Electrocardiographic Abnormalities and Treatment with Benznidazole among Children with Chronic Infection by Trypanosoma cruzi: A Retrospective Cohort Study

Background: Chronic infection by Trypanosoma cruzi could cause heart conduction disturbances. We sought to analyze electrocardiographic abnormalities among children with chronic T. cruzi infection with and without trypanocidal treatment with benznidazole. Methodology/Principal Findings: We studied 111 children 6–16 years of age with asymptomatic chronic T. cruzi infection who were recruited in 1991–1992 in Salta, Argentina. Most children were randomly assigned to benznidazole 5 mg/Kg/day (n = 47) or matching placebo (n = 48) for 60 days. Remaining children (n = 16) received treatment with benznidazole 5 mg/Kg/day open-label. Electrocardiograms were obtained at baseline and in 1995–1996, 1998, 2000 and 2005, and were analyzed using the Buenos Aires method. Among the 94 children with an electrocardiogram at baseline, 8 (8.5%) had electrocardiographic abnormalities, including 4 (4.7%) children with right bundle branch block. Proportion of abnormal electrocardiograms in the full population (n = 111) remained constant over time (media follow-up 8.6 years). Multivariable adjusted prevalence ratios (95% confidence interval [95%CI]) for electrocardiographic abnormalities in 1995–1996, 1998, 2000 and 2005 comparing children treated with benznidazole versus those not treated were 2.76 (0.66, 11.60), 2.33 (0.44, 12.31), 3.06 (0.48, 19.56), and 1.94 (0.33, 11.25), respectively. Among the 86 children with a normal electrocardiogram at baseline, 16 (18.6%) developed electrocardiographic abnormalities during follow-up. The multivariable adjusted hazard ratio for incident electrocardiographic abnormalities comparing children treated with benznidazole versus those not treated was 0.68 (95%CI: 0.25, 1.88). Conclusions/Significance: Electrocardiographic abnormalities are frequent among children with chronic T. cruzi infection. Treatment with benznidazole for 60 days may not be associated with less electrocardiographic abnormalities.Fil: Colantonio, Lisandro Damián. University of Alabama at Birmingahm; Estados Unidos. Universidad de Buenos Aires. Facultad de Medicina; ArgentinaFil: Prado, Nilda. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud “Dr. C. G. Malbrán”. Instituto Nacional de Parasitología "Dr. Mario Fatala Chaben”; ArgentinaFil: Segura, Elsa Leonor. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud “Dr. C. G. Malbrán”. Instituto Nacional de Parasitología "Dr. Mario Fatala Chaben”; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Sosa-Estani, Sergio Alejandro. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud “Dr. C. G. Malbrán”. Instituto Nacional de Parasitología "Dr. Mario Fatala Chaben”; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Use Of Medicare Inpatient Claims Data For The Identification Of Myocardial Infarction

Claims are being used for the identification of myocardial infarctions (MI) in research studies, either as a complement of primary data collection or as the sole data source. However, few data are available to support these approaches. The current dissertation analyzes the use of claims for the identification of MIs in a large population-based cohort linked to Medicare data, the REasons for Geographic and Racial Differences in Stroke study. Analyses included 9,951 study participants ≥65 years of age with Medicare Part A (inpatient) fee-for-service coverage at baseline in 2003-2007. Participant self-report and Medicare inpatient claims with a diagnosis code for MI (i.e., international classification of diseases, ninth revision codes 410.x0-410.x1) were used to identify hospitalizations through December 31, 2012 which were subsequently classified as MIs or no MIs by expert adjudication. Using expert adjudication as the reference standard, Medicare claims with a code for MI in any and in the primary position had a sensitivity of 49.0% and 40.1%, respectively, and a positive predictive value (PPV) of 84.3% and 89.7%, respectively. Very small non-ST-segment elevation MIs and type 2 and type 4-5 MIs were more likely to be identified through participant self-report but not present in claims. The rate for MI was 10.7 per 1,000 person-years using MIs identified through participant self-report. Adding MIs identified through claims with a code for MI in any and in the primary position increased the rate for MI by 12% and 6%, respectively. Using claims with a code for MI in any and in the primary position without adjudication underestimated the rate for MI by 8% and 32%, respectively compared with using MIs identified through participant self-report. Associations between participant characteristics and MI were similar using MIs identified through participant self-report, MIs identified through participant self-report or Medicare claims, and Medicare claims with a code for MI without adjudication. In conclusion, Medicare claims have high PPV but moderate sensitivity for MI identification. The improvement in MI identification using Medicare claims as a complement of participant self-report is small. Using claims data as a complement of participant self-report for MI identification may not be needed

Therapy of Chagas Disease: Implications for Levels of Prevention

This paper reviews the evidence supporting the use of etiological treatment for Chagas disease that has changed the standard of care for patients with Trypanosoma cruzi infection in the last decades. Implications of this evidence on different levels of prevention as well as gaps in current knowledge are also discussed. In this regard, etiological treatment has shown to be beneficial as an intervention for secondary prevention to successfully cure the infection or to delay, reduce, or prevent the progression to disease, and as primary disease prevention by breaking the chain of transmission. Timely diagnosis during initial stages would allow for the prescription of appropriate therapies mainly in the primary health care system thus improving chances for a better quality of life. Based on current evidence, etiological treatment has to be considered as an essential public health strategy useful to reduce disease burden and to eliminate Chagas disease altogether

Generalizability of SPRINT Results to the U.S. Adult Population

Background In SPRINT (Systolic Blood Pressure Intervention Trial), a systolic blood pressure (SBP) goal of <120 mm Hg resulted in lower cardiovascular disease (CVD) risk compared with an SBP goal of <140 mm Hg. Objectives The purpose of this study was to estimate the prevalence, number, and characteristics of U.S. adults meeting SPRINT eligibility criteria and determine the broader population to whom SPRINT could be generalized. Methods We conducted a cross-sectional, population-based study using data from the National Health and Nutrition Examination Survey, 2007 to 2012. The SPRINT inclusion criteria were age ≥50 years, SBP 130 to 180 mm Hg depending on the number of antihypertensive medication classes being taken, and high CVD risk (history of coronary heart disease, estimated glomerular filtration rate of 20 to 59 ml/min/1.73 m2, 10-year CVD risk ≥15%, or age ≥75 years). Exclusion criteria were diabetes, history of stroke, >1 g in 24 h of proteinuria daily, heart failure, estimated glomerular filtration rate <20 ml/min/1.73 m2, or receiving dialysis. Treated hypertension was defined by self-reported use of medication to lower blood pressure with ≥1 class of antihypertensive medication identified through a pill bottle review. Results Overall, 7.6% (95% confidence interval [CI]: 7.0% to 8.3%) or 16.8 million (95% CI: 15.7 to 17.8 million) U.S. adults, and 16.7% (95% CI: 15.2% to 18.3%) or 8.2 million (95% CI: 7.6 to 8.8 million) adults with treated hypertension met the SPRINT eligibility criteria. Among both the overall U.S. population and adults with treated hypertension, the percentage meeting SPRINT eligibility criteria increased with older age, was higher among males than females, and was higher among non-Hispanic whites compared with non-Hispanic blacks or Hispanics. Of U.S. adults eligible for SPRINT, 51.0% (95% CI: 47.8% to 54.1%) or 8.6 million (95% CI: 8.0 to 9.1 million) were not treated for hypertension. Conclusions A substantial percentage of U.S. adults meet the eligibility criteria for SPRINT

Concurrent Stress and Depressive Symptoms Increase Risk of Myocardial Infarction or Death

BACKGROUND: Depression and stress have each been found to be associated with poor prognosis in patients with coronary heart disease. A recently offered psychosocial perfect storm conceptual model hypothesizes amplified risk will occur in those with concurrent stress and depressive symptoms. We tested this hypothesis in a large sample of US adults with coronary heart disease. METHODS AND RESULTS: Participants included 4487 adults with coronary heart disease from the Reasons for Geographic and Racial Differences in Stroke study, a prospective cohort study of 30,239 black and white adults. We conducted Cox proportional hazards regression with the composite outcome of myocardial infarction or death and adjustment for demographic, clinical, and behavioral factors. Overall, 6.1% reported concurrent high stress and high depressive symptoms at baseline. During a median 5.95 years of follow-up, 1337 events occurred. In the first 2.5 years of follow-up, participants with concurrent high stress and high depressive symptoms had increased risk for myocardial infarction or death (adjusted hazard ratio, 1.48 [95% confidence interval, 1.08-2.02]) relative to those with low stress and low depressive symptoms. Those with low stress and high depressive symptoms (hazard ratio, 0.92 [95% confidence interval, 0.66-1.28]) or high stress and low depressive symptoms (hazard ratio, 0.86 [95% confidence interval, 0.57-1.29]) were not at increased risk. The association on myocardial infarction or death was not significant after the initial 2.5 years of follow-up (hazard ratio, 0.89 [95% confidence interval, 0.65-1.22]). CONCLUSIONS: Our results provide initial support for a psychosocial perfect storm conceptual model; the confluence of depressive symptoms and stress on medical prognosis in adults with coronary heart disease may be particularly destructive in the shorter term

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

Background. Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions. Methods. An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved). Conclusions. Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.Centro de Endocrinología Experimental y Aplicada (CENEXA

A cost-effectiveness analysis of a 10-valent pneumococcal conjugate vaccine in children in six Latin American countries.

BACKGROUND: A recently developed 10-valent pneumococcal non-typeable H influenzae protein D-conjugate vaccine (PHiD-CV) is expected to afford protection against more than two thirds of isolates causing IPD in children in Latin America, and also against acute otitis media caused by both Spn and NTHi. The objective of this study is to assess the cost-effectiveness of PHiD-CV in comparison to non-vaccination in children under 10 years of age in Argentina, Brazil, Chile, Colombia, Mexico and Peru. METHODS: We used a static, deterministic, compartmental simulation model. The dosing regimen considered included three vaccine doses (at 2 months, 4 months and 6 months) and a booster dose (at 13 months) (3 + 1 schedule). Model outcomes included number of cases prevented, deaths averted, quality-adjusted life-years (QALYs) gained and costs. Discount for costs and benefits of long term sequelae was done at 3.5%, and currency reported in 2008-2009 U$S varying between countries. RESULTS: The largest effect in case prevention was observed in pneumococcal meningitis (from 27$ Dollars per QALY gained. Results were robust in the sensitivity analysis, and scenarios with indirect costs affected results more than those with herd immunity. CONCLUSIONS: The incorporation of the 10-valent pneumococcal conjugate vaccine into routine infant immunization programs in Latin American countries could be a cost-effective strategy to improve infant population health in the region

Mortality in survivors of torture ad prison during the chilean dictatorship between 1973 and 1990

Background: Studies on the long-term consequences of torture in survivors in Chile have only addressed the consequences for mental health, leaving aside the physical consequences. Aim: To report the causes of death in the universe of victims of the Chilean civic-military dictatorship recognized by the Reports of the National Commission for Political Prison and Torture (CNPPT) and the Advisory Commission for the qualification of Disappeared Detainees, Politically Executed individuals and Victims of Political Prison and Torture. Material and Methods: The causes of death, age at the time of death, sex, political context of death and opportunity of repair up to June 2016 are described in 38,254 victims of the Chilean civic-military dictatorship. Results: Of the universe of 38,254 victims, 9,152 (23.9%) died until June 2016. The median age at death was 68 years. The main causes of death were malignant tumors in 28%, cardiovascular diseases in 27%, respiratory diseases in 10%, digestive diseases in 9% and external causes in 8%. Conclusions: These results can inform prevention and treatment strategies for victims of the Chilean dictatorship.Antecedentes: Los estudios sobre las consecuencias a largo plazo de la tortura en sobrevivientes en Chile solo han abordado las consecuencias para la salud mental, dejando de lado las consecuencias físicas. Objetivo: Informar las causas de muerte en el universo de víctimas de la dictadura cívico-militar chilena reconocidas por los Informes de la Comisión Nacional de Prisión Política y Tortura (CNPPT) y la Comisión Asesora para la Calificación de Detenidos Desaparecidos, Ejecutados Políticamente y Víctimas de Prisión Política y Tortura. Material y métodos: Se describen las causas de muerte, edad al momento de la muerte, sexo, contexto político de muerte y oportunidad de reparación hasta junio de 2016 en 38.254 víctimas de la dictadura cívico-militar chilena. Resultados: Del universo de 38.254 víctimas, 9.152 (23,9%) murieron hasta junio de 2016. La mediana de edad al momento de la muerte fue de 68 años. Las principales causas de muerte fueron tumores malignos en 28%, enfermedades cardiovasculares en 27%, enfermedades respiratorias en 10%, enfermedades digestivas en 9% y causas externas en 8%. Conclusiones: Estos resultados pueden informar las estrategias de prevención y tratamiento para las víctimas de la dictadura chilena

Prevalence of mood and anxiety disorders among adults seeking care in primary healthcare centers in Cordoba, Argentina.

Objective To estimate the prevalence of mood and anxiety disorders among adults seeking care in primary healthcare centers in Cordoba city, Argentina. Methods Cross-sectional analysis of a random sample of adults 18-69 years of age seeking care for general health problems in public (i.e., government-funded) primary healthcare centers in Cordoba city, Argentina in 2010-2011. Mood and anxiety disorders were assessed in the participants' lifetime, and in the last 12 months and 30 days using the World Mental Health Composite International Diagnostic Interview 3.0, and defined following the International Classification of Diseases, tenth revision. Results Overall, 1,067 participants were included in the current analysis [mean age 35.6 (SD 13.2) years, 83.7% female]. The lifetime, 12-month and 30-day prevalence of any mood or anxiety disorder was 40.4% [95% confidence interval (95%CI) 37.4-43.4%], 20.1% (17.8-22.7%) and 7.8% (6.2-9.6%), respectively. The prevalence of anxiety disorders was higher compared to mood disorders when assessed in the participants' lifetime [29.7% (95%CI 27.0-32.5%) versus 19.3% (17.0-21.8%)], and in the last 12 months [14.9% (12.8-17.2%) versus 8.7% (7.1-10.6%)] and 30 days [5.8% (4.5-7.4%) versus 2.3% (1.5-3.4%)]. Age and marital status-adjusted odds ratios for any mood or anxiety disorder in the participants' lifetime and in the last 12 months and 30 days comparing women versus men were 1.19 (95%CI 0.85-1.67), 1.70 (1.07-2.69), and 2.26 (1.02-5.00), respectively. Conclusion The prevalence of mood and anxiety disorders is high among adults seeking care in primary healthcare centers in Cordoba city, particularly among women. Integration of primary and mental health services is warranted.Facultad de Ciencias Medicas de la Universidad Nacional de Cordoba, Argentina (PROMED) Florencio Fiorini Foundation, Argentine Academy of Medicin