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Chagas cardiomyopathy caused by infection with the intracellular parasite Trypanosoma cruzi is the most common and severe expression of human Chagas disease. Heart failure, systemic and pulmonary thromboembolism, arrhythmia, and sudden cardiac death are the principal clinical manifestations of Chagas cardiomyopathy. Ventricular arrhythmias contribute significantly to morbidity and mortality and are the major cause of sudden cardiac death. Significant gaps still exist in the understanding of the pathogenesis mechanisms underlying the arrhythmogenic manifestations of Chagas cardiomyopathy. This article will review the data from experimental studies and translate those findings to draw hypotheses about clinical observations. Human- and animal-based studies at molecular, cellular, tissue, and organ levels suggest 5 main pillars of remodeling caused by the interaction of host and parasite: immunologic, electrical, autonomic, microvascular, and contractile. Integrating these 5 remodeling processes will bring insights into the current knowledge in the field, highlighting some key features for future management of this arrhythmogenic disease.

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PURPOSE OF REVIEW: More than a century since its discovery, the pathogenesis of Chagas heart disease (CHD) remains incompletely understood. The role of derangements in the autonomic control of the heart in triggering malignant arrhythmia before the appearance of contractile ventricular impairment was reviewed. RECENT FINDINGS: Although previous investigations had demonstrated the anatomical and functional consequences of parasympathetic dysautonomia upon the heart rate control, only recently, coronary microvascular disturbances and sympathetic denervation at the ventricular level have been reported in patients and experimental models of CHD, exploring with nuclear medicine methods their impact on the progression of myocardial dysfunction and cardiac arrhythmias. More important than parasympathetic impaired sinus node regulation, recent evidence indicates that myocardial sympathetic denervation associated with coronary microvascular derangements is causally related to myocardial injury and arrhythmia in CHD. Additionally, 123I-MIBG imaging is a promising tool for risk stratification of progression of ventricular dysfunction and sudden death.

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Resumo Objetivos Conhecer a percepção da equipe de enfermagem da unidade neonatal sobre os cuidados prestados ao recém-nascido hospitalizado com estomia intestinal e discutir os fatores que interferem na assistência de enfermagem. Método Estudo exploratório, descritivo, com abordagem qualitativa. Participaram oito enfermeiros e oito técnicos de enfermagem que trabalham em uma Unidade Neonatal do Rio de Janeiro. Os dados foram coletados entre abril e junho de 2022, através de entrevista semiestruturada e análise de conteúdo. Resultados Emergiram duas categorias: "percepções da equipe de enfermagem quanto ao cuidar de recém-nascidos hospitalizados com estomias intestinais e a educação em saúde da família"; e "aspectos facilitadores e dificultadores da assistência de enfermagem ao recém-nascido com estomia intestinal e a importância da educação permanente no cenário da Unidade Neonatal". Conclusão e implicações para prática O manejo de neonatos com estomias intestinais é atual e implica em cuidados de enfermagem com o estoma e pele do recém-nascido, estendendo-se para a prática da educação em saúde dos familiares. É desafiador o manejo de complicações, a indisponibilidade de materiais e o cuidado fragmentado. Tal achado pode subsidiar o desenvolvimento de intervenções de enfermagem sistematizada para os recém-nascidos e seus pais na unidade neonatal.

Resumen Objetivos Conocer la percepción del equipo de enfermería de la unidad neonatal sobre el cuidado prestado al neonato hospitalizado con ostomías intestinales y discutir los factores que interfieren en el cuidado de enfermería. Método Estudio exploratorio, descriptivo, con abordaje cualitativo. Participaron ocho enfermeros y ocho técnicos de enfermería que actúan en una Unidad Neonatal de Rio de Janeiro. Datos colectados entre abril y junio de 2022, por entrevistas semiestructuradas y análisis de contenido. Resultados Emergieron dos categorías: "percepciones del equipo de enfermería sobre el cuidado al recién nacido hospitalizado con ostomías intestinales y la educación en salud de la familia"; y "aspectos que facilitan y dificultan el cuidado de enfermería al recién nacido con ostomía intestinal y la importancia de la educación continua en el ámbito de la Unidad Neonatal". Conclusión e implicaciones para la práctica El manejo de neonatos con ostomías intestinales es actual e implica cuidados de enfermería con el estoma y la piel del recién nacido, extendiéndose a la práctica de educación en salud para familiares. El manejo de complicaciones, la falta de materiales y la atención fragmentada son desafíos. Este hallazgo puede apoyar el desarrollo de intervenciones de enfermería sistematizadas para los recién nacidos y sus padres en la unidad neonatal.

Abstract Objectives To understand the perception of the nursing team of the neonatal unit about the care provided to hospitalized newborns with intestinal ostomy and to discuss the factors that interfere in nursing care. Method Exploratory and descriptive study, with a qualitative approach. Eight nurses and eight nursing technicians who work in a Neonatal Unit in Rio de Janeiro took part. Data were collected between April and June 2022, through semi-structured interviews and content analysis. Results Two categories emerged: "perceptions of the nursing team regarding the care of hospitalized newborns with intestinal ostomies and family health education"; and "facilitating and hindering aspects of nursing care for newborns with intestinal ostomy and the importance of continuing education in the setting of the Neonatal Unit". Conclusion and implications for practice The management of newborns with intestinal ostomies is current and involves nursing care with the stoma and skin of the newborn, extending to the practice of health education for family members. The management of complications, the unavailability of materials and fragmented care are challenging. This finding can support the development of systematized nursing interventions for newborns and their parents in the neonatal unit.

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Objetivo: mapear as estratégias para o controle e regulação da temperatura corporal em recém-nascidos prematuros. Método: revisão de escopo sobre termorregulação do prematuro, orientada pelas recomendações do Instituto Joanna Briggs, desenvolvida em oito bases de informações eletrônica. A busca, síntese e análise dos resultados ocorreu em dezembro de 2022. Resultados: compuseram a revisão 15 estudos que foram agrupados em duas categorias: Fontes de calor e Uso de pacotes de medidas/bundle. Como estratégias para a manutenção da temperatura corporal do prematuro, destacam-se: temperatura adequada materna e do ambiente; envoltório plástico; touca dupla; panos aquecidos; aquecimento do ar no suporte respiratório; contato pele a pele; berços aquecidos e incubadoras. Evidenciou-se que os recursos conjugados foram mais efetivos do que quando usados isoladamente. Conclusão: os resultados da revisão de escopo apontaram para estratégias que podem ser utilizadas para mitigar os riscos de hipotermia em recém-nascidos prematuros(AU)

Objective: to map strategies for controlling and regulating body temperature in premature newborns. Method: scope review on premature thermoregulation, guided by the recommendations of the Joanna Briggs Institute, developed in eight electronic databases. The search, synthesis and analysis of the results took place in December 2022. Results: the review was made up of 15 studies, which were grouped into two categories: Heat sources and use of measurement packages/bundle. As strategies for maintaining the body temperature of preterm infants, the following stand out: adequate maternal and environmental temperature; plastic wrap; double bonnet; heated cloths; air heating in respiratory support; skin-to-skin contact; heated cribs and incubators. It was evident that the combined resources were more effective than when used separately. Conclusion: the scoping review results pointed to strategies that can be used to mitigate the risks of hypothermia in premature newborns(AU)

Objetivo: mapear estrategias para el control y regulación de la temperatura corporal en recién nacidos prematuros. Método: revisión de alcance sobre la termorregulación prematura, siguiendo las recomendaciones del Instituto Joanna Briggs, desarrollada en ocho bases de datos electrónicas. La búsqueda, la síntesis y el análisis de los resultados se llevaron a cabo en diciembre de 2022. Resultados: la revisión fue conformada de 15 estudios, agrupados en dos categorías: fuentes de calor y uso de paquetes de medidas/bundle. Como estrategias para mantener la temperatura corporal del prematuro se destacan: temperatura adecuada materna y ambiental; envoltura de plástico; gorro doble; paños tibios; calentamiento del aire en soporte respiratorio; contacto piel a piel; cunas calefaccionadas e incubadoras. Se evidenció que los recursos combinados fueron más efectivos que si usados de forma individual. Conclusión: los resultados de la revisión de alcance señalaron estrategias que pueden usarse para mitigar los riesgos de hipotermia en recién nacidos prematuros(AU)

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Endocrine Disrupting Chemicals (EDCs) encompass a wide variety of substances capable of interfering with the endocrine system, including but not limited to bisphenol A, organochlorines, polybrominated flame retardants, alkylphenols and phthalates. These compounds are widely produced and used in everyday modern life and have increasingly been detected in aquatic matrices worldwide. In this context, this study aimed to carry out a literature review to assess the evolution of EDCs detected in different matrices in the last thirty years. A bibliometric analysis was conducted at the Scopus, Web of Science, and Google Scholar databases. Data were evaluated using the Vosviewer 1.6.17 software. A total of 3951 articles in English were retrieved following filtering. The results demonstrate a gradual and significant growth in the number of published documents, strongly associated with the increasing knowledge on the real environmental impacts of these compounds. Studied were mostly conducted by developed countries in the first two decades, 1993 to 2012, but in the last decade (2013 to 2022), an exponential leap in the number of publications by countries such as China and an advance in research by developing countries, such as Brazil, was verified.

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INTRODUCTION: Myocardial ischemia is common in patients with chronic Chagas cardiomyopathy (CCC), but only recently clinical and experimental studies highlighted the involvement of this abnormality as contributing to the progression of myocardial damage. AREAS COVERED: Despite the absence of obstructive epicardial coronary artery disease at angiography, and limited evidence of abnormal flow regulation at the macrovascular level, remarkable functional and structural microvascular abnormalities are consistently reported by independent investigations of CCC. These derangements occur early and contribute to myocardial dysfunction. Recent research focused on reversing microvascular dysfunction as a target to positively impact the course of CCC. We conducted an extensive review of the scientific literature, aiming to summarize the role of coronary dysfunction causing myocardial ischemia in CCC, with a focus on implications for clinical management of individuals affected by this disease. EXPERT OPINION: Preclinical studies showed a clear correlation between perfusion defects and inflammation in viable but impaired dysfunctional myocardium. These findings provided further insight into the CCC complex pathophysiology and support the role of very few recent therapeutic interventions aiming to relieve myocardial ischemia. Further research is warranted to assess the efficacy of new interventions addressing reversal of microvascular ischemia and inflammation modulation and halting ventricular dysfunction progression in CCC.

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Introdução: Face à melhor compreensão da fisiopatologia da estenose valvar aórtica, cresceu paralelamente a complexidade da avaliação de sua gravidade, persistindo relevante incerteza quanto à aplicabilidade dos métodos invasivos pelo cateterismo cardíaco e os não invasivos, com base em ecocardiografia. O objetivo deste estudo foi analisar os padrões hemodinâmicos da avaliação com ecocardiografia comparativamente à estimativa da gravidade da estenose aórtica com o cateterismo em pacientes consecutivos referidos para avaliação diagnóstica por laboratório de hospital acadêmico terciário no triênio 2016-2018. Métodos: Estudo observacional, descritivo e retrospectivo das características clínicas e dos resultados das avaliações da gravidade da estenose valvar aórtica obtidas em 96 pacientes consecutivos, por meio de cateterismo e ecocardiografia. Resultados: Amostra populacional de 49 homens e 47 mulheres, com mediana de idade de 66,5 (56,5 a 72,8) anos, estenose valvar aórtica degenerativa em 49% e reumática em 40%, além de diversas comorbidades, inclusive doença coronária (37%). Pelo cateterismo, com base no gradiente pico de 48 (20 a 68), a estenose valvar aórtica foi avaliada como grave em 56%, sendo a pressão telediastólica ventricular de 20mmHg (16 a 30mmHg). Pela ecocardiografia, a área valvar foi 0,9cm2 (0,7 a 1,2cm2), sendo indexado 0,5cm2/m2 (0,43 a 0,5cm2/m2), com gradiente pico de 62±26 mmHg. A estenose valvar aórtica foi considerada severa em 69,2%. Houve discordância entre os métodos sobre a severidade da estenose valvar aórtica em 30% dos exames, com coeficiente de Spearman entre área valvar pelo ecocardiograma e gradiente pico pelo cateterismo de -0,7 (p<0,001). Conclusão: Em amostra representativa dos vários padrões hemodinâmicos, a avaliação da gravidade da estenose valvar aórtica, como praticada rotineiramente em laboratório acadêmico, limitou-se à medida de pico de gradiente transvalvar. A estimativa da área valvar pelo método ecocardiográfico, sendo indireta e também passível de crítica, contribui para as discrepâncias encontradas, tornando-se justificável buscar o aperfeiçoamento de ambos os métodos, em vista da complexidade clínica e hemodinâmica detectada.

Background: In view of the better understanding of the pathophysiology of aortic valve stenosis, the complexity of assessing its severity has simultaneously grown, with relevant uncertainty persisting as to the applicability of invasive methods by cardiac catheterization and non-invasive methods based on echocardiography. The objective of this study was to analyze the hemodynamic patterns of evaluation with echocardiography compared to the estimation of severity of aortic stenosis with catheterization in consecutive patients referred for diagnostic evaluation by the laboratory of a tertiary academic hospital in the 2016 to 2018 triennium. Methods: An observational, descriptive and retrospective study of clinical characteristics and results of assessments of severity of aortic valve stenosis obtained in 96 consecutive patients, through catheterization and echocardiography. Results: A population sample of 49 men and 47 women, with a median age of 66.5 (56.5 to 72.8) years, degenerative aortic valve stenosis in 49%, and rheumatic aortic stenosis in 40%, in addition to several comorbidities, including coronary disease (37%). Using catheterization, based on the peak gradient of 48 (20 to 68), aortic valve stenosis was assessed as severe in 56%, with ventricular end-diastolic pressure of 20mmHg (16 to 30mmHg). Using echocardiography, the valve area was 0.9cm2 (0.7 to 1.2cm2), indexed valve area was 0.5cm2/m2 (0.43 to 0.5cm2/m2), with peak gradient of 62±26mmHg. Aortic valve stenosis was considered severe in 69.2%. There was disagreement between the methods regarding severity of aortic valve stenosis in 30% of exams, with a Spearman coefficient between the valve area on the echocardiogram and the peak gradient on catheterization of -0.7 (p<0.001). Conclusion: In a representative sample of various hemodynamic patterns, the assessment of severity of aortic valve stenosis, as routinely practiced in an academic laboratory, was limited to measuring the peak transvalvular gradient. The estimation of the valve area using the echocardiographic method was indirect and also subject to criticism, and contributed to the discrepancies found, rendering it justifiable to seek the improvement of both methods, in view of the clinical and hemodynamic complexity detected.

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BACKGROUND: Chagas disease (ChD) is caused by Trypanosoma cruzi. The genetic structure of the species is divided into seven distinct genetic groups, TcI to TcVI, and Tcbat, which have shown differences in terms of geographic distribution, biological properties, and susceptibility to drugs. However, the association between genetic variability and clinical forms of ChD has not yet been fully elucidated. The predominance of TcII and TcVI discrete typing units (DTUs) (genetic groups) is known to occur in several Brazilian regions and is associated with both the domestic and the wild cycles of ChD. Thus, this study aimed to verify the genotypes of the parasites present in 330 patients with chronic Chagas cardiomyopathy (CCC) from different Brazilian states attended at the Clinical Hospital of the Ribeirão Preto Medical School and to assess the existence of a correlation between the clinical forms with the main cardiovascular risk factors and the genetics of the parasite. METHODOLOGY PRINCIPAL FINDINGS: All patients with CCC were clinically evaluated through anamnesis, physical examination, biochemical tests, 12-lead electrocardiogram, echocardiogram and chest X-ray. Peripheral blood (5 mL) was collected in guanidine/ethylenediaminetetraacetic acid from each patient for DNA extraction and real-time polymerase chain reaction (PCR) for Chagas disease and genotyping of the parasite in the 7 DTUs. Parasite genotyping was performed using conventional multilocus PCR. Samples of only 175 patients were positive after amplification of the specific genes contained in the T. cruzi genotyping criteria. TcII (64/175), TcVI (9/175), and TcI (3/175) DTUs were predominant, followed by TcII/TcV/TcVI (74/175), and TcII/TcVI (23/175). The TcIII and TcIV DTU´s was detected in only one sample of CCC patients. CONCLUSIONS/SIGNIFICANCE: Our data corroborate previous findings, indicating the predominance of the TcII genotype in patients with CCC of Brazilian origin. Moreover, this study pioneered disclosing a direct correlation between the TcII DTU and severe CCC.

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Objetivo: analisar as práticas profissionais no primeiro encontro dos pais com recém-nascido na unidade neonatal. Método: estudo quantitativo, descritivo e transversal, desenvolvido com 69 profissionais de saúde da unidade de terapia intensiva neonatal de um Hospital Universitário no Rio de Janeiro, após aprovação pelo Comitê de Ética em Pesquisa. Os dados foram coletados no período de março a julho de 2021, por meio de questionário online, e analisados mediante estatística descritiva simples, percentual e média. Resultados: as práticas profissionais foram adequadas quanto possibilitar aos pais: o toque materno/paterno (91,3%); o livre acesso à unidade neonatal (86,9%); e a realização de cuidados com o bebê (81,1%). Conclusão: a maioria das práticas profissionais está alinhada às recomendações do Método Canguru. Contudo, as fragilidades relativas ao acolhimento evidenciam lacunas na abordagem da temática na formação profissional e em atividades de educação continuada.

Objective: to examine the professional practices in the first meeting between parents and newborn in the neonatal unit. Method: in this quantitative, descriptive, cross-sectional study conducted with 69 health personnel from the neonatal intensive care unit of a university hospital in Rio de Janeiro, after approval by the research ethics committee, data were collected from March to July 2021 by online survey and analyzed using simple percentage and average descriptive statistics. Results: the professional practices were appropriate in that they allowed parents: maternal/paternal touch (91.3%); free access to the neonatal unit (86.9%); and to provide care for the baby (81.1%). Conclusion: the professional practices were mostly in line with the recommendations of the Kangaroo Method. However, weaknesses in receptiveness highlighted gaps in how the subject was approached in training activities and continued professional development.

Objetivo: analizar las prácticas profesionales en el primer encuentro entre padres y recién nacido en la unidad neonatal. Método: estudio cuantitativo, descriptivo y transversal, desarrollado con 69 profesionales de la salud de la unidad de cuidados intensivos neonatales de un Hospital Universitario de Rio de Janeiro, previa aprobación del Comité de Ética en Investigación. Los datos fueron recolectados de marzo a julio de 2021, a través de una encuesta en línea, y analizados mediante estadística descriptiva simple, porcentaje y promedio. Resultados: las prácticas profesionales fueron adecuadas en cuanto a posibilitar a los padres: el toque materno/paterno (91,3%); el libre acceso a la unidad neonatal (86,9%); y la prestación de cuidados al bebé (81,1%). Conclusión: la mayoría de las prácticas profesionales está acorde con las recomendaciones del Método Canguro. Sin embargo, las debilidades relacionadas con la acogida evidencian lagunas acerca del enfoque del tema en la formación profesional y en actividades de educación continua.

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BACKGROUND: Although Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy. METHODS: This retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack-TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up. RESULTS: A total of 113 patients were included. Median age was 56 years (IQR: 45-67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41-62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93-0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38-7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year. CONCLUSIONS: LV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.

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A screening for microcontaminants performed by gas chromatography detected several microcontaminants in 12 sediment samples from the eutrophic estuary Guanabara Bay (GB) in southeastern Brazil. Bisphenol A (BPA) ranged from 1.4 to 20.3 ng g-1, 4-octylphenol, from

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

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

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Chagas disease, caused by the protozoan Trypanosoma cruzi, is an endemic parasitic disease of Latin America, affecting 7 million people. Although most patients are asymptomatic, 30% develop complications, including the often-fatal Chronic Chagasic Cardiomyopathy (CCC). Although previous studies have demonstrated some genetic deregulations associated with CCCs, the causes of their deregulations remain poorly described. Based on bulk RNA-seq and whole genome DNA methylation data, we investigated the genetic and epigenetic deregulations present in the moderate and severe stages of CCC. Analysis of heart tissue gene expression profile allowed us to identify 1407 differentially expressed transcripts (DEGs) specific from CCC patients. A tissue DNA methylation analysis done on the same tissue has permitted the identification of 92 regulatory Differentially Methylated Regions (DMR) localized in the promoter of DEGs. An in-depth study of the transcription factors binding sites (TFBS) in the DMRs corroborated the importance of TFBS's DNA methylation for gene expression in CCC myocardium. TBX21, RUNX3 and EBF1 are the transcription factors whose binding motif appears to be affected by DNA methylation in the largest number of genes. By combining both transcriptomic and methylomic analysis on heart tissue, and methylomic analysis on blood, 4 biological processes affected by severe CCC have been identified, including immune response, ion transport, cardiac muscle processes and nervous system. An additional study on blood methylation of moderate CCC samples put forward the importance of ion transport and nervous system in the development of the disease.

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OBJECTIVE: to describe and compare the frequency of neurobehavioral signs in preterm infants in traditional and humanized body weight check. METHODS: a quantitative, quasi-experimental, cross-over study, carried out in a Neonatal Unit at a university hospital with a sample of 30 preterm newborns, randomly assigned and allocated in control group (traditional) and intervention group (humanized), with collection of general data, vital signs before and after procedures and footage. RESULTS: there was a higher frequency of approach signs in humanized weight check compared to traditional check. Moreover, withdrawal signs were more frequent in traditional weight check compared to humanized check. CONCLUSION: in this regard, humanized body weight check provided greater benefits to preterm infants, making it necessary to foster discussions about humanization of care, so that this practice can be performed routinely in health units.

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Abstract: Chagas disease, caused by the protozoan Trypanosoma cruzi, is an endemic parasitic disease of Latin America, affecting 7 million people. Although most patients are asymptomatic, 30% develop complications, including the often-fatal Chronic Chagasic Cardiomyopathy (CCC). Although previous studies have demonstrated some genetic deregulations associated with CCCs, the causes of their deregulations remain poorly described. Based on bulk RNA-seq and whole genome DNA methylation data, we investigated the genetic and epigenetic deregulations present in the moderate and severe stages of CCC. Analysis of heart tissue gene expression profile allowed us to identify 1407 differentially expressed transcripts (DEGs) specific from CCC patients. A tissue DNA methylation analysis done on the same tissue has permitted the identification of 92 regulatory Differentially Methylated Regions (DMR) localized in the promoter of DEGs. An in-depth study of the transcription factors binding sites (TFBS) in the DMRs corroborated the importance of TFBS's DNA methylation for gene expression in CCC myocardium. TBX21, RUNX3 and EBF1 are the transcription factors whose binding motif appears to be affected by DNA methylation in the largest number of genes. By combining both transcriptomic and methylomic analysis on heart tissue, and methylomic analysis on blood, 4 biological processes affected by severe CCC have been identified, including immune response, ion transport, cardiac muscle processes and nervous system. An additional study on blood methylation of moderate CCC samples put forward the importance of ion transport and nervous system in the development of the disease.

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Electrocardiographic (ECG) abnormalities are frequently identified in Chronic Chagas cardiomyopathy (CCC) patients and advanced abnormalities are related to a worse prognosis. Cardiac Magnetic Resonance (CMR) can precisely assess ventricular systolic dysfunction and quantify myocardial fibrosis (MF), both identified as prognostic factors. We sought to investigate if ECG abnormalities in CCC patients were associated with more severe myocardial involvement as evaluated by CMR. METHODS: CCC patients with 12­lead ECG and CMR closely obtained were included. ECG analysis evaluated rhythm, presence, and type of intraventricular conduction disturbances (IVCD) and, ventricular premature beats (VPB). CMR short-axis cine and late gadolinium enhancement images were evaluated to obtain left and right ventricular ejection fractions and MF mass, respectively. Statistical significance was set in 5%. RESULTS: 194 CCC patients (98 women, 56 ± 14 years) were evaluated, and no IVCD was detected in 71. The most common IVCD was the association of right bundle branch block and left anterior fascicular block (RBBB+LAFB) in 58 patients, followed by isolated RBBB in 34, isolated LAFB in 17, and left bundle branch block (LBBB) in 14 patients. Of patients with no IVCD, 63% had MF and the burden of fibrosis (no IVCD - 7.4 ± 8.6%; RBBB - 6.6 ± 6.5%; p = 1.00), as well as left ventricular ejection fraction (LVEF) (no IVCD - 52 ± 14%; RBBB - 55 ± 10%; p = 1.00) were similar to patients with isolated RBBB. Left conduction system impairment was associated with lower LVEF (LAFB - 39 ± 15%; RBBB+LAFB- 41 ± 15%; and LBBB - 35 ± 15%; p < 0.001) and more MF (RBBB+LAFB - 12.2 ± 10.4%; LBBB - 10.6 ± 7.5%; and LAFB - 12.0 ± 7.0%; p < 0.001). The univariable model showed that the presence of MF was related to RBBB+LAFB (OR 5.0; p = 0.001) and VPB (OR 6.3; p = 0.014). After adjustment for age, gender, and different risk factors in a multivariable model, the same findings were still significantly related to CMR myocardial fibrosis (RBBB+LAFB OR 5.0; p = 0.002 / VPB OR 6.9; p = 0.015). CONCLUSIONS: ECG without IVCD does not exclude serious cardiac abnormalities in CCC, and isolated RBBB seems to have a benign course. The presence of VPB and left branch conduction impairment, especially LAFB associated with RBBB, indicate a more severe cardiac involvement.

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Resumo Fundamento Cerca de 40% dos pacientes com infarto agudo do miocárdio com supradesnível do segmento ST (IAMCSST) no Brasil não recebem terapia de reperfusão. Objetivo A utilização de uma rede de telemedicina baseada no WhatsApp® poderia aumentar a porcentagem de pacientes que recebem terapia de reperfusão. Métodos Estudo transversal do tipo antes e depois da organização de uma rede de telemedicina para envio e análise do eletrocardiograma através do WhatsApp® dos pacientes suspeitos de IAMCSST oriundos dos 25 municípios integrantes do Departamento Regional de Saúde de Ribeirão Preto (DRS−XIII), para hospital terciário que poderia autorizar a transferência imediata do paciente utilizando o mesmo sistema. O desfechos analisados foram a porcentagem de pacientes que receberam terapia de reperfusão e a taxa de mortalidade intra-hospitalar. Considerou-se valor de p <0,05 como estatisticamente significativo. Resultados Foram comparados 82 pacientes antes desta rede (1º de fevereiro de 2016 a 31 de janeiro de 2018) com 196 pacientes depois da implantação da mesma (1º de fevereiro de 2018 a 31 de janeiro de 2020). Após a implantação da rede, houve aumento significativo da proporção de pacientes que receberam terapia de reperfusão (60% vs. 92%), risco relativo (RR): 1,594 [intervalo de confiança (IC) 95% 1,331 - 1,909], p <0,0001 e redução da mortalidade intra-hospitalar (13,4% vs. 5,6%), RR: 0,418 [IC 95% 0,189 - 0,927], p = 0,028. Conclusão Rede de telemedicina baseada no WhatsApp® associou-se a aumento da porcentagem de pacientes com IAMCSST que receberam terapia de reperfusão e a redução na mortalidade intra-hospitalar.

Abstract Background About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy. Objective The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy. Methods A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS−XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant. Results The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028. Conclusion The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.

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