West Nile Fever Virus Infection in Horses in São Paulo State, Brazil

Background: The West Nile virus (WNV) antibodies were reported in Brazil in the serum samples taken from horses and birds in the Midwest region and Paraíba state in 2008 and 2013, respectively. In 2014, the first human case was confirmed in a rural worker in the state of Piauí and, in 2018, the virus was isolated from the central nervous system of a horse with nervous symptoms in the state of Espírito Santo. The virus is a member of the Flaviviridae family of the genus Flavivirus (neurotropic), infecting several mammalian species, with humans and horses being the most susceptible. Approximately 35% of horses develop clinical signs, thus they are considered the best sentinels for this disease. The aim of this case report is to describe the first confirmed cases of West Nile Fever (WNF) in two horses in the state of São Paulo.Cases: Two horses with neurological symptoms were treated at the Veterinary Hospital of Cruzeiro do Sul University (São Paulo, SP), in 2019. Both horses came from neighboring regions that have a large Atlantic Forest preservation area and are also routes for migratory birds, known to be competent hosts for transmitting the West Nile Fever virus, such as the swallow, the falcon and the hawk. The first one had symptoms, such as weakness and sporadic seizures; however, after recovering, it was hospitalized a few days later due to kidney failure and laminitis. The second one showed incoordination, pelvic limb weakness, and was walking in circles, evolving to seizures. Both animals were euthanized, and their central nervous system samples and total blood samples were tested for rabies, herpes virus, and WNV; the first 2 tests showed negative results. Ribonucleic acids (RNA) were extracted from erythrocytes using the polymerase chain reaction (PCR) technique in-house. The WNV-specific reverse transcription-polymerase chain reaction amplification products were obtained using the nested PCR-multiplex PCR combination.Discussion: Since the 1940s, several WNF outbreaks have been reported around the world (Africa, Europe, Asia and Middle East). In the 2000s, the USA had the most amount of WNF cases reported; cases started being reported in Central and South America in the following years. The virus was identified for the first time in Brazil in 2014. Since then, our country is a route for migratory birds, with many states still having forests, several arboviruses are found such as WNF, which could become a public health problem. Both horses in the present study showed neurological signs and the horse that recovered had renal failure. Such signs are inconclusive, however, similar to those that occur in humans infected by the virus in its neurotropic form. The emergence of new diseases is an important aspect of public health. The literature is vast regarding the description of the pathogenesis, clinical signs, diagnosis, viral persistence and sequelae of WNF in humans, however, it is scarce regarding the viral persistence and sequelae of the disease in horses. Future studies are needed to understand the post-infection period in horses, as they are the most sensitive animals along with humans to this virus. Here, we report the first confirmed cases of WNF in the city of São Paulo to bring awareness about considering this disease while diagnosing horses with nervous system disorders.Keywords: encephalitis, horses, flavivirus, mosquito.Título: Infecção pelo vírus da Febre do Nilo Ocidental em equinos no Estado de São PauloDescritores: encefalite, equinos, flavivírus, mosquito

West Nile Fever Virus Infection in Horses in São Paulo State, Brazil

Background: The West Nile virus (WNV) antibodies were reported in Brazil in the serum samples taken from horses and birds in the Midwest region and Paraíba state in 2008 and 2013, respectively. In 2014, the first human case was confirmed in a rural worker in the state of Piauí and, in 2018, the virus was isolated from the central nervous system of a horse with nervous symptoms in the state of Espírito Santo. The virus is a member of the Flaviviridae family of the genus Flavivirus (neurotropic), infecting several mammalian species, with humans and horses being the most susceptible. Approximately 35% of horses develop clinical signs, thus they are considered the best sentinels for this disease. The aim of this case report is to describe the first confirmed cases of West Nile Fever (WNF) in two horses in the state of São Paulo.Cases: Two horses with neurological symptoms were treated at the Veterinary Hospital of Cruzeiro do Sul University (São Paulo, SP), in 2019. Both horses came from neighboring regions that have a large Atlantic Forest preservation area and are also routes for migratory birds, known to be competent hosts for transmitting the West Nile Fever virus, such as the swallow, the falcon and the hawk. The first one had symptoms, such as weakness and sporadic seizures; however, after recovering, it was hospitalized a few days later due to kidney failure and laminitis. The second one showed incoordination, pelvic limb weakness, and was walking in circles, evolving to seizures. Both animals were euthanized, and their central nervous system samples and total blood samples were tested for rabies, herpes virus, and WNV; the first 2 tests showed negative results. Ribonucleic acids (RNA) were extracted from erythrocytes using the polymerase chain reaction (PCR) technique in-house. The WNV-specific reverse transcription-polymerase chain reaction amplification products were obtained using the nested PCR-multiplex PCR combination.Discussion: Since the 1940s, several WNF outbreaks have been reported around the world (Africa, Europe, Asia and Middle East). In the 2000s, the USA had the most amount of WNF cases reported; cases started being reported in Central and South America in the following years. The virus was identified for the first time in Brazil in 2014. Since then, our country is a route for migratory birds, with many states still having forests, several arboviruses are found such as WNF, which could become a public health problem. Both horses in the present study showed neurological signs and the horse that recovered had renal failure. Such signs are inconclusive, however, similar to those that occur in humans infected by the virus in its neurotropic form. The emergence of new diseases is an important aspect of public health. The literature is vast regarding the description of the pathogenesis, clinical signs, diagnosis, viral persistence and sequelae of WNF in humans, however, it is scarce regarding the viral persistence and sequelae of the disease in horses. Future studies are needed to understand the post-infection period in horses, as they are the most sensitive animals along with humans to this virus. Here, we report the first confirmed cases of WNF in the city of São Paulo to bring awareness about considering this disease while diagnosing horses with nervous system disorders.Keywords: encephalitis, horses, flavivirus, mosquito.Título: Infecção pelo vírus da Febre do Nilo Ocidental em equinos no Estado de São PauloDescritores: encefalite, equinos, flavivírus, mosquito

Tentativa de suicídio entre pacientes com uso nocivo de bebidas alcoólicas internados em hospital geral Suicide attempt amongst patients with alcohol misuse admitted to a general hospital

OBJETIVO: Detectar fatores associados a histórico de tentativa de suicídio (TS) em pacientes internados em hospital geral que fazem uso nocivo de bebidas alcoólicas. MÉTODO: 4.352 pacientes admitidos consecutivamente foram avaliados utilizando-se um rastreamento do qual constavam as escalas AUDIT (Alcohol Use Disorder Identification Test) e HAD (Escala Hospitalar de Ansiedade e Depressão). Fixando-se histórico de tentativa de suicídio ao longo da vida como variável dependente, foram realizados testes do qui-quadrado e regressão logística múltipla. RESULTADOS: Uso nocivo de álcool (AUDIT > 8) foi detectado em 423 pacientes. Dentre eles, 60 (14,2%) apresentavam sintomas de depressão (HAD > 8) e 34 (8%) tinham histórico de TS. Este se associou a ser adulto jovem [razão de chance (RC) = 3,4], depressão (RC = 6,6), uso pregresso de psicofármaco (RC = 7) e ter SIDA (RC = 24). CONCLUSÃO: Os resultados fortalecem a necessidade de detectar e tratar adequadamente condições que, combinadas, aumentam consideravelmente o risco de suicídio.<br>OBJECTIVE: To detect factors associated to previous suicide attempt among patients admitted to a general hospital who presented harmful alcohol drinking pattern. METHOD: 4.352 patients consecutively admitted were screened by means of the AUDIT (Alcohol Use Disorder Identification Test) and HAD (Hospital Anxiety and Depression Scale). Qui-squared tests and multiple logistic regression were performed. RESULTS: 423 individuals presented alcohol harmful use or dependence (AUDIT > 8), 60 (14.2%) of which had depression (HAD > 8) and 34 (8%) previous suicide attempt. The latter was more frequent among young adults [odds ratio (OR) = 3.4], those who were depressed (OR = 6.6), had previously taken psychotropic medicines (OR = 7) and had AIDS (OR = 24). CONCLUSION: Our findings reinforce the need for detection and adequate treatment of conditions that, when together, strongly increase the suicide risk

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used