Myocarditis manifestations in dengue cases: A systematic review and meta-analysis

Cardiovascular Complications of Dengue Virus

Dengue virus is an arbovirus primarily transmitted by Aedes aegypti and Aedes albopictus mosquitoes and can cause a range of symptoms from mild febrile illness to severe dengue hemorrhagic fever and shock leading to cardiovascular collapse. The incidence of dengue globally has been on the rise, partially due to higher travel volumes to dengue-endemic regions and climate change allowing for an expanded range of Aedes mosquito vectors. As the incidence of dengue rises, atypical presentations of dengue are reported with increasing frequency and cardiac manifestations such as electrocardiographic abnormalities, myocarditis, and pericarditis warrant further investigation. This review will discuss our current understanding of the cardiovascular manifestations of dengue and management, explore its proposed pathogenesis, and conclude with a discussion of possible future research directions.

Pathogenesis and clinical management of arboviral diseases

Arboviral diseases are viral infections transmitted to humans through the bites of arthropods, such as mosquitoes, often causing a variety of pathologies associated with high levels of morbidity and mortality. Over the past decades, these infections have proven to be a significant challenge to health systems worldwide, particularly following the considerable geographic expansion of the dengue virus (DENV) and its most recent outbreak in Latin America as well as the difficult-to-control outbreaks of yellow fever virus (YFV), chikungunya virus (CHIKV), and Zika virus (ZIKV), leaving behind a substantial portion of the population with complications related to these infections. Currently, the world is experiencing a period of intense globalization, which, combined with global warming, directly contributes to wider dissemination of arbovirus vectors across the globe. Consequently, all continents remain on high alert for potential new outbreaks. Thus, this review aims to provide a comprehensive understanding of the pathogenesis of the four main arboviruses today (DENV, ZIKV, YFV, and CHIKV) discussing their viral characteristics, immune responses, and mechanisms of viral evasion, as well as important clinical aspects for patient management. This includes associated symptoms, laboratory tests, treatments, existing or developing vaccines and the main associated complications, thus integrating a broad historical, scientific and clinical approach.

Structural heart disease in the tropics: A comprehensive review

Structural heart disease (SHD) remains a significant global health challenge, disproportionately impacting populations in tropical regions where the burden of infectious diseases, limited healthcare infrastructure, and socio-economic disparities exacerbate the issue. The tropics are uniquely affected by conditions such as rheumatic heart disease (RHD), endomyocardial fibrosis, tropical cardiomyopathies, and pericardial diseases, often resulting from or complicated by endemic infections like malaria, dengue, tuberculosis, and parasitic diseases. Moreover, Human Immunodeficiency Virus-Associated Cardiac Disease (HIVAC) represents an emerging concern in regions with high HIV prevalence, adding complexity to the interplay between infectious and structural cardiac conditions. Despite the significant morbidity and mortality associated with SHD in these areas, research and clinical focus have often been inadequate, underscoring the need for a comprehensive synthesis of available evidence to guide future efforts. This review aims to provide a detailed examination of SHD in the tropics, with a focus on valvular, myocardial, and pericardial diseases linked to tropical infections and conditions. It highlights the epidemiology, pathophysiology, and clinical presentation of key diseases, including RHD, endocarditis, Chagas disease, and HIVAC, as well as other less commonly recognized tropical cardiomyopathies and pericardial disorders. The review also explores diagnostic challenges, advances in imaging and molecular tools, and the role of public health interventions and policy in addressing these conditions. By synthesizing current knowledge and identifying gaps, this review aims to inform research priorities, improve clinical care, and support the development of tailored prevention and management strategies for SHD in resource-constrained tropical settings.

Arbovirus exposure and subclinical myocardial dysfunction in an Indigenous population in Northeast Brazil: a cross-sectional study

BACKGROUND

Human activities, such as urbanization and climate change, have facilitated the spread of arbovirus-carrying vectors, disproportionately affecting vulnerable traditional Indigenous communities.

OBJECTIVE

To explore the relationships between subclinical myocardial dysfunction, assessed by global longitudinal strain (GLS), and comprehensive arbovirus serology in an Indigenous population, while also describing the serological and epidemiological profile of dengue, chikungunya, and Zika viruses.

METHODS

This ancillary study is part of the first phase (2016-2017) of the Project of Atherosclerosis among Indigenous Populations (PAI), a cross-sectional study involving participants from two Indigenous communities with different degrees of urbanization and a highly urbanized city in Northeast Brazil. We assessed the seroprevalence of dengue, chikungunya, and Zika viruses in the Fulni-ô Indigenous community, the less urbanized and most traditional group. Additionally, we explored the relationship between these viruses and subclinical heart disease, assessed by speckle-tracking echocardiography-derived GLS.

RESULTS

One hundred seventy-four participants were included, with a median age of 45.0 years (interquartile range 38.0-55.0). The majority were female (58.6%; n = 102). The prevalence of anti-ZIKV IgG was 95.3%; anti-DENV IgG was 85.8%, and anti-CHIKV IgG was 70.9%. GLS abnormalities were detected in nearly half (48.3%) of the cohort. However, no significant association was found between arbovirus serology and GLS.

CONCLUSIONS

The findings reveal a high prevalence of positive serology for arboviruses and a significant rate of subclinical cardiac dysfunction. There was no significant association between reduced left ventricular longitudinal strain and positive arbovirus serology, likely due to the limited number of participants with indications of acute contact with the viruses studied. However, the unprecedented and relevant results of this study are noteworthy, as they address critical public health issues, particularly in vulnerable populations. Further research is needed to explore these findings in more depth.

Prevalence of Vitamin D deficiency among individuals with Fontan palliation: A systematic review and meta-analysis

Background

Children with one functional ventricle might receive the Fontan procedure as palliative management to prolong their lives. However, the heart remains functionally univentricular, which may result in disrupted absorption of nutrients, including Vitamin D. Individuals with Fontan circulation have limited physical activity and sun exposure, which might further contribute to Vitamin D deficiency.

Objective

This study aimed to estimate the prevalence of Vitamin D deficiency among individuals with Fontan circulation and analyze probable contributing factors to it through meta-regression analysis.

Methods

A predetermined search strategy was applied on PubMed, Scopus, Scilit, Web of Science, Europe PMC, and Google Scholar to identify relevant literature as of July 2024. In general, studies reporting the prevalence or incidence of Vitamin D deficiency (<20 ng/mL) among Fontan patients were eligible for inclusion. Only cohort and cross-sectional studies were included. The pooled estimates were carried out using a restricted maximum-likelihood model and Freeman-Tukey double-arcsine transformation (FTT).

Results

Six studies were included, comprising 255 individuals with the Fontan circulation. The prevalence of Vitamin D deficiency was 51% (95% confidence interval: 35%- 67%) with noticeable heterogeneity (I 2 = 84.38%; p-Het <0.001). Extracardiac conduit/lateral tunnel (P = 0.003) was the main contributor to the heterogeneity.

Conclusion

Vitamin D deficiency is highly prevalent among individuals with Fontan palliation, highlighting the need for active monitoring and investigation into the benefits of Vitamin D supplementation.PROSPERO registration: CRD42024574724.

Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) as a Novel Score in Early Detection of Complicated Dengue Fever

INTRODUCTION

The occurrence of dengue fever presents a considerable burden for public health care in developing countries. This study aims to validate APRI as predictor score for severity of dengue fever so that catastrophic events could be prevented, and early triage can save lives.

METHODS

The retrospective cross-sectional study was done on dengue positive patients from August to November 2023. APRI score was calculated for every patient at the time of admission. The primary end-point was non-complicated disease (Simple dengue fever) vs complicated disease (dengue hemorrhagic fever and dengue shock syndrome). ROC curve was used to identify the role of APRI in prediction of dengue complication. Youden index was used to find the cut-off value of APRI along with sensitivity, specificity, positive and negative likelihood ratios. To further evaluate the role of APRI score, patients were divided into two groups, patients with APRI score greater and lesser than cut-off value. The qualitative variables among two groups were compared by chi-square testing. The predictors of complicated dengue were first determined by univariate regression analysis and then confirmed by multivariate regression analysis.

RESULTS

The mean APRI score of 135 patients was 20.06 ± 6.31. AUC for APRI score was 0.93 (p < 0.0001) indicating that APRI score calculated at the time of admission is an excellent marker in determining the complicated dengue. The cut-off value for APRI score was 9.04 (sensitivity 84.91%, specificity 89.02%, p < 0.0001). The patients with APRI <9.04 mostly developed simple dengue fever (54.1%) vs DHF (4.4%) and DSS (1.5%), while patients with APRI >9.04 had more DHF (20.7%) and DSS (12.6%) vs simple dengue fever (6.7%). None of the patient died with APRI <9.04 while the mortality rate was 3.7% in patients with APRI >9.04.

CONCLUSION

The APRI score, calculated at the time of admission, is an excellent marker in determining the severe dengue.

Global Rate of Willingness to Volunteer Among Medical and Health Students During Pandemic: Systemic Review and Meta-Analysis

BACKGROUND

During health crises such as the COVID-19 pandemic, shortages of health care workers often occur. Recruiting students as volunteers could be an option, but it is uncertain whether the idea is well-accepted.

OBJECTIVE

This study aims to estimate the global rate of willingness to volunteer among medical and health students in response to the COVID-19 pandemic.

METHODS

A systematic search was conducted on PubMed, Embase, Scopus, and Google Scholar for studies reporting the number of health students willing to volunteer during COVID-19 from 2019 to November 17, 2023. The meta-analysis was performed using a restricted maximum-likelihood model with logit transformation.

RESULTS

A total of 21 studies involving 26,056 health students were included in the meta-analysis. The pooled estimate of the willingness-to-volunteer rate among health students across multiple countries was 66.13%, with an I2 of 98.99% and P value of heterogeneity (P-Het)<.001. Removing a study with the highest influence led to the rate being 64.34%. Our stratified analyses indicated that those with older age, being first-year students, and being female were more willing to volunteer (P<.001). From highest to lowest, the rates were 77.38%, 77.03%, 65.48%, 64.11%, 62.71%, and 55.23% in Africa, Western Europe, East and Southeast Asia, Middle East, and Eastern Europe, respectively. Because of the high heterogeneity, the evidence from this study has moderate strength.

CONCLUSIONS

The majority of students are willing to volunteer during COVID-19, suggesting that volunteer recruitment is well-accepted.

Once-Weekly Somapacitan as an Alternative Management of Growth Hormone Deficiency in Prepubertal Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

Growth hormone treatment has effectively restored normal growth in children with growth hormone deficiency (GHD); however, it poses challenges in compliance with a daily growth hormone injection regimen, leading to low adherence and persistence rates. Once-weekly Somapacitan is a potential alternative for treating children with GHD. This study aimed to evaluate the efficacy, safety, and adherence of once-weekly subcutaneous Somapacitan compared to daily growth hormone injection in prepubertal children with GHD. A search for the published records was carried out on 17 October 2023 utilizing the searching feature available on PubMed, Embase, and Scopus. Primary study outcomes included (1) efficacy, measured by height velocity (HV), standard deviation score (SDs), height SDs, insulin-like growth factor-SDs (IGF-I SDs), and bone age vs. chronological age ratio (BA vs. CA); (2) safety, assessed through adverse events and injection site reactions; and (3) adherence, determined by the percentage of the sample completing treatments. Secondary outcomes evaluated disease burden scores, divided into three subgroup domains: emotional well-being, physical functional, and social well-being scores. We retrieved 6 studies that were eligible for the systematic review (417 versus 186 for intervention and control, respectively). Only 2 of the total included studies were eligible for pooled analysis (175 versus 82 for intervention and control, respectively). The efficacy profile of Somapacitan was similar to daily growth hormones, indicated by HV (mean difference (MD = 0.04; p = 0.96), HV SDs (MD = -0.71; p = 0.09), height SDs (MD = 0.11; p = 0.69), IGF-I SDs (MD = 0.06; p = 0.70), and CA vs. BA (MD = 0.67; p = 0.70)), demonstrated similar and non-inferior outcomes. Treatment adherence is 3 times higher in the Somapacitan group as compared to control (OR = 3.02; p = 0.03) with adherence rates reaching 95% and 88% for Somapacitan and Norditropin®, respectively. The disease burden measurement is similar in Somapacitan and daily growth hormones (MD = -0.62; p = 0.83), as indicated by the Growth Hormone Deficiency-Child Impact Measure. In almost all outcomes, the level of confidence is strong. The confidence level in the data is generally strong, but for CA vs. BA and the subgroup of severe adverse events with heterogeneity >50%, the confidence level is moderate. Although the efficacy and safety profiles of Somapacitan were found to be similar to those of daily growth hormones, a reduced frequency of once-weekly Somapacitan injections led to increased adherence. PROSPERO registration: CRD42023473209.