Pedro V. Schwartzmann

Zika Virus Meningoencephalitis in an Immunocompromised Patient

ABSTRACT The World Health Organization considers the Zika virus (ZIKV) outbreak in the Americas a global public health emergency. The neurologic complications due to ZIKV infection comprise microcephaly, meningoencephalitis, and Guillain‐Barré syndrome. We describe a fatal case of an adult patient receiving an immunosuppressive regimen following heart transplant. The patient was admitted with acute neurologic impairment and experienced progressive hemodynamic instability and mental deterioration that finally culminated in death. At autopsy, a pseudotumoral form of ZIKV meningoencephalitis was confirmed. Zika virus infection was documented by reverse trancriptase–polymerase chain reaction, immunohistochemistry, and immunofluorescence and electron microscopy of the brain parenchyma and cerebral spinal fluid. The sequencing of the viral genome in this patient confirmed a Brazilian ZIKV strain. In this case, central nervous system involvement and ZIKV propagation to other organs in a disseminated pattern is quite similar to that observed in other fatal Flaviviridae viral infections.

Rehabilitation Practice Patterns for Patients with Heart Failure: The South American Perspective

Heart failure (HF) is an important public health issue in South America. Economic impacts are substantial. Chagas heart disease is a prevalent HF etiology; it is caused by the protozoan Trypanosoma cruzi. Cardiac rehabilitation (CR) is an integral component of HF care. The benefits of CR in HF patients need to be assessed. The effectiveness and safety of CR delivery, such as home-based interventions, should be explored. Strategies to improve adherence in CR are imperative. We describe past and current CR trends for HF patients and discuss the future of this important intervention.

Addition of Protein in Carbohydrate Supplementation Does not Improve Performance of Amateur Runners in Exercise above the Anaerobic Threshold

There is no consensus in the literature that supports the inclusion of protein in the carbohydrate supplement in endurance exercise. The purpose of this study was to compare the physical performance of amateur runners under three different supplementation protocols: placebo (PLA), carbohydrate (CHO) and carbohydrate plus protein (CHO + PTN). Twelve amateur runners performed three exercise protocols on separate occasions consisting of 60 initial minutes with intensity referring to the Anaerobic Threshold (AT) and then 10% above the AT until exhaustion. Supplements (150 mL) were ingested 15 minutes before starting the activity and every 20 minutes until the first hour of exercise. Biochemical analyzes (blood glucose and lactate) and rating of perceived exertion (RPE) were measured before, during and after exercise protocols. Total caloric intake (Kcal) and macronutrients (g) were evaluated in the 24 hours preceding each exercise protocol. The time of exhaustion was higher for the CHO group when compared to the PLA group (24.6±13.6 vs. 15.2±8.9 minutes, p = 0.001) and the CHO + PTN group (24.6±13.6 vs. 18.6±8.4 minutes, p = 0.01). In general, glycemia was higher for the CHO and CHO + PTN groups when compared to the PLA group at all times whereas lactate, RPE and dietary assement did not show great differences. Our results suggest that, unlike supplementation with CHO alone, the addition of PTN in CHO supplements does not result in improved performance for the studied population and exercise intensity.

The presence of contractile reserve predicts the left ventricular systolic function improvement after prolonged oral dipyridamole use in patients with non-ischemic dilated cardiomyopathy

Despite current optimized treatment including neurohormonal blockers, inmany cases chronic heart failure (HF) is a progressive disease with high morbidity and mortality [1], indicating that new treatment options are warranted. A promising therapeutic approach is the enhancement of endogenous counter-regulatory mechanisms [2] such as adenosine, a potent endogenous arteriolar vasodilator, that may contribute to alleviate the severity of the HF syndrome [3]. Previous studies reported on the use of oral dipyridamole to promote sustained increase of the circulating levels of adenosine with beneficial effects including improvement of functional capacity and LVEF at rest, mainly in patients with ischemic DCM [4,5]. The present study aimed at investigating the impact of oral dipyridamole in a population constituted exclusively by non-ischemic DCM patients, describing the individual responses of the LV systolic function and investigating the baseline LV contractile reserve as a predictor of a positive response. In this regard, LV contractile reserve has been employed to predict prognosis [6] and the favorable outcome of the ventricular function in other clinical scenarios [7,8,9]. The studywasprospectivelyconductedon31 subjectswith chronicHF due to DCMof non-ischemic etiology being followed at the outpatient HF clinic of our institution. The eligibility criteria included DCM as a cause of HF, with mild to moderate reduction of LVEF measured by echocardiography (LVEF b 50% and≥ 35%), both genders, age between 18 and 75 years. All patients were in stable clinical condition, not requiring changes in treatment within the past 3 months. The exclusion criteria were advanced or decompensated heart failure, cardiac valve disease, asthma or chronic obstructive pulmonary disease with bronchial hyperreactivity, pregnancy or important disorder of heart rhythm that prevents the effective acquisition of ECG-synchronized scintigraphic images. Coronary artery disease was ruled out by the finding of a normal stressrest myocardial perfusion imaging or by coronary artery angiography in patients presenting an abnormal myocardial perfusion study (n= 10). Patients were submitted to a radionuclide ventriculography (RNV) at rest and during graded exercise at baseline evaluation and after a two-month period of treatment with oral dipyridamole, 75 mg TID, in addition to the standard HF pharmacological treatment. The studywas conducted according to the precepts of the Helsinki Declaration and was approved by the Research Ethics Committee of our institution. All patients gave written informed consent to participate. Multigated planar equilibrium RNVwas performed with a medium field-of-view gamma camera (Orbiter Siemens, Erlangen, Germany), with a frame rate of 16 frames/cardiac cycle. An initial rest image was followed by the exercise phase. The effort was limited by symptoms and was performed in the supine position on a cycle-ergometer, with stages of 3 min and increments of 25 W per stage; images were acquired during exercise within the last 2 min of each stage. The presence of significant LV contractile reserve in individual patients was defined as an LVEF increase during exercise≥5%. For this analysis the higher value of the LVEF during exercise was considered. The Shapiro–Wilk test was used to test whether the variables showed normal distribution. For comparison of the normally distributed variable mean values we used the Student paired test, for correlation analysis we used the Pearson correlation test and Fischers exact test was used to test the association between the nominal variables. The level of significance was set at p b 0.05 in all analyses. The software Stata® (StataCorp. 2011; Release 12. College Station, TX: StataCorp LP) was used in all analyses. Demographic and clinical characteristics of the study population at the baseline evaluation are summarized in Table 1.