higher in patients who died (1556) versus (759) p=0.029, (levels >1230, 79% sensitivity, 75% specificity, 20% positive predicted value and 98% negative). In the multivariate logistic regression model sTNF-RI (OR=1.002, IC95% 1.000-1.005, p=0.014) and age (OR=1.083, IC95% 1.010-1.161, p=0.025) were independently related to the risk of bad outcome.

CONCLUSIONS

Basal levels of sTNF-RI yield prognostic information in patients who undergo heart surgery.

Enhancing longevity of pacemakers through reprogramming. Underutilization and cost-effectiveness

OBJECTIVE

This study was performed to observe the number of pacemakers that had never been reprogrammed after implantation, and the effect of optimised output programming on estimated longevity of pulse generators in patients with pacemaker

METHODS

Sixty patients with Teletronics Reflex pacemakers were evaluated in a pacemaker clinic, from the time of the beginning of its activities, in June 1998, until March 1999. Telemetry was performed during the first clinic visit, and we observed how many pulse generators retained nominal output settings of the manufactures indicating the absence of reprogramming until that date. After evaluation of the capture threshold, reprogramming of pacemakers was performed with a safety margin of 2 to 2.5:1, and we compared the estimated longevity based on battery current at the manufacturer's settings with that based on settings achieved after reprogramming.

RESULTS

In 95% of the cases, the original programmed setting was never reprogrammed before the patients attended the pacemaker clinic. Reprogramming the pacemaker prolonged estimated pulse generator life by 19.7+/-15.6 months (35.5%).

CONCLUSION

The majority of the pacemakers evaluated had never been reprogrammed. Estimated pulse generator longevity can be prolonged significantly, using this simple, safe, efficacious, and cost-effective procedure.

Tissue Doppler imaging enables the identification of diastolic dysfunction of pseudonormal pattern in Chagas' disease

The Doppler pseudonormal pattern of left ventricular (LV) diastolic function filling, characterized by apparent normal transmitral flow velocities, indicates advanced diastolic dysfunction with abnormal relaxation and compliance. Left ventricular diastolic dysfunction has been shown to occur in the early stages of the outcome of Chagas cardiopathy, and its identification may potentially contribute to the management of those patients. The aim of this study was to evaluate the usefulness of tissue Doppler imaging (TDI) in identifying LV diastolic dysfunction in patients with Chagas' disease with pseudonormal transmitral flow. For this purpose, 89 patients with Chagas' disease (48 men) who had no other pathology and showed normal (n = 79) or pseudonormal (n = 10) patterns of diastolic function by pulsed wave Doppler were submitted to TDI. A significant LV systolic impairment in terms of the dimensions (P = .00001), ejection fraction (P = .000001), and wall motion score (P = .000002) was observed in patients with diastolic dysfunction when compared with the group with normal LV diastolic function. Tissue Doppler imaging enabled the recognition of a pseudonormal type of transmitral flow velocity with high statistical significance through early (P = .000008) and late (P = .0003) expansion waves. The sensitivity and specificity in detecting LV diastolic dysfunction with TDI in the septal, anterior, inferior, posterior, and lateral walls were 90% and 87.3%, 87.3% and 90%, 87.3% and 90%, 84.8% and 90%, and 84.8 and 90%, respectively. In conclusion, TDI enabled the differentiation of patients with Chagas' disease with normal LV diastolic function and those with the pathologic LV pseudonormal pattern with high statistical significance. Moreover, this article shows the potential in demonstrating the occurrence of major alterations in the LV performance of patients with Chagas' disease with LV diastolic dysfunction, as well as the occurrence of signs of an increased LV filling pressure in those patients.

Parasympathetic dysautonomia precedes left ventricular systolic dysfunction in Chagas disease

BACKGROUND

Parasympathetic dysautonomia is an established feature of advanced Chagas cardiomyopathy. However, in the absence of cardiac involvement, the presence of vagal dysfunction remains controversial. In a cross-sectional study, we compared patients with Chagas disease without cardiac involvement and healthy individuals by three different methods to determine whether vagal dysfunction is present in the early phase of Chagas disease.

METHODS

Sixty-one patients with Chagas disease without cardiac involvement and 38 controls were submitted to respiratory sinus arrhythmia test and 24-hour Holter monitoring. Vagal heart influences were assessed by the expiratory/inspiratory (E/I) ratio, time-domain indexes of heart rate variability (HRV), and by the quantification of a 3-dimensional return map.

RESULTS

The two groups were comparable in terms of left ventricular ejection fraction and left ventricular end-diastolic dimension. Compared with the control group, patients with Chagas disease had significantly lower values of the E/I ratio (mean +/- SD: 1.38 +/- 0.02 and 1.25 +/- 0.02, P <.004) and short-term indexes of HRV (median [interquartile range]-rMSSD: 23 [18-27] and 17 [13-23], P =.00; pNN50: 11 [7-17] and 6 [2-12], P =.00). P(3), a beat-to-beat HRV index derived from the 3-dimensional return map, also was significantly reduced in the Chagas disease group (mean +/- SD: 118 +/- 5 vs 100 +/- 4, P =.00). None of these indexes of vagal heart control were significantly correlated with left ventricular function or to the presence of esophageal radiologic abnormalities.

CONCLUSION

Parasympathetic dysautonomia is an independent and early phenomenon in Chagas disease and may precede left ventricular systolic dysfunction.

Doppler tissue imaging to evaluate early myocardium damage in patients with undetermined form of Chagas' disease and normal echocardiogram

Chagas' disease can lead to severe and potentially lethal damage of cardiac function. Thus, the identification of contractile abnormalities in asymptomatic patients can be important for risk stratification in those patients. Doppler tissue imaging (DTI) is a new diagnostic modality for the study of regional and longitudinal contractility of the left ventricle. However, DTI has not been used for the assessment of Chagas' cardiopathy. The purpose of this study was to identify abnormalities related to longitudinal contractility by means of DTI in patients with an undetermined form of Chagas' disease and with normal echocardiogram and Doppler studies. Forty patients were studied, including 21 chagasic ones with normal electrocardiographic, radiologic, and echocardiographic studies, and 19 normal control individuals. All of the patients were submitted to DTI to evaluate longitudinal contractility in the various myocardial segments, including assessment of systolic and diastolic velocities and isovolumic contraction time (IVCT). Similar values were observed among the various systolic function rates in both groups, except for the IVCT along the septal wall, which was significantly higher in the chagasic group. DTI enabled the early detection of contractile abnormalities in patients with an undetermined form of Chagas' disease and with normal echocardiogram. Such abnormalities were particularly striking in the interventricular septum. The present study could be useful in risk stratification for those patients.

A narrow QRS does not predict a normal left ventricular function in Chagas' disease

Left ventricular (LV) systolic dysfunction is a major prognostic determinant in Chagas' disease (ChD), a potentially fatal disorder which affects nearly 20 million individuals in Latin America. Therefore, reliable screening methods are needed to identify patients in need of a detailed evaluation of LV function. Since previous reports have suggested that a prolonged QRS duration may be an accurate predictor of LV dysfunction, the relationship between QRS duration and LV function was evaluated in ChD patients, in order to determine whether a narrow QRS on surface electrocardiogram (ECG) predicts a normal LV function. Ninety-eight patients with ChD and no other cardiac or systemic illness were underwent standard 12-lead ECG and Doppler echocardiogram (echo) examination. An investigator (blinded to the echo data) measured manually the QRS duration. LV dysfunction was defined by the presence of LV dilatation (LV diastolic dimension > 55 mm), depressed LV ejection fraction (LVEF < 0.50), segmental contractile abnormalities (SCA) or LV aneurysm. QRS duration was significantly correlated with LV diastolic dimension (r = 0.44, P = 0.000) and LVEF (r = 0.24, P = 0.016). A significant percentage of patients with QRS < 100 ms had abnormal systolic LV parameters, including LV dilatation (8.1%), reduced EF (10.2%), SCA (42.8%) and LV aneurysm (14.2%). A narrow QRS does not exclude the presence of significant global and segmental LV dysfunction in ChD patients. Since these abnormalities have prognostic and therapeutic implications, further evaluation of LV systolic performance is desirable in such patients.

The Two-Component Virial Theorem and the Physical Properties of Stellar Systems

Motivated by present indirect evidence that galaxies are surrounded by dark matter halos, we investigate whether their physical properties can be described by a formulation of the virial theorem that explicitly takes into account the gravitational potential term representing the interaction of the dark halo with the baryonic or luminous component. Our analysis shows that the application of such a "two-component virial theorem" not only accounts for the scaling relations displayed by, in particular, elliptical galaxies, but also for the observed properties of all virialized stellar systems, ranging from globular clusters to galaxy clusters.

Bilateral Pseudomonas corneal ulcer in a disposable contact lens wearer

PURPOSE

To describe a case of bilateral corneal ulcers caused by Pseudomonas in a disposable soft contact lens wearer. This case study discusses the role of patient examination, contact lens care instruction, and adequate patient supervision in reducing the risk of serious potential complications.

METHODS AND RESULTS

A 17 year old student who had been using disposable soft contact lenses on an extended wear basis for 6 months presented complaining of pain in the left eye. When he was examined, a corneal ulcer with surrounding infiltrate was observed in the superior middle periphery of the left eye. Samples were collected for culture, and treatment with fortified cefalotin and gentamicin was started. After 8 hours the patient returned, now complaining of pain in the right eye. Examination of the right eye revealed a diffused keratitis with a mucopurulent discharge. A culture was taken, and the same treatment was instituted. The laboratory tests revealed Pseudomonas in both eyes. The bilateral corneal ulcers responded to therapy after 1 week of treatment.

CONCLUSIONS

We discuss the factors involved in the occurrence of infectious keratitis in contact lens wearers, and stress that even disposable contact lens wear can be associated with serious complications. This case also highlights extended wear as one of the main risk factors for complications in disposable soft contact lens wear.

Electrocardiographic changes during low-dose, short-term therapy of cutaneous leishmaniasis with the pentavalent antimonial meglumine

The pentavalent antimonial (Sb5+) meglumine is the drug of choice for the treatment of cutaneous leishmaniasis (CL) in Brazil. Although the cardiotoxicity of high-dose, long-term Sb5+ therapy is well known, the use of low-dose, short-term meglumine has been considered to be safe and relatively free from significant cardiac effects. In order to investigate the cardiotoxicity of low-dose, short-term therapy with meglumine in cutaneous leishmaniasis, 62 CL patients treated with meglumine were studied. A standard ECG was obtained before and immediately after the first cycle of treatment (15 mg Sb5+ kg-1 day-1). The electrocardiographic interpretation was carried out blindly by two investigators using the Minnesota Code. There were no significant differences in qualitative ECG variables before and after meglumine treatment. However, the corrected QT interval was clearly prolonged after antimonial therapy (420.0 vs 429.3 ms, P < 10(-6)). QTc augmentation exceeded 40 ms in 12 patients, 7 of whom developed marked QTc interval enlargement (500 ms) after meglumine therapy. This previously unrecognized cardiac toxicity induced by short-term, low-dose antimonial therapy has potentially important clinical implications. Since sudden death has been related to QTc prolongation over 500 ms induced by high-dose antimonial therapy, routine electrocardiographic monitoring is probably indicated even in CL patients treated with short-term, low-dose meglumine schedules. Until further studies are conducted to establish the interactions between pentavalent antimonials and other drugs, special care is recommended when using meglumine in combination with other medications, in particular with drugs that also increase the QTc interval.

[Indeterminate form of Chagas disease: considerations about diagnosis and prognosis]

The indeterminate form of Chagas' disease is defined by the absence of clinical, radiological and electrocardiographic manifestations of cardiac or digestive involvement in Trypanosoma cruzi chronic infected persons. When submitted to advanced cardiovascular tests, these patients may present significant abnormalities. However, the indeterminate form concept was reaffirmed as valid, since diagnostic criteria are simple and prognosis is benignant. In clinical practice, diagnostic difficulties are frequent, related to subjectivity and uncertain meaning of clinical, electrocardiographic and radiological findings. Moreover, indeterminate form prognosis is not equally good: after five to 10 years, a third of patients will have cardiopathy. Sudden death, a rare complication, may be the first manifestation of Chagas' disease. It is necessary to reappraise indeterminate form concept, redefining diagnostic criteria and therapeutic management. Clinical and noninvasive evaluation may allow individual risk stratification; therapeutic interventions may be beneficial in high risk groups. Since etiologic treatment may prevent cardiopathy, its role in indeterminate form management must be reassessed.

Experimental American trypanomiasis in rats: sympathetic denervation, parasitism and inflammatory process

Tissue parasitism, inflammatory process (histologic methods) and sympathetic denervation (glyoxylic acid-induced histofluorescence for demonstration of catecholamines) were studied in the heart (atrium and ventricle) and the submandibular gland of rats infected with the Y strain of Trypanosoma cruzi. In the heart paralleling intense parasitism and inflammatory process, the sympathetic denervation started at day-6 of infection and at the end of the acute phase (day 20) practically no varicose nerve terminals were found in both myocardium and vessels. In the submandibular gland, in spite of the rarity of amastigote pseudocysts and the scarcity of inflammatory foci, slight to moderate (days 13-15 of infection) or moderate to severe denervation (day 20) was found. At day 120 of infection both organs exhibited normal pattern of sympathetic innervation and only the heart showed some inflammatory foci and rare pseudocysts (ventricle). Our data suggest the involvement of circulating factors in the sympathetic denervation phenomena but indicate that local inflammatory process is, at least, an aggravating factor.

Presence of Psychodopygus wellcomei (Diptera: Psychodidae), a proven vector of Leishmania braziliensis braziliensis, in Ceará State

Psychodopygus wellcomei, a proven vector of (muco-)cutaneous leishmaniasis, has been found for the first time outside of the Amazon Basin, in Ceará State. Parasitological and entomological evidence suggests that the Leishmania braziliensis braziliensis/Ps. wellcomei zoonosis is widespread on the Brazilian Shield.