Transcranial Doppler assessment of cerebral blood flow: effect of cardiac transplantation

The authors prospectively studied transcranial Doppler changes in patients with refractory congestive heart failure before and after cardiac transplantation. They evaluated 22 patients preoperatively and 14 patients after transplantation. Mean postoperative flow velocity increased by 53.3% (p < 0.0001). Preoperative waveform changes became normal after transplantation.

Is there a dural wall between the cavernous sinus and the pituitary fossa? Anatomical and MRI findings

We compared MRI studies of the sellar area and embryological and adult histological studies of the cavernous sinuses and pituitary fossa. MRI studies were performed in 50 normal subjects with coronal sections using a fast inversion-recovery sequence to demonstrate the dural walls of the cavernous sinus and pituitary fossa. With this sequence, dura mater appears as a high-signal linear structure. The lateral and superior walls of the cavernous sinus was easily identified on all studies, but demonstration of a dural wall separating the cavernous sinus from the pituitary fossa was not possible. These results correlated well with embryological and adult histological studies obtained from 14 specimens. The absence of a strong separation between the pituitary fossa and the cavernous sinus explains the high incidence of extension of pituitary tumours to the cavernous sinuses and vice versa.

Interleukin-2 gene polymorphism is associated with renal but not cardiac transplant outcome

It was recently shown that IL-2 gene single nucleotide polymorphism (SNP) at position -330 (G-->T) is related to in vitro cytokine production levels, with the T/T and T/G genotypes being associated with low production and the G/G genotype associated with high production. The objective of this study was to investigate a possible influence of this polymorphism on renal and cardiac allograft outcomes. IL-2 SNP G-T (-330) was determined by PCR-RFLP in 67 recipients of heart allografts and in 63 recipients of renal grafts from HLA-haplo-identical, related donors. A higher frequency of the T/T genotype was observed in renal transplant patients who experienced at least one acute rejection episode during the first 3 months after transplantation than in those without rejection during this period (80% vs 49%, respectively, P <.05). Accordingly, the same genotype tended to be more frequent in renal recipients with a 6-month serum creatinine level above 1.5 mg/dL (median value for the whole group of kidney recipients) than in patients with lower creatinine levels (79% vs 45%, P <.08). Regarding cardiac transplant recipients, no associations were observed concerning acute rejection or graft survival. The finding of the association of T/T but not T/G genotype with acute kidney rejection was unexpected considering that both genotypes were shown to be associated with equal (low) IL-2 in vitro production. Further studies are necessary not only to dissect the nature of IL-2 T/T genotype association with kidney rejection, but also to explain why this genotype does not apparently influence cardiac allograft outcome.

Expression of Fas, FasL, and Soluble Fas mRNA in Endomyocardial Biopsies of Human Cardiac Allografts

Apoptosis mediated by the Fas/Fas ligand (FasL) has been implicated in rejection of solid organ allografts and it has been recently proposed that soluble forms of Fas could interfere with this interaction, blocking apoptosis. The purpose of this study was to analyze intragraft Fas, FasL, and soluble Fas mRNA levels in relation to acute rejection in cardiac allografts in humans. mRNA levels were determined by quantitative reverse transcriptase-polymerase chain reaction in 42 samples of endomyocardial biopsies obtained from 18 cardiac transplant recipients within the first 6 months after transplantation. FasL and Fas mRNA levels were higher in biopsies with rejection than in biopsies without rejection, and no difference was observed in soluble Fas mRNA. During rejection, there was a positive correlation between the mRNA levels of Fas-FasL, Fas-soluble Fas, and FasL-soluble Fas. During quiescent periods, however, the only correlation observed was between Fas and soluble Fas mRNA levels. In conclusion, our findings do not suggest a role for soluble Fas, confirm the heightened expression of FasL, and indicate, for the first time, an increased expression of Fas in acute rejection of cardiac allografts.

Chagas disease: morbidity profile in an endemic area of Northeastern Brazil

INTRODUCTION

This study evaluated the clinical forms and manifestation severities of Chagas disease among serologically reactive individuals from Western Rio Grande do Norte (Northeastern Brazil).

METHODS

This cross-sectional study included 186 adults who were evaluated using electrocardiography, echocardiography, chest radiography, and contrast radiography of the esophagus and colon. A clinical-epidemiological questionnaire was also used.

RESULTS

The indeterminate, cardiac, digestive, and cardiodigestive clinical forms of Chagas disease were diagnosed in 51.6% (96/186), 32.2% (60/186), 8.1% (15/186) and 8.1% (15/186) of the participants, respectively. Heart failure (functional classes I-IV) was detected in 7.5% (14/186) of the participants, and 36.4% (24/66), 30.3% (20/66), 15.2% (10/66), 13.6% (9/66), and 4.5% (3/66) of the patients were at stage A, B1, B2, C, and D, respectively. Dilated cardiomyopathy and electrocardiographic changes were detected in 10.2% (19/186) and 48.1% (91/186) of the participants, respectively. Apical aneurysm was diagnosed in 10.8% (20/186) of the participants, and other changes in the segmental myocardial contractility of the left ventricle were diagnosed in 33.9% (63/186) of the participants. Megaesophagus (groups I-IV) was observed in 7% (13/186) of the participants, megacolon (grades 1-3) was detected in 12.9% (24/186) of the participants, and both organs were affected in 29.2% (7/24) of the megacolon cases.

CONCLUSIONS

We detected various clinical forms of Chagas disease (including the digestive form). Our findings indicate that clinical symptoms alone may not be sufficient to exclude or confirm cardiac and/or digestive damage, and the number of patients with symptomatic clinical forms may be underestimated.

SPIKES-D: a proposal to adapt the SPIKES protocol to deliver the diagnosis of dementia

Dementia is a life-threatening and stigmatizing condition, with devastating impacts on the patient's personal identity and caregivers. There are many barriers to an effective diagnosis disclosure of dementia, including fear of causing distress, uncertainty of diagnosis, caregivers' objection and lack of training in communication skills in undergraduate medical schools. Although some studies have been published on how to help physicians deliver an Alzheimer's disease diagnosis, no specific protocol has been published yet. The SPIKES protocol is a didactic approach designed to deliver bad news related to cancer, but it has been used globally and in a variety of clinical settings, including the teaching of communication skills to medical students and residents. It is known, however, that the cognitive impairment of Alzheimer's disease and other dementias may limit the understanding of the diagnosis' complexity; hence, a few adaptations of this model were made after reviewing the current literature on dementia diagnosis disclosure. The suggested SPIKES-D protocol seems to encompass current guidelines about the communication of the diagnosis of dementia, keeping its didactic approach on breaking bad news and helping fulfill the gaps in this topic.

Morphological and functional measurements of the heart obtained by magnetic resonance imaging in Brazilians

BACKGROUND

Still today, measurements used as a reference in the cardiac magnetic resonance imaging have been obtained mainly from studies carried out in North-American and European populations.

OBJECTIVE

To obtain measurements of the diastolic diameter, systolic diameter, end diastolic volume, end systolic volume, ejection fraction, and myocardial mass of the left and right ventricles in Brazilians.

METHODS

54 men and 53 women, with mean age of 43.4 ± 13.1 years, asymptomatic, with no cardiomyopathies, have been subjected to the cardiac magnetic resonance imaging, using a balanced steady state free precession technique.

RESULTS

The averages and the standard deviations of the parameters for the left ventricle have been: diastolic diameter = 4.8 ± 0.5 cm; systolic diameter = 3.0 ± 0.6 cm; end diastolic volume = 128.4 ± 29.6 mL; end systolic volume = 45.2 ± 16.6 mL; ejection fraction = 65.5 ± 6.3%; mass = 95.2 ± 30.8 g. For the right ventricle, they have been: diastolic diameter = 3.9 ± 1.3 cm; systolic diameter = 2.5 ± 0.5 cm; end diastolic volume = 126.5 ± 30.7 mL; end systolic volume = 53.6 ± 18.4 mL; ejection fraction = 58.3 ± 8.0%, and mass = 26.1 ± 6.1 g. The masses and the volumes were significantly greater in the men, except for the end systolic volume of the left ventricle. The ejection fraction of the right ventricle has been significantly greater in the women. There has been a significant and inverted correlation of the systolic volume of the right volume with the progression of the age.

CONCLUSION

This study has described, for the first time, cardiac measurements obtained through the cardiac magnetic resonance imaging in Brazilians, asymptomatic, with no cardiomyopathies, showing differences in accordance with gender and age.

Body composition, lipid profile and clinical parameters are predictors of prognosis in patients with heart failure: Two-year follow-up

BACKGROUND

Heart failure (HF) is a complex syndrome that leads to changes in body composition and eventually results in unfavorable outcomes.

AIM

This study aimed to evaluate body composition, lipid profiles and clinical parameters of patients with HF, and their associations with both survival and unfavorable clinical outcomes.

METHODS

This prospective cohort study included 94 adults and older people with HF. Body composition was assessed by bioelectrical impedance analysis (BIA). Anthropometric variables and lipid profile were also evaluated. Electronic medical records were checked to collect information on clinical outcomes (mortality and hospitalization), considering a follow-up period of 24 months. Survival was calculated using the Kaplan-Meier estimate, and the curves compared using Log-Rank. The death risk rate (Hazard Ratio, HR) was calculated using Cox's univariate models.

RESULTS

Mean age was 55.1 (13.9) years and there was a higher frequency of males. There was a predominance of HF with reduced ejection fraction, and ischemic etiology. Patients with New York Heart Association (NYHA) functional classification I/II had a better overall survival rate at 24 months than those with NYHA III/IV (univariate HR 4.93 (1.76-13.82); p = 0.001). Greater survival rates were found in patients without chronic kidney disease (CKD) (univariate HR 2.93 (1.59-5.39); p = 0.01). In the multivariate analyses, both dyslipidemia (adjusted HR 3.84 (1.22-12.00); p = 0.021) and increased fat mass index (FMI) were associated with overall survival rate (adjusted HR 3.59 (1, 10-11.74); p = 0.034).

CONCLUSION

The severity of HF symptoms and the presence of chronic kidney disease are associated with higher mortality. Increased fat mass index and dyslipidemia are predictors of favorable outcomes in this population.

Biomarkers of Zinc and Copper Status and Associated Factors in Outpatients with Ischemic and Non-Ischemic Heart Failure

Background: Few studies have explored the impact of ischemic and non-ischemic etiologies of heart failure and other factors associated with heart failure on zinc and copper status. This study examined zinc and copper status in 80 outpatients with ischemic (n = 36) and non-ischemic (n = 44) heart failure and associations with biodemographic, clinical, biochemical, and nutritional parameters.Materials: Biomarkers of plasma zinc and copper, copper-zinc ratio, 24-h urinary zinc excretion, ceruloplasmin, and dietary intake of zinc and copper were assessed. Plasma zinc and copper and urinary zinc were measured by inductively coupled plasma mass spectrometry (ICP-MS).Results: Patients with ischemic heart failure showed lower dietary zinc intake and higher dietary copper intake (both p = 0.02). Zinc and copper in plasma, copper-zinc ratio, ceruloplasmin, and 24-h urinary zinc excretion showed no statistical differences between the groups (all p ≥ 0.05). An inverse association was found between age (β =-0.001; p = 0.005) and the use of diuretics (β = -0.047; p = 0.013) and plasma zinc. Copper levels in plasma (β = 0.001; p < 0.001), and albumin (β = 0.090; p<0.001) were directly associated with plasma zinc. A positive association was found between ceruloplasmin (β = 0.011; p < 0.001), gamma-glutamyl transferase (β = 0.001; p < 0.001), albumin (β = 0.077; p = 0.001), and high-sensitivity c-reactive protein (β = 0.001; p = 0.024) and plasma copper.Conclusion: Zinc and copper biomarkers in clinically stable patients with heart failure did not seem to be responsive to the differences in zinc and copper intake observed in this study, regardless of heart failure etiology. The predictors of plasma zinc and copper levels related to oxidative stress and inflammation should be monitored in heart failure clinical practice.

Helper (OKT4)/suppressor (OKT8) ratios in the peripheral blood and synovial fluid of patients with rheumatoid arthritis

Lymphocyte subsets in the peripheral blood of 10 patients with RA were studied using monoclonal antibodies. The mean percentages of total T, T helper, T suppressor and TAR in the peripheral blood of RA patients were not different from those observed in normal controls. In the synovial fluid the mean percentages of T suppressor cells were present in increased numbers associated with a decreased number of autorosette T cells. We conclude that patients with rheumatoid arthritis present distinct immunoregulatory abnormalities in the synovial fluid not present in the peripheral blood. These changes may be related to the immune abnormalities present and related to the etiology of RA.

Predictors of Plasma Selenium Levels and Association with Prognosis in Outpatients with Heart Failure: a 36-Month Prospective Cohort Study

Selenium plays a role in the context of heart failure (HF), but still, there are gaps regarding the factors associated with selenium status, as well as its association with the prognosis of HF. We aimed to investigate predictors of plasma selenium and its association with hospitalization and all-cause mortality. This prospective cohort study included 80 outpatients with HF. Non-elective hospitalization and all-cause mortality were assessed during 36 months of follow-up. The associations between plasma selenium, dietary selenium intake, and sociodemographic, clinical, and biochemical parameters were evaluated by a multiple linear regression model. The risk of these clinical outcomes was assessed with multivariate Cox regression and cubic splines analysis. Albumin (β = 0.113, p < 0.001; R2 = 0.291) and triacylglycerol levels (β = 0.0002, p < 0.021, R2 = 0.376) were predictors of plasma selenium levels. No significant associations were found between dietary selenium intake and plasma selenium tertiles with hospitalization and all-cause mortality (all p > 0.05). The cubic splines analysis revealed that both low and high selenium concentrations influence these outcomes. The predictors of plasma selenium were related to the clinical conditions of HF. Selenium in plasma should be interpreted cautiously, considering that low and high levels may be associated with risks of adverse outcomes in HF.

Lack of Association between Inadequate Micronutrient Intake and Prognosis in Outpatients with Heart Failure

Inadequate nutrient intake can lead to worse outcomes in patients with heart failure (HF). This prospective cohort study aimed to assess the prevalence of inadequate micronutrient intake and their association with prognosis in 121 adult and elderly outpatients with HF. Habitual micronutrient intake was evaluated using 24-h dietary recalls (minimum 2 and maximum 6). Participants were grouped into moderate (n = 67) and high (n = 54) micronutrient deficiency groups, according to the individual assessment of each micronutrient intake. Patients' sociodemographic, clinical, and anthropometric data and clinical outcomes (hospitalization and mortality) within 24 months were collected. Overall and event-free survival rates were calculated using Kaplan-Meier estimates, and curves were compared using the log-rank test. The death risk rate (hazard ratio (HR)) was calculated using Cox's univariate model. The rate of inadequate intake was 100% for vitamins B1 and D and above 80% for vitamins B2, B9, and E, calcium, magnesium, and copper. No differences in overall survival and event-free survival were observed between groups of HF outpatients with moderate and high micronutrient deficiencies (HR = 0.94 (CI = 0.36-2.48), p = 0.91, and HR = 1.63 (CI = 0.68-3.92), p = 0.26, respectively), as well as when the inadequacy of each micronutrient intake was evaluated alone (all p > 0.05). In conclusion, a high prevalence of inadequate micronutrient intake was observed in outpatients with HF. Inadequate micronutrient intake was not associated with hospitalization and mortality in this group of patients.

Comparison of the adequacies of the OSCE and vOSCE to assess the competencies required under Brazilian medical curriculum guidelines: a multicenter study

BACKGROUND

The COVID-19 pandemic has led to the popularization of information and communication technology in medical education. This study aimed to compare the objective structured clinical examination (OSCE) and the virtual objective structured clinical examination (vOSCE), based on expert opinion, as tools for assessing the competencies needed under medical curriculum guidelines in Brazil.

METHODS

In this multicenter study, the suitability levels of the OSCE and vOSCE for assessing the competencies needed under the Brazilian National Curriculum Guidelines (DCNs) were compared. The DCNs encompass five groups of domains, namely, health education; general; health management; public health needs; and individual health needs. Sixteen teaching experts served as judges. They responded to a questionnaire with the provided Likert scores indicating the ability of the OSCE and vOSCE to assess each type of competency. Virtual meetings were held via the Delphi method and a focus group-based approach to enable the experts to reach a consensus.

RESULTS

A total of 200 items included in the guidelines (100 for the OSCE and 100 for the vOSCE) were evaluated across a total of 3,200 responses. Analysis via the Likert scale revealed a high proportion of positive evaluations for the use of the vOSCE, with kappa values ​​ranging from 0.4 to 0.72. The values ​​of the absolute agreement (positive view) between examiners and equivalence with the kappa statistic for the adoption of the vOSCE ranged from 0.38 to 0.72. Via the use of virtual meetings (Delphi and focus groups), consensus was reached regarding the capacity of the OSCE and vOSCE to evaluate 97% and 92% of these items, respectively.

CONCLUSION

The vOSCE can be employed to assess relevant competencies. However, it faces limitations regarding 8% (8/100) of the items, and some items (3%) cannot be assessed via either method. The difference in results between the two assessment methodologies (OSCE and vOSCE) is 5%. It is necessary to invest in the creation of instruments that can be used to apply the vOSCE and to conduct cost‒benefit analysis of its broader application in health education institutions. We conclude that the vOSCE is an effective tool for assessing most competencies of medical professionals and students required under Brazilian guidelines.

School of Medicine of Federal University of Rio Grande Do Norte: A traditional curriculum with innovative trends in medical education

INTRODUCTION

The Medical School of the Federal University of Rio Grande do Norte (UFRN) is one of the biggest public medical schools in Northeast Brazil. In the last decade, significant investment in faculty development, innovative learning methodologies and student engagement has been key milestones in educational improvement at this medical school, harnessed to recent political changes that strengthened community-based and emergency education. This study describes how curriculum changes in UFRN Medical School have been responsible for major improvements in medical education locally and which impacts such transformations may have on the educational community.

METHODS

A group of students and teachers revised the new curriculum and established the key changes over the past years that have been responsible for the local enhancement of medical education. This information was compared and contrasted to further educational evidences in order to define patterns that can be reproduced in other institutions.

RESULTS

Improvements in faculty development have been fairly observed in the institution, exemplified by the participation of a growing number of faculty members in programs for professional development and also by the creation of a local masters degree in health education. Alongside, strong student engagement in curriculum matters enhanced the teaching-learning process.

CONCLUSIONS

Due to a deeper involvement of students and teachers in medical education, it has been possible to implement innovative teaching-learning and assessment strategies over the last ten years and place UFRN Medical School at a privileged position in relation to undergraduate training, educational research and professional development of faculty staff.

The let-7b-5p, miR-326, and miR-125a-3p are associated with left ventricular systolic dysfunction in post-myocardial infarction

Background

Acute ST-elevation myocardial infarction (STEMI) can lead to adverse cardiac remodeling, resulting in left ventricular systolic dysfunction (LVSd) and heart failure. Epigenetic regulators, such as microRNAs, may be involved in the physiopathology of LVSd.

Objective

This study explored microRNAs in peripheral blood mononuclear cells (PBMC) of post-myocardial infarction patients with LVSd.

Methods

Post-STEMI patients were grouped as having (LVSd, n = 9) or not LVSd (non-LVSd, n = 16). The expression of 61 microRNAs was analyzed in PBMC by RT-qPCR and the differentially expressed microRNAs were identified. Principal Component Analysis stratified the microRNAs based on the development of dysfunction. Predictive variables of LVSd were investigated through logistic regression analysis. A system biology approach was used to explore the regulatory molecular network of the disease and an enrichment analysis was performed.

Results

The let-7b-5p (AUC: 0.807; 95% CI: 0.63-0.98; p = 0.013), miR-125a-3p (AUC: 0.800; 95% CI: 0.61-0.99; p = 0.036) and miR-326 (AUC: 0.783; 95% CI: 0.54-1.00; p = 0.028) were upregulated in LVSd (p < 0.05) and discriminated LVSd from non-LVSd. Multivariate logistic regression analysis showed let-7b-5p (OR: 16.00; 95% CI: 1.54-166.05; p = 0.020) and miR-326 (OR: 28.00; 95% CI: 2.42-323.70; p = 0.008) as predictors of LVSd. The enrichment analysis revealed association of the targets of these three microRNAs with immunological response, cell-cell adhesion, and cardiac changes.

Conclusion

LVSd alters the expression of let-7b-5p, miR-326, and miR-125a-3p in PBMC from post-STEMI, indicating their potential involvement in the cardiac dysfunction physiopathology and highlighting these miRNAs as possible LVSd biomarkers.