Care to patients with Chagas disease (CD) is still a challenge for health systems in endemic and non-endemic countries. In the Brazilian public health system, the expansion of Primary Health Care ...(PHC) services to remote and disadvantaged areas has facilitated the access of patients with CD to medical care, however this is in a context where care gaps remain, with insufficient public funding and inadequate distribution of services. Considering the need for studies on care to patients with CD in different settings, this study explored the challenges of family doctors to provide care to patients with CD in an endemic region in Brazil with high coverage of public PHC services.
This is a qualitative study. A focus group with 15 family doctors was conducted in a municipality participating in a multicenter cohort that monitors almost two thousand patients with CD in an endemic region in Brazil. The data were analyzed using a thematic content analysis technique. The family doctors pointed out the following challenges for care to patients with CD: unsatisfactory medical training (academic education not suitable for the clinical management of the disease, and lack of training on CD in PHC); uncertainties regarding antiparasitic treatment in the chronic phase of the disease; difficulty in patients' access to specialized care when necessary, especially to the cardiologist; and trivialization of the disease by patients as a barrier to seeking care.
The access of CD patients to adequate medical care, even in regions with high coverage of public PHC services, still represents an important challenge for health systems. The results of this study may contribute to the development of strategies to improve the clinical management of CD in PHC.
Brazil ranks 5th in the number of deaths due to road injuries. This study aimed to analyze mortality and disabilities resulting from road injuries in Brazil, and to assess the Sustainable Development ...Goals (SDG) target of reducing deaths due to road injuries by 50% by 2030.
This descriptive and exploratory study used the estimates from the Global Burden of Disease 2019: indicators of mortality, premature deaths, and disabilities according to sex, age group, and type of transport for 1990, 2015, and 2019. Time trends in mortality rates from 1990 to 2019 were assessed, and a projection for 2030 was calculated, applying a linear regression model.
Deaths due to road injuries were 44,236 in 1990, and 44,529 in 2019, representing a 43% reduction in mortality rates. The highest rates were in the North, Northeast, and Midwest regions of Brazil, in males and young adults. A 77% reduction was observed in mortality rates for pedestrians and an increase of 53% for motorcyclists and of 54% for cyclists during the period. In terms of motorcycle road injuries, the mortality rate for men increased from 7.3/100,000 (1990) to 11.7/100,000 inhabitants (2019). The rates of premature deaths and disabilities were also higher for men when compared to women. Amputations, fractures, spinal cord injuries, and head trauma were the main types of road injuries. The projections for 2030 show that Brazil might not reach the SDG target.
Despite the decline in mortality rates, the 2030 Agenda's target might not be achieved.
Systemic lupus erythematosus (SLE) patients have a high risk for cardiovascular events, but few studies have evaluated the recognition and none have evaluated the control of cardiovascular risk ...factors (RF) in SLE patients. The study aims to describe the recognition and control frequencies of systemic arterial hypertension (SAH), dyslipidemia, and diabetes mellitus (DM) in SLE patients. Of the female patients with SLE, 137 answered a questionnaire focused on general knowledge of the RF for coronary artery disease (CAD) and on recognition of the risk factors that they possess. The patient’s information collected on a structured medical record was reviewed to evaluate the RF control. The mean age was 29.1 (9.6) years. Seventy patients had SAH; 85.7% recognized their condition and 71.4% had desirable blood pressure (BP) control (< 140 × 90 mmHg). From a group of 63 patients with dyslipidemia, 68.3% recognized that they had dyslipidemia and 69.8% had desirable LDL-cholesterol (< 130 mg/dL). Sixteen patients had DM; 87.5% admitted being diabetic and 50.0% had desirable glycemic control (HbA1C < 7%). Most patients were aware of presenting SAH, DM, or dyslipidemia, and the recognition frequency was higher in comparison to general population. The SAH and dyslipidemia control frequencies were higher than that described for the general population.
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, ...increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non‐spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non‐spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non‐spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.
Central illustration: The new ECG‐LVH paradigm. LAD: left axis deviation, LAFB: left anterior fascicular block, LBBB: left bundle branch block.
ObjectivesEchocardiographic (echo) screening is an important tool to estimate rheumatic heart disease (RHD) prevalence, but the natural history of screen-detected RHD remains unclear. The PROVAR+ ...(Programa de RastreamentO da VAlvopatia Reumática) study, which uses non-experts, telemedicine and portable echo, pioneered RHD screening in Brazil. We aimed to assess the mid-term evolution of Brazilian schoolchildren (5–18 years) with echocardiography-detected subclinical RHD and to assess the performance of a simplified score consisting of five components of the World Heart Federation criteria, as a predictor of unfavourable echo outcomes.SettingPublic schools of underserved areas and private schools in Minas Gerais, southeast Brazil.ParticipantsA total of 197 patients (170 borderline and 27 definite RHD) with follow-up of 29±9 months were included. Median age was 14 (12–16) years, and 130 (66%) were woman. Only four patients in the definite group were regularly receiving penicillin.Primary and secondary outcome measuresUnfavourable outcome was based on the 2-year follow-up echo, defined as worsening diagnostic category, remaining with mild definite RHD or development/worsening of valve regurgitation/stenosis.ResultsAmong patients with borderline RHD, 29 (17.1%) progressed to definite, 49 (28.8%) remained stable, 86 (50.6%) regressed to normal and 6 (3.5%) were reclassified as other heart diseases. Among those with definite RHD, 13 (48.1%) remained in the category, while 5 (18.5%) regressed to borderline, 5 (18.5%) regressed to normal and 4 (14.8%) were reclassified as other heart diseases. The simplified echo score was a significant predictor of RHD unfavourable outcome (HR 1.197, 95% CI 1.098 to 1.305, p<0.001).ConclusionThe simple risk score provided an accurate prediction of RHD status at 2-year follow-up, showing a good performance in Brazilian schoolchildren, with a potential value for risk stratification and monitoring of echocardiography-detected RHD.
The potential of chatbots for screening and monitoring COVID-19 was envisioned since the outbreak of the disease. Chatbots can help disseminate up-to-date and trustworthy information, promote healthy ...social behavior, and support the provision of health care services safely and at scale. In this scenario and in view of its far-reaching postpandemic impact, it is important to evaluate user experience with this kind of application.
We aimed to evaluate the quality of user experience with a COVID-19 chatbot designed by a large telehealth service in Brazil, focusing on the usability of real users and the exploration of strengths and shortcomings of the chatbot, as revealed in reports by participants in simulated scenarios.
We examined a chatbot developed by a multidisciplinary team and used it as a component within the workflow of a local public health care service. The chatbot had 2 core functionalities: assisting web-based screening of COVID-19 symptom severity and providing evidence-based information to the population. From October 2020 to January 2021, we conducted a mixed methods approach and performed a 2-fold evaluation of user experience with our chatbot by following 2 methods: a posttask usability Likert-scale survey presented to all users after concluding their interaction with the bot and an interview with volunteer participants who engaged in a simulated interaction with the bot guided by the interviewer.
Usability assessment with 63 users revealed very good scores for chatbot usefulness (4.57), likelihood of being recommended (4.48), ease of use (4.44), and user satisfaction (4.38). Interviews with 15 volunteers provided insights into the strengths and shortcomings of our bot. Comments on the positive aspects and problems reported by users were analyzed in terms of recurrent themes. We identified 6 positive aspects and 15 issues organized in 2 categories: usability of the chatbot and health support offered by it, the former referring to usability of the chatbot and how users can interact with it and the latter referring to the chatbot's goal in supporting people during the pandemic through the screening process and education to users through informative content. We found 6 themes accounting for what people liked most about our chatbot and why they found it useful-3 themes pertaining to the usability domain and 3 themes regarding health support. Our findings also identified 15 types of problems producing a negative impact on users-10 of them related to the usability of the chatbot and 5 related to the health support it provides.
Our results indicate that users had an overall positive experience with the chatbot and found the health support relevant. Nonetheless, qualitative evaluation of the chatbot indicated challenges and directions to be pursued in improving not only our COVID-19 chatbot but also health chatbots in general.
Chagas disease (ChD) is a neglected tropical disease that is caused by the protozoan parasite Trypanosoma cruzi and can negatively impact quality of life (QoL). This study aimed to assess and compare ...QoL between individuals with and without ChD.
This cross-sectional study was performed within a concurrent cohort study (REDS). The participants were derived from two blood donation centers: São Paulo capital and Montes Claros, Minas Gerais, Brazil. Participants with ChD were identified in blood donations by serological diagnosis between 2008 and 2010, and those without ChD were donors with negative serology identified during the same period. QoL was assessed using the World Health Organization Quality of Life-BREF questionnaire. Logistic regression was used to compare sociodemographic and clinical characteristics between the groups, and mean, standard deviation, and beta regression were used to compare QoL.
In total, 611 individuals participated in the study (328 with ChD and 283 without ChD). Participants with ChD had lower QoL in the physical (p=0.02) and psychological (p<0.01) domains than did individuals without CD.
Individuals with ChD had worse QoL perceptions. These results provide a comprehensive understanding of the impact of ChD on individuals' QoL, while also highlighting potential opportunities for improving the care and treatment of those affected.
INTRODUCTIONCardiac involvement seems to impact prognosis of COVID-19, being more frequent in critically ill patients. We aimed to assess the prognostic value of right ventricular (RV) and left ...ventricular (LV) dysfunction, evaluated by bedside echocardiography (echo), in patients hospitalized with COVID-19.METHODSPatients admitted in 2 reference hospitals in Brazil from Jul to Sept/2020 with confirmed COVID-19 and moderate/severe presentations underwent clinical and laboratory evaluation, and focused bedside echo (GE Vivid-IQ), at the earliest convenience, with remote interpretation. The association between demographics, clinical comorbidities and echo variables with all-cause hospital mortality was assessed, and factors significant at p<0.10 were put into multivariable models.RESULTSTotal 163 patients were enrolled, 59% were men, mean age 64±16 years, and 107 (66%) were admitted to intensive care. Comorbidities were present in 144 (88%) patients: hypertension 115 (71%), diabetes 61 (37%) and heart failure 22 (14%). In-hospital mortality was 34% (N=56). In univariate analysis, echo variables significantly associated with death were: LV ejection fraction (LVEF, OR=0.94), RV fractional area change (OR=0.96), tricuspid annular plane systolic excursion (TAPSE, OR=0.83) and RV dysfunction (OR=5.3). In multivariate analysis, after adjustment for clinical and demographic variables, independent predictors of mortality were age≥63 years (OR=5.53, 95%CI 1.52-20.17), LVEF<64% (OR=7.37, 95%CI 2.10-25.94) and TAPSE<18.5 mm (OR=9.43, 95% CI 2.57-35.03), and the final model had good discrimination, with C-statistic=0.83 (95%CI 0.75-0.91).CONCLUSIONMarkers of RV and LV dysfunction assessed by bedside echo are independent predictors of mortality in hospitalized COVID-19 patients, after adjustment for clinical variables.
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