Prevalence of digestive disorders associated with imported Chagas disease (PADChI study): an observational study

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Ramírez-Olivencia, M. Arsuaga, D. Torrús, M. Belhassen-Garcia, A. Rodríguez-Guardado, M.D. Herrero-Mendoza, M. Mateo-Maestre, R.P. Campos-Rivas, F.J. Membrillo-de Novales" "autores" => array:9 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Ramírez-Olivencia" "email" => array:1 [ 0 => "germanro.76@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Arsuaga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Torrús" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "M." 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"apellidos" => "Membrillo-de Novales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Sección de Infecciosas, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Infecciosas, Servicio de Medicina Interna, Hospital Universitario La Paz-Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario Dr. Balmis de Alicante-Instituto de Investigación Sanitaria y Biomédica de ALICANTE (ISABIAL), Alicante, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Área de Gestión Clínica Medicina Interna, Hospital Universitario Central de Asturias, Grupo de Microbiología Traslacional, Instituto de Investigación del Principado de Asturias, Asturias, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevalencia de alteraciones digestivas asociadas a Chagas importado (estudio PADChI): un estudio observacional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1304 "Ancho" => 3449 "Tamanyo" => 238705 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Symptoms reported by patients with Chagas disease." ] ] ] "textoCompleto" => "IntroductionChagas disease (CD) is a parasitic disease caused by Trypanosoma cruzi. It is estimated that six to seven million people are infected worldwide. The disease was initially restricted to continental Latin America, but due to increased international travel, it is spreading to other continents.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The United States of America is the country with the highest rate of imported CD and Spain has the second highest number of cases (approximately 50,000–80,000 cases).<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>Imported CD is an important problem in nonendemic countries because it may be wrongly diagnosed by physicians who are not experts.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> What’s more, it must be detected in order to prevent secondary cases.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The infection tends to have an acute period, which may go unnoticed. Heart involvement is the most common type of organ involvement in patients with chronic infection. In addition, 10%–20% of patients with chronic infection have digestive, neurological, or combined disorders.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The gastrointestinal form is mainly observed in countries in the Southern Cone of South America.The pathogenesis of the disease consists of the destruction of neurons in the enteric nervous system, which manifests as abnormalities in the motor, secretory, and absorption functions of the gastrointestinal tract. Esophageal and colon manifestations are the most characteristic, with symptoms similar to idiopathic achalasia in the first case and progressive colonic dilation in the second. Other parts of the digestive tract may be involved (stomach, small intestine, bile duct, and/or salivary glands).A diagnosis can be established through radiological tests with contrast (esophagogram, barium enema), endoscopic tests, or functional tests (esophageal or anorectal manometry). Antitrypanosomal therapy does not seem to change the course of digestive disease and the treatment is fundamentally symptomatic. Evaluating a surgical option is necessary in some cases.The digestive discomfort that patients with CD report may be due to Chagas involvement (functional and/or structural), but may also be due to other causes. When studying these patients, it is important to know that whether due to the Chagas disease itself or the epidemiological profile, some digestive disorders, fundamentally those of infectious origin, are reported more often. For example, an association between CD and Helicobacter pylori infection has been described.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Therefore, knowing the frequency of digestive abnormalities in patients with CD may facilitate care.Though multiple studies have been conducted on CD in nonendemic countries, they often investigate epidemiological and clinical characteristics or the presence of heart disease; the prevalence of digestive disorders has not been studied in such depth.The aim of this study is to determine the prevalence of digestive disorders in imported CD at the time of first care (the first year of study). A composite objective was established: structural involvement (radiological) and/or associated intestinal comorbidity. A secondary objective was the characterization of structural involvement (esophageal, colonic, mixed).MethodsStudy design and configurationA descriptive, cross-sectional analysis of patients diagnosed with imported CD was performed. The data records were obtained from five different hospitals in Spain—all of which have specialized units for patients with tropical diseases—which agreed to participate in the study after its announcement: the Gómez Ulla Central Military Hospital, the La Paz-Carlos III University Hospital, the Dr. Balmis University General Hospital of Alicante-Institute for Healthcare and Biomedical Research of Alicante (ISABIAL, for its initials in Spanish), the University Hospital of Salamanca, and the Central University Hospital of Asturias.Data for the study were gathered from the medical records available in the electronic systems of the different hospitals from their creation until December 31, 2020. Demographic, clinical, diagnostic, and treatment data were gathered for each patient. More specifically, the symptoms reported and radiological and microbiological diagnostic tests included in the analysis were those performed during the first year of follow-up at the participating center. The microbiological tests included three stool stamps for an ova and parasite test (O&P) as well as the detection of H. pylori antigen (HPA) in feces. The imaging tests included an esophagogram, barium enema, and echocardiogram. The esophagogastroduodenal study or barium enema were interpreted according to the Rezende and Ximenes<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> classification (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Patients with a diagnosis of CD according to World Health Organization (WHO) criteria were included.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The exclusion criteria were age under 18 years and/or the simultaneous lack of the following three tests: radiological tests, O&P tests, and H. pylori tests (patients with only one or two digestive tests were able to be included).DefinitionsChagas-related structural involvement was defined as when radiological tests revealed abnormalities (Chagas disease of the esophagus or colon).Infectious comorbidity was defined as when tests for detecting H. pylori and/or O&P tests in feces were positive.The terms “disorders” or “digestive abnormalities in patients with Chagas disease” were defined as when there was Chagas-related structural involvement, infectious comorbidity, or both.Abnormalities on cardiologic tests were defined as the presence of pathological changes in the electrocardiogram (ECG) or echocardiogram (ECHO). These included abnormalities related or not related to Chagas disease.Sample sizeTo calculate the sample size, a binomial distribution of the unknown population size was assumed, with an expected prevalence of between 1% and 5% (based on previous reports)12 and an accepted absolute error of 2%. The estimated sample size was 174–424 patients.Statistical analysisThe data were entered into an Excel spreadsheet and transferred to Stata/IC version 12.1. Categorical variables were summarized as frequencies (percentages) and continuous variables were summarized as means. All prevalences were evaluated through estimators using the Wilson method. The prevalence of gastrointestinal disorders in patients with CD was calculated based on all patients included in the study. The prevalence of Chagas-related structural involvement was evaluated based on patients who had at least one radiological test performed. The prevalence of infectious comorbidity was determined based on patients who had any microbiological test performed.The statistical association between Chagas-related structural involvement and abnormalities on cardiologic tests or presence of gastrointestinal symptoms was evaluated. The statistical association between infectious comorbidity and digestive symptoms was also investigated. Tests of the association among variables were evaluated by means of the chi-square test (Fisher’s exact test) and logistic regression. A value of p < 0.05 was considered significant.ResultsInitially, a total of 1,216 medical records of patients diagnosed with CD were reviewed. Of them, 752 (61.84%) were rejected as they did not have simultaneous radiological, fecal parasite, and HPA tests.The analysis was conducted on 464 patients: 141 (30.39%) were men and the median age was 42.71 years (interquartile range (IQR) 36–59 years). The sociodemographic and clinical characteristics of patients included are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Medical recordTreatment for CD had been administered before the study enrollment date in 43 (9.27%) patients. Fifty-nine patients (12.72%) had some risk factor for cardiovascular disease such as hypertension, diabetes, or dyslipidemia (alone or combined). Information on the ECG was available for 427 patients and on the ECHO for 384 patients. Abnormalities on the cardiologic tests were present in 75 patients.A medical history of abdominal surgery or non-Chagas digestive disorders were reported in 45 (9.70%) patients, mainly lithiasis/cholecystectomy (16 (3.45%)), liver disease (11 (2.37%)), hiatal hernia (9 (1.94%)), peptic ulcer disease (8 (1.72%)), and appendectomy (8 (1.72%)). There were 232 patients with gastrointestinal symptoms, with the most common complains being constipation and pyrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A total of 392 patients (84.48%) had a digestive radiological test (esophagogram and/or barium enema); 396 patients (85.34%) had an O&P test in feces; and 118 patients (25.43%) had a HPA test. Radiological, O&P, and HPA tests had been performed jointly in 96 patients (20.69%).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The prevalence of Chagas-related structural involvement was 23.28% (108/464) with a 95% confidence interval (95%CI) (19.41–27.13). CD-related esophageal abnormalities were present in 63 of 380 patients who had had an esophagogram. The CD-related esophageal disease classification was as follows: group 0: 317 patients (68.32%); group I: 52 (11.21%); group II: 7 (1.51%); group III: 3 (0.65%), and group IV: 1 (0.22%).Colonic abnormalities were found in 84 of 378 patients with a barium enema; 294 (63.6%), 57 (12.28%), and 27 (5.82%) patients were classified into group 0, group 1, and group 2, respectively. Mixed Chagas-related structural involvement (esophageal and colonic abnormalities) was present in 39 patients (36.11% of patients with Chagas-related structural involvement). Chagas-related structural involvement was present in 81 patients without abnormalities on cardiologic tests (20.82%) and in 27 patients with abnormalities on cardiologic tests (36%) (odds ratio (OR) 2.14, 95%CI 1.26–3.64, p = 0.004). Chagas-related structural involvement was present in 81 patients with digestive symptoms (34.91%) whereas it was present in only 27 asymptomatic patients (11.64%) (OR 4.07, 95%CI 2.51−6.61, p < 0.001) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The prevalence of infectious comorbidity was 40.73% (189/464, 95%CI 36.25–45.22). The HPA test was positive in 46 patients (38.98% of patients analyzed). Of them, 16 (34.78%) had digestive symptoms (dyspepsia or pyrosis). Information was not gathered on whether the attending clinician attributed the symptoms to H. pylori infection. A parasitic finding of any type was reported in 155 patients (39.14% of patients analyzed) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The description of the parasites found in the feces examination is as follows: Blastocystis hominis, 118 patients (29.80%), Endolimax spp 28 (7.07%), Entamoeba spp 25 (6.13%), Dientamoeba fragilis 14 (3.54%), Giardia intestinalis 12 (3.03%), Strongyloides stercoralis 8 (2.02%), Iodamoeba bütschlii 2 (0.51%), Enterobius vermicularis 2 (0.51%), and Ancylostoma duodenale 1 (0.25%). Twelve patients had simultaneous positive HPA and O&P tests. There were no differences between symptomatic (43.10%) and asymptomatic patients (38.36%) (OR 1.22; 95%CI 0.84−1.76; p = 0.299). Only 24 patients had clearly pathogenic parasites (Giardia intestinalis, Strongyloides stercoralis, Enterobius vermicularis, and Ancylostoma duodenale). The prevalence of infectious comorbidity calculated by excluding parasites that were not clearly pathogenic was 14.87% (69/464, 95%CI 11.62–18.12).Globally, the prevalence of gastrointestinal abnormalities in patients with imported CD was 57.76% (268/464, 95%CI 53.25–62.27). The prevalence of simultaneous structural involvement and infectious comorbidity was 6.25% (29/464, 95%CI 4.04–8.46).DiscussionThe Spanish healthcare system is complex and management and decision-making is the responsibility of the various autonomous communities. There is no consensus on screening and follow-up on Chagas-related digestive involvement, despite the availability of resources for diagnosis, treatment, and follow-up on cases.In 2009, the Spanish Ministry of Health and Social Policy published guidelines on CD.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> They concluded that routinely conducting tests aimed at identifying digestive involvement may not be indicated. These guidelines were based on patient series<a class="elsevierStyleCrossRef" href="#bib0065">13</a> which reported that just 3% of patients had esophageal manometric compromise (considered the most useful technique for detecting early organ failure). One year later, entirely different indications were published in a special article by Pinazo et al.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The authors affirmed that “Given the existence of digestive tract alterations in up to 11% of all asymptomatic patients, radiological evaluation is recommended in all patients with T. cruzi infection.” Nevertheless, other studies conducted by the same working group<a class="elsevierStyleCrossRef" href="#bib0075">15</a> indicated that radiological abnormalities were detected almost exclusively in symptomatic patients.The recommendations of the Imported Diseases Study Group, on behalf of the Spanish Society of Infectious Diseases and Clinical Microbiology (GEPI-SEIMC, for its initials in Spanish<a class="elsevierStyleCrossRef" href="#bib0080">16</a>) concluded that radiological tests should only be indicated in the case of digestive symptoms compatible with disease for detecting megasyndromes (megacolon, megaesophagus, etc.). From an international point of view, the Pan American Health Organization (PAHO) guidelines, published in 2018, established recommendations on the diagnosis and treatment of patients with T. cruzi infection. They did not suggest recommendations related to investigating organ damage or detecting digestive disorders.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>The indications for the diagnosis and management of gastrointestinal CD based on recommendations for the screening and diagnosis of CD in the United States of America<a class="elsevierStyleCrossRef" href="#bib0090">18</a> refer to the work by Pinazo et al.,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> which recommends a systematic study. Other more detailed guidelines on the clinical diagnosis (diagnosis and classification of the different disease stages) are also needed.The prevalence of digestive disorders in CD at the time of first care is high in this study. According to classic studies, up to 10% of patients present with digestive involvement during the chronic phase of the disease, but these data are based on series from endemic areas and usually only refer to megasyndromes. Salvador et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> conducted an excellent review of the main clinical series of patients with chronic CD.Other recent studies have found a greater incidence in digestive disorders (in endemic areas up to 70%<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; in non-endemic areas up to 21%<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a>), and some of them include structural involvement, infectious comorbidities, and/or series from non-endemic areas.<a class="elsevierStyleCrossRefs" href="#bib0075">15,23</a> The high prevalence of CD-related digestive disorders may be the result of up-to-date radiological diagnostic techniques, the introduction of systemic detection tests in clinical practice, and/or combined assessment criteria.Variations in the results of different studies is probably also related to the different prevalence of Chagas disease according to geographical region. This study included a large population and analyzed not only structural changes but also infectious comorbidity associated with CD.The main gastrointestinal disorder in this study was related to infectious comorbidity. These results must be analyzed with caution because some parasites found in this study are not considered pathogenic. For example, the pathogenicity in humans of Endolimax spp or Blastocystis spp is a controversial topic.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> However, the presence of non-pathogenic parasites in feces is considered a good marker of fecal-oral contamination due to food or water (potential exposure to other pathogenic parasites) and patients are generally treated with antiparasitic drugs if they have symptoms. The interactions between colonic bacterial communities and parasites considered nonpathogenic could alter the microbial profile and be responsible for some digestive symptoms.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In addition to this, given that this study was conducted based on medical records, it was not possible to distinguish species of Entamoeba spp (histolytica vs. other non-pathogenic species) in most cases.The prevalence of Strongyloides stercoralis infection in this study differed from others<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> because only results from feces were collected; data from other serological tests were not described. A high prevalence of H. pylori infection has been reported in patients with CD in endemic regions (up to 77%) and it is responsible for esophagitis, chronic gastritis, peptic ulcer, and intestinal metaplasia. Gastritis is associated with H. pylori infection regardless of CD, but differences in mononuclear and polymorphonuclear cell infiltration have been reported.<a class="elsevierStyleCrossRefs" href="#bib0040">8,28</a> Few studies have published the prevalence of H. pylori infection in patients with CD.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> According to the results of this work, the detection of H. pylori in the systematic screening of patients with CD could be proposed.The prevalence of Chagas-related structural involvement diagnosed through radiological procedures was also significant (around one out of every five patients) in this study. Nevertheless, as the study analyzed the results out of all tests conducted, the real proportion could be lower if they had been systematically ordered (including in asymptomatic patients). Despite this, a non-negligible percentage of abnormalities were also found in asymptomatic patients. In addition, it must be taken into account that manometric findings, which are more sensitive for detecting Chagas abnormalities, were not available in this study. This finding is relevant given that imaging tests are often considered burdensome and are not without risk (especially a barium enema). It is common to avoid them to prevent cases of adverse events reported during the barium sulfate diagnostic procedure, such as allergic reactions or bowel perforation. However, these complications are considered rare or very rare,<a class="elsevierStyleCrossRefs" href="#bib0150">30–32</a> and thus they do not seem to be a sufficient reason for systematically refraining from conducting these tests in asymptomatic patients. In this study, no adverse event reports were collected.Financial reasons are also typically used to justify not conducting radiological tests. The approximate unit cost of an esophagogram and a barium enema is Є55.38 and Є83.07, respectively, in the Spanish National Health System.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> A cost-benefit analysis of the radiological screening for CD is needed. At this point, it is necessary to reflect on the potential benefit that a systematic radiological digestive assessment in all patients regardless of the presence of symptoms would have (which could lead to greater knowledge of the disease's natural history as well as the detection of asymptomatic morphological abnormalities that could justify indicating trypanocidal therapy in order to halt disease progression and/or symptoms development) and the harm posed by the increase in costs, the infrequent but possible side effects, and the inevitable ethical question of whether to screen and establish a diagnosis for a disease with a small treatment arsenal.In this study, the presence of digestive symptoms or heart disease was associated with infectious comorbidity and thus, they could be considered valuable clues for decision-making. Some studies on CD conducted in Spain showed a prevalence of gastrointestinal involvement (only structural changes) of 0.9%–11%.<a class="elsevierStyleCrossRefs" href="#bib0065">13,34,35</a> The differences between these studies are linked to sample size and gastrointestinal assessment. The prevalence of Chagas-related structural involvement is similar to what was described by Pinazo et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> However, this series is retrospective and includes a greater proportion of asymptomatic patients.LimitationsThe main limitations of this study are related to the nature of retrospective studies based on medical records. The number of medical records excluded is noteworthy and not explained by the size of the pediatric population. The lack of information on radiological and microbiological tests may be the main reason for excluding a large proportion of medical records.Immigrants are a group of patients who face difficulties accessing the healthcare system and difficulties adhering to follow-up and treatment; they are lost at a greater frequency in the first year of follow-up.<a class="elsevierStyleCrossRefs" href="#bib0180">36–38</a> Cultural, economic, and social barriers impede continued follow-up on patients. Therefore, in this study, they were likely diagnosed with CD but did not complete follow-up. What’s more, this situation could have worsened during the two years of the COVID-19 pandemic.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>The differences in routine clinical practice and recommendations among centers made it so that the routine radiological or microbiological tests were not the same. A definitive prevalence out of all patients in this study was not able to be obtained, but rather a prevalence out of all patients who had the same tests.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060">a)In regard to radiological tests, some centers where they were not routinely conducted only offered them to symptomatic patients. It is reasonable to argue that structural changes in the gastrointestinal tract due to CD would produce more symptoms than no changes. Therefore, the hypothesis could be proposed that the prevalence of radiological changes would have been lower if all asymptomatic patients had been included in the analysis.</li><li class="elsevierStyleListItem" id="lsti0065">b)The situation with microbiological tests is different. Asymptomatic carriers for digestive parasites and H. pylori have been described. In this study, the proportion of patients with infectious digestive comorbidity (IDC) may be higher (mainly asymptomatic carriers of H. pylori without HPA). The latter situation represents approximately 75% of these cases. On the other hand, it would be expected that variations in the prevalence of IDC in this study (related to asymptomatic carriers of parasites) would not be affected, given that individuals not analyzed for parasites represented only 15% of the sample.</li></ul>This study did not use a chronic cardiac CD classification system. There are various classification systems for chronic CD based on the ECG, chest x-ray, echocardiogram, and clinical symptoms. They have disparities that hinder comparisons among clinical studies and management guidelines.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> In addition, whereas some changes on the ECG or ECHO are considered specific, others may be related to cardiovascular risk factors. However, the association between these abnormal findings and Chagas-related digestive involvement may support the decision to order the pertinent digestive radiological studies in asymptomatic patients.ConclusionsThe prevalence of CD-associated digestive disorders is high. Therefore, it is recommendable to rule out the presence of infectious diseases (mainly parasitic diseases and H. pylori infection). It would be desirable to rule out structural involvement in all symptomatic patients and it should be considered and offered to asymptomatic patients as well.Ethics approval declarationThis study was conducted pursuant to the Declaration of Helsinki on research in human subjects. This research was approved by the Gómez Ulla Hospital research committee (DREC-HCDGU, PADChI Study, Code 65/19). The Gómez Ulla Hospital research committee granted an exemption to obtaining informed consent.FundingThis research has not received specific funding from agencies in the public, commercial, or non-profit sectors.Conflicts of interestThe authors declare that they do not have any conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1881014" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1630393" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1881013" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1630392" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and configuration" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Definitions" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Sample size" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Medical record" ] ] ] 7 => array:3 [ "identificador" => "sec0045" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Ethics approval declaration" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-09-12" "fechaAceptado" => "2023-01-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1630393" "palabras" => array:4 [ 0 => "Chagas disease" 1 => "Trypanosoma cruzi" 2 => "Digestive disorder" 3 => "Prevalence" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1630392" "palabras" => array:4 [ 0 => "Enfermedad de Chagas" 1 => "Trypanosoma cruzi" 2 => "Alteraciones digestivas" 3 => "Prevalence" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundChagas disease (CD) is a parasitic disease caused by Trypanosoma cruzi, in which up to 10–20% of those affected may suffer digestive disorders. Multiple studies have been carried out on CD in non-endemic countries, mainly related to cardiological involvement. However, digestive disorders have not been analyzed in such depth. The objective of the study was to determine the prevalence of digestive disorders in imported CD at the time of first care. MethodsAn observational cross-sectional descriptive analysis of imported CD was performed. Chagasic structural damage and infectious digestive comorbidity were evaluated. The association between Chagasic structural damage and heart disease in Chagas patients was also investigated. ResultsAfter reviewing a total of 1,216 medical records, those of 464 patients were selected for analysis. Globally, the prevalence of digestive disorders in imported Chagas was 57.76%, 95% CI (53.25–62.27). The prevalence of comorbidity of infectious diseases was 40.73% CI 95% (36.25–45.22). Colonic abnormalities were found in 84 of 378 barium enema patients. CD-related esophageal abnormalities were present in 63 of 380 patients studied with esophagogram. ConclusionsThe prevalence of digestive disorders associated with CD is high, so the presence of infectious diseases (mainly parasitic and H. pylori infection) should be ruled out. It is important to exclude structural involvement in all symptomatic patients, and asymptomatic patients should also be considered and offered." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesLa enfermedad de Chagas (EC) es una enfermedad parasitaria causada por Trypanosoma cruzi, en la que hasta un 10–20% de los afectados pueden sufrir trastornos digestivos. Se han realizado múltiples estudios sobre la EC en países no endémicos, principalmente relacionados con el compromiso cardiológico. Sin embargo, los trastornos digestivos no se han analizado con tanta profundidad. El objetivo del estudio fue determinar la prevalencia de los trastornos digestivos en la EC importada en el momento de la primera atención. MétodosSe realizó un análisis descriptivo transversal observacional de la EC importada. Se evaluó el daño estructural chagásico y la comorbilidad digestiva infecciosa. También se investigó la asociación entre el daño estructural chagásico y la enfermedad cardíaca en pacientes con Chagas. ResultadosTras la revisión de un total de 1.216 historias clínicas, se seleccionaron para el análisis las de 464 pacientes. A nivel global, la prevalencia de trastornos digestivos en Chagas importado fue del 57,76% IC95% (53,25–62,27). La prevalencia de comorbilidad de enfermedades infecciosas fue de 40,73% IC95% (36,25–45,22). Se encontraron anomalías colónicas en 84 de 378 pacientes con enema de bario. Las anomalías esofágicas relacionadas con la EC estuvieron presentes en 63 de 380 pacientes estudiados con esofagograma. ConclusionesLa prevalencia de trastornos digestivos asociados a EC es alta, por lo que conviene descartar la presencia de enfermedades infecciosas (principalmente parasitarias e infección por H. pylori). Es importante excluir afectación estructural en todos los pacientes sintomáticos, y también se debería considerar y ofrecer a pacientes asintomáticos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1304 "Ancho" => 3449 "Tamanyo" => 238705 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Symptoms reported by patients with Chagas disease." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Esophageal disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Group 0: asymptomatic cases without radiological abnormalities which have some degree of denervation according to what is established by pharmacological methods. Air in the gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0010">•Group I: esophagus with an apparently normal caliber on the radiological study. Slow transit, with minimal retention on x-rays at one minute from swallowing the contrast medium. The contrast medium forms a small residual column, level on the top end and perpendicular to the esophageal walls. Air in the gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0015">•Group II: esophagus with a small-moderate increase in caliber. Notable retention of contrast medium. Presence of a residual column of variable height. Frequent presence of tertiary waves with or without hypotonia of the lower esophageal sphincter. Absence of air in the gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0020">•Group III: esophagus with a large increase in diameter. Reduced motor activity. Hypotonia of the lower esophageal sphincter. Significant retention of contrast medium. Absence of air in the gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0025">•Group IV: dolichomegaesophagus with large capacity of atonic, elongated retention. Absence of gas in the gastric fundus.</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colon disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">•Group 0: no abnormalities in the barium enema.</li><li class="elsevierStyleListItem" id="lsti0035">•Group 1: patients with dolichocolon.</li><li class="elsevierStyleListItem" id="lsti0040">•Group 2: patients with dolicomegacolon, defined as:</li><li class="elsevierStyleListItem" id="lsti0045">a)Descending colon >6.5 cm in diameter.</li><li class="elsevierStyleListItem" id="lsti0050">b)Ascending colon >8 cm in diameter.</li><li class="elsevierStyleListItem" id="lsti0055">c)Patients with a cecum >12 cm in diameter.</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Rezende<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and Ximenes<a class="elsevierStyleCrossRef" href="#bib0050">10</a> classification for the interpretation of the esophagogastroduodenal study and barium enema." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">141 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">323 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age groups (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18−34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35−44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45−54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">193 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55−64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Country of birth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Argentina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bolivia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">426 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ecuador \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Honduras \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paraguay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of first-degree family members with Chagas disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">247 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior treatment for Chagas disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">269 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown/not reported \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">152 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive abnormalities (non-Chagas) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.70 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Sociodemographic and clinical characteristics of the patients included." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95%CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sociodemographic characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.67−1.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.761 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age; reference age group: 18−34 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35−44 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15−4.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.774 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45−54 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29−6.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.695 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55−64 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.34−7.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.542 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.42−11.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.356 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of family members affected (for each member) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.91−1.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.379 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.11−1.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.112 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of any cardiovascular risk factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.61−2.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.676 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.51−6.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strictly pathogenic infectious comorbidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49−1.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.743 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.26−3.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Univariate analysis of Chagas-related structural involvement and sociodemographic and clinical characteristics." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"></th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infectious comorbidity</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Strictly pathogenic infectious comorbidity</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95%CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95%CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sociodemographic characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53−1.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.278 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.32−1.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.096 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age; reference age group: 18−34 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35−44 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.04−1.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.694 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.96−0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.467 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45−54 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.96−1.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.642 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−2.14−0.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.287 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55−64 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.20−1.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.898 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−2.67−0.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.101 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−1.54−1.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.813 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−0.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−2.11−0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.460 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of family members affected<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (for each member) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.15−1.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77−1.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.652 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Characteristics of the previous medical history</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antichagas treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.43−1.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.754 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.41−2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.941 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of any cardiovascular risk factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.73−2.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.401 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.78−3.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.209 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Digestive symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.84−1.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.299 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00−2.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.052 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.58−1.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.888 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.64−2.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.513 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Spurious relationship." ] ] ] "descripcion" => array:1 [ "en" => "Univariate analysis of infectious comorbidity; 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Original article

Prevalence of digestive disorders associated with imported Chagas disease (PADChI study): an observational study

Prevalencia de alteraciones digestivas asociadas a Chagas importado (estudio PADChI): un estudio observacional

G. Ramírez-Olivenciaa,b,

Corresponding author

germanro.76@gmail.com

Corresponding author.

, M. Arsuagac, D. Torrúsd, M. Belhassen-Garciae, A. Rodríguez-Guardadof, M.D. Herrero-Mendozab, M. Mateo-Maestreg, R.P. Campos-Rivash, F.J. Membrillo-de Novalesa

a Sección de Infecciosas, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain

b Servicio de Medicina Interna, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain

c Sección de Infecciosas, Servicio de Medicina Interna, Hospital Universitario La Paz-Carlos III, Madrid, Spain

d Servicio de Medicina Interna, Hospital General Universitario Dr. Balmis de Alicante-Instituto de Investigación Sanitaria y Biomédica de ALICANTE (ISABIAL), Alicante, Spain

e Servicio de Medicina Interna, Hospital Universitario de Salamanca, Salamanca, Spain

f Área de Gestión Clínica Medicina Interna, Hospital Universitario Central de Asturias, Grupo de Microbiología Traslacional, Instituto de Investigación del Principado de Asturias, Asturias, Spain

g Servicio de Microbiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain

h Servicio de Radiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain

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        "titulo" => "Prevalencia de alteraciones digestivas asociadas a Chagas importado &#40;estudio PADChI&#41;&#58; un estudio observacional"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Symptoms reported by patients with Chagas disease&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0060" class="elsevierStylePara elsevierViewall">Chagas disease &#40;CD&#41; is a parasitic disease caused by <span class="elsevierStyleItalic">Trypanosoma cruzi</span>&#46; It is estimated that six to seven million people are infected worldwide&#46; The disease was initially restricted to continental Latin America&#44; but due to increased international travel&#44; it is spreading to other continents&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The United States of America is the country with the highest rate of imported CD and Spain has the second highest number of cases &#40;approximately 50&#44;000&#8211;80&#44;000 cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Imported CD is an important problem in nonendemic countries because it may be wrongly diagnosed by physicians who are not experts&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> What&#8217;s more&#44; it must be detected in order to prevent secondary cases&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The infection tends to have an acute period&#44; which may go unnoticed&#46; Heart involvement is the most common type of organ involvement in patients with chronic infection&#46; In addition&#44; 10&#37;&#8211;20&#37; of patients with chronic infection have digestive&#44; neurological&#44; or combined disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The gastrointestinal form is mainly observed in countries in the Southern Cone of South America&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The pathogenesis of the disease consists of the destruction of neurons in the enteric nervous system&#44; which manifests as abnormalities in the motor&#44; secretory&#44; and absorption functions of the gastrointestinal tract&#46; Esophageal and colon manifestations are the most characteristic&#44; with symptoms similar to idiopathic achalasia in the first case and progressive colonic dilation in the second&#46; Other parts of the digestive tract may be involved &#40;stomach&#44; small intestine&#44; bile duct&#44; and&#47;or salivary glands&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A diagnosis can be established through radiological tests with contrast &#40;esophagogram&#44; barium enema&#41;&#44; endoscopic tests&#44; or functional tests &#40;esophageal or anorectal manometry&#41;&#46; Antitrypanosomal therapy does not seem to change the course of digestive disease and the treatment is fundamentally symptomatic&#46; Evaluating a surgical option is necessary in some cases&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The digestive discomfort that patients with CD report may be due to Chagas involvement &#40;functional and&#47;or structural&#41;&#44; but may also be due to other causes&#46; When studying these patients&#44; it is important to know that whether due to the Chagas disease itself or the epidemiological profile&#44; some digestive disorders&#44; fundamentally those of infectious origin&#44; are reported more often&#46; For example&#44; an association between CD and <span class="elsevierStyleItalic">Helicobacter pylori</span> infection has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Therefore&#44; knowing the frequency of digestive abnormalities in patients with CD may facilitate care&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Though multiple studies have been conducted on CD in nonendemic countries&#44; they often investigate epidemiological and clinical characteristics or the presence of heart disease&#59; the prevalence of digestive disorders has not been studied in such depth&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The aim of this study is to determine the prevalence of digestive disorders in imported CD at the time of first care &#40;the first year of study&#41;&#46; A composite objective was established&#58; structural involvement &#40;radiological&#41; and&#47;or associated intestinal comorbidity&#46; A secondary objective was the characterization of structural involvement &#40;esophageal&#44; colonic&#44; mixed&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and configuration</span><p id="par0100" class="elsevierStylePara elsevierViewall">A descriptive&#44; cross-sectional analysis of patients diagnosed with imported CD was performed&#46; The data records were obtained from five different hospitals in Spain&#8212;all of which have specialized units for patients with tropical diseases&#8212;which agreed to participate in the study after its announcement&#58; the G&#243;mez Ulla Central Military Hospital&#44; the La Paz-Carlos III University Hospital&#44; the Dr&#46; Balmis University General Hospital of Alicante-Institute for Healthcare and Biomedical Research of Alicante &#40;ISABIAL&#44; for its initials in Spanish&#41;&#44; the University Hospital of Salamanca&#44; and the Central University Hospital of Asturias&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Data for the study were gathered from the medical records available in the electronic systems of the different hospitals from their creation until December 31&#44; 2020&#46; Demographic&#44; clinical&#44; diagnostic&#44; and treatment data were gathered for each patient&#46; More specifically&#44; the symptoms reported and radiological and microbiological diagnostic tests included in the analysis were those performed during the first year of follow-up at the participating center&#46; The microbiological tests included three stool stamps for an ova and parasite test &#40;O&#38;P&#41; as well as the detection of <span class="elsevierStyleItalic">H&#46; pylori</span> antigen &#40;HPA&#41; in feces&#46; The imaging tests included an esophagogram&#44; barium enema&#44; and echocardiogram&#46; The esophagogastroduodenal study or barium enema were interpreted according to the Rezende and Ximenes<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> classification &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with a diagnosis of CD according to World Health Organization &#40;WHO&#41; criteria were included&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The exclusion criteria were age under 18 years and&#47;or the simultaneous lack of the following three tests&#58; radiological tests&#44; O&#38;P tests&#44; and <span class="elsevierStyleItalic">H&#46; pylori</span> tests &#40;patients with only one or two digestive tests were able to be included&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Definitions</span><p id="par0115" class="elsevierStylePara elsevierViewall">Chagas-related structural involvement was defined as when radiological tests revealed abnormalities &#40;Chagas disease of the esophagus or colon&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Infectious comorbidity was defined as when tests for detecting <span class="elsevierStyleItalic">H&#46; pylori</span> and&#47;or O&#38;P tests in feces were positive&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The terms &#8220;disorders&#8221; or &#8220;digestive abnormalities in patients with Chagas disease&#8221; were defined as when there was Chagas-related structural involvement&#44; infectious comorbidity&#44; or both&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Abnormalities on cardiologic tests were defined as the presence of pathological changes in the electrocardiogram &#40;ECG&#41; or echocardiogram &#40;ECHO&#41;&#46; These included abnormalities related or not related to Chagas disease&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Sample size</span><p id="par0135" class="elsevierStylePara elsevierViewall">To calculate the sample size&#44; a binomial distribution of the unknown population size was assumed&#44; with an expected prevalence of between 1&#37; and 5&#37; &#40;based on previous reports&#41;12 and an accepted absolute error of 2&#37;&#46; The estimated sample size was 174&#8211;424 patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0140" class="elsevierStylePara elsevierViewall">The data were entered into an Excel spreadsheet and transferred to Stata&#47;IC version 12&#46;1&#46; Categorical variables were summarized as frequencies &#40;percentages&#41; and continuous variables were summarized as means&#46; All prevalences were evaluated through estimators using the Wilson method&#46; The prevalence of gastrointestinal disorders in patients with CD was calculated based on all patients included in the study&#46; The prevalence of Chagas-related structural involvement was evaluated based on patients who had at least one radiological test performed&#46; The prevalence of infectious comorbidity was determined based on patients who had any microbiological test performed&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The statistical association between Chagas-related structural involvement and abnormalities on cardiologic tests or presence of gastrointestinal symptoms was evaluated&#46; The statistical association between infectious comorbidity and digestive symptoms was also investigated&#46; Tests of the association among variables were evaluated by means of the chi-square test &#40;Fisher&#8217;s exact test&#41; and logistic regression&#46; A value of <span class="elsevierStyleItalic">p</span>&#8239;&#60;&#8239;0&#46;05 was considered significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0150" class="elsevierStylePara elsevierViewall">Initially&#44; a total of 1&#44;216 medical records of patients diagnosed with CD were reviewed&#46; Of them&#44; 752 &#40;61&#46;84&#37;&#41; were rejected as they did not have simultaneous radiological&#44; fecal parasite&#44; and HPA tests&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The analysis was conducted on 464 patients&#58; 141 &#40;30&#46;39&#37;&#41; were men and the median age was 42&#46;71 years &#40;interquartile range &#40;IQR&#41; 36&#8211;59 years&#41;&#46; The sociodemographic and clinical characteristics of patients included are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Medical record</span><p id="par0160" class="elsevierStylePara elsevierViewall">Treatment for CD had been administered before the study enrollment date in 43 &#40;9&#46;27&#37;&#41; patients&#46; Fifty-nine patients &#40;12&#46;72&#37;&#41; had some risk factor for cardiovascular disease such as hypertension&#44; diabetes&#44; or dyslipidemia &#40;alone or combined&#41;&#46; Information on the ECG was available for 427 patients and on the ECHO for 384 patients&#46; Abnormalities on the cardiologic tests were present in 75 patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A medical history of abdominal surgery or non-Chagas digestive disorders were reported in 45 &#40;9&#46;70&#37;&#41; patients&#44; mainly lithiasis&#47;cholecystectomy &#40;16 &#40;3&#46;45&#37;&#41;&#41;&#44; liver disease &#40;11 &#40;2&#46;37&#37;&#41;&#41;&#44; hiatal hernia &#40;9 &#40;1&#46;94&#37;&#41;&#41;&#44; peptic ulcer disease &#40;8 &#40;1&#46;72&#37;&#41;&#41;&#44; and appendectomy &#40;8 &#40;1&#46;72&#37;&#41;&#41;&#46; There were 232 patients with gastrointestinal symptoms&#44; with the most common complains being constipation and pyrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A total of 392 patients &#40;84&#46;48&#37;&#41; had a digestive radiological test &#40;esophagogram and&#47;or barium enema&#41;&#59; 396 patients &#40;85&#46;34&#37;&#41; had an O&#38;P test in feces&#59; and 118 patients &#40;25&#46;43&#37;&#41; had a HPA test&#46; Radiological&#44; O&#38;P&#44; and HPA tests had been performed jointly in 96 patients &#40;20&#46;69&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The prevalence of Chagas-related structural involvement was 23&#46;28&#37; &#40;108&#47;464&#41; with a 95&#37; confidence interval &#40;95&#37;CI&#41; &#40;19&#46;41&#8211;27&#46;13&#41;&#46; CD-related esophageal abnormalities were present in 63 of 380 patients who had had an esophagogram&#46; The CD-related esophageal disease classification was as follows&#58; group 0&#58; 317 patients &#40;68&#46;32&#37;&#41;&#59; group I&#58; 52 &#40;11&#46;21&#37;&#41;&#59; group II&#58; 7 &#40;1&#46;51&#37;&#41;&#59; group III&#58; 3 &#40;0&#46;65&#37;&#41;&#44; and group IV&#58; 1 &#40;0&#46;22&#37;&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Colonic abnormalities were found in 84 of 378 patients with a barium enema&#59; 294 &#40;63&#46;6&#37;&#41;&#44; 57 &#40;12&#46;28&#37;&#41;&#44; and 27 &#40;5&#46;82&#37;&#41; patients were classified into group 0&#44; group 1&#44; and group 2&#44; respectively&#46; Mixed Chagas-related structural involvement &#40;esophageal and colonic abnormalities&#41; was present in 39 patients &#40;36&#46;11&#37; of patients with Chagas-related structural involvement&#41;&#46; Chagas-related structural involvement was present in 81 patients without abnormalities on cardiologic tests &#40;20&#46;82&#37;&#41; and in 27 patients with abnormalities on cardiologic tests &#40;36&#37;&#41; &#40;odds ratio &#40;OR&#41; 2&#46;14&#44; 95&#37;CI 1&#46;26&#8211;3&#46;64&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;004&#41;&#46; Chagas-related structural involvement was present in 81 patients with digestive symptoms &#40;34&#46;91&#37;&#41; whereas it was present in only 27 asymptomatic patients &#40;11&#46;64&#37;&#41; &#40;OR 4&#46;07&#44; 95&#37;CI 2&#46;51&#8722;6&#46;61&#44; <span class="elsevierStyleItalic">p</span>&#8239;&#60;&#8239;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">The prevalence of infectious comorbidity was 40&#46;73&#37; &#40;189&#47;464&#44; 95&#37;CI 36&#46;25&#8211;45&#46;22&#41;&#46; The HPA test was positive in 46 patients &#40;38&#46;98&#37; of patients analyzed&#41;&#46; Of them&#44; 16 &#40;34&#46;78&#37;&#41; had digestive symptoms &#40;dyspepsia or pyrosis&#41;&#46; Information was not gathered on whether the attending clinician attributed the symptoms to <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#46; A parasitic finding of any type was reported in 155 patients &#40;39&#46;14&#37; of patients analyzed&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The description of the parasites found in the feces examination is as follows&#58; <span class="elsevierStyleItalic">Blastocystis hominis&#44;</span> 118 patients &#40;29&#46;80&#37;&#41;&#44; <span class="elsevierStyleItalic">Endolimax</span> spp 28 &#40;7&#46;07&#37;&#41;&#44; <span class="elsevierStyleItalic">Entamoeba</span> spp 25 &#40;6&#46;13&#37;&#41;&#44; <span class="elsevierStyleItalic">Dientamoeba fragilis</span> 14 &#40;3&#46;54&#37;&#41;&#44; <span class="elsevierStyleItalic">Giardia intestinalis</span> 12 &#40;3&#46;03&#37;&#41;&#44; <span class="elsevierStyleItalic">Strongyloides stercoralis</span> 8 &#40;2&#46;02&#37;&#41;&#44; <span class="elsevierStyleItalic">Iodamoeba b&#252;tschlii</span> 2 &#40;0&#46;51&#37;&#41;&#44; <span class="elsevierStyleItalic">Enterobius vermicularis</span> 2 &#40;0&#46;51&#37;&#41;&#44; and <span class="elsevierStyleItalic">Ancylostoma duodenale</span> 1 &#40;0&#46;25&#37;&#41;&#46; Twelve patients had simultaneous positive HPA and O&#38;P tests&#46; There were no differences between symptomatic &#40;43&#46;10&#37;&#41; and asymptomatic patients &#40;38&#46;36&#37;&#41; &#40;OR 1&#46;22&#59; 95&#37;CI 0&#46;84&#8722;1&#46;76&#59; <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;299&#41;&#46; Only 24 patients had clearly pathogenic parasites &#40;<span class="elsevierStyleItalic">Giardia intestinalis</span>&#44; <span class="elsevierStyleItalic">Strongyloides stercoralis&#44; Enterobius vermicularis</span>&#44; and <span class="elsevierStyleItalic">Ancylostoma duodenale</span>&#41;&#46; The prevalence of infectious comorbidity calculated by excluding parasites that were not clearly pathogenic was 14&#46;87&#37; &#40;69&#47;464&#44; 95&#37;CI 11&#46;62&#8211;18&#46;12&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Globally&#44; the prevalence of gastrointestinal abnormalities in patients with imported CD was 57&#46;76&#37; &#40;268&#47;464&#44; 95&#37;CI 53&#46;25&#8211;62&#46;27&#41;&#46; The prevalence of simultaneous structural involvement and infectious comorbidity was 6&#46;25&#37; &#40;29&#47;464&#44; 95&#37;CI 4&#46;04&#8211;8&#46;46&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">The Spanish healthcare system is complex and management and decision-making is the responsibility of the various autonomous communities&#46; There is no consensus on screening and follow-up on Chagas-related digestive involvement&#44; despite the availability of resources for diagnosis&#44; treatment&#44; and follow-up on cases&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In 2009&#44; the Spanish Ministry of Health and Social Policy published guidelines on CD&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> They concluded that routinely conducting tests aimed at identifying digestive involvement may not be indicated&#46; These guidelines were based on patient series<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which reported that just 3&#37; of patients had esophageal manometric compromise &#40;considered the most useful technique for detecting early organ failure&#41;&#46; One year later&#44; entirely different indications were published in a special article by Pinazo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The authors affirmed that &#8220;Given the existence of digestive tract alterations in up to 11&#37; of all asymptomatic patients&#44; radiological evaluation is recommended in all patients with <span class="elsevierStyleItalic">T&#46; cruzi</span> infection&#46;&#8221; Nevertheless&#44; other studies conducted by the same working group<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> indicated that radiological abnormalities were detected almost exclusively in symptomatic patients&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The recommendations of the Imported Diseases Study Group&#44; on behalf of the Spanish Society of Infectious Diseases and Clinical Microbiology &#40;GEPI-SEIMC&#44; for its initials in Spanish<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#41; concluded that radiological tests should only be indicated in the case of digestive symptoms compatible with disease for detecting megasyndromes &#40;megacolon&#44; megaesophagus&#44; etc&#46;&#41;&#46; From an international point of view&#44; the Pan American Health Organization &#40;PAHO&#41; guidelines&#44; published in 2018&#44; established recommendations on the diagnosis and treatment of patients with <span class="elsevierStyleItalic">T&#46; cruzi</span> infection&#46; They did not suggest recommendations related to investigating organ damage or detecting digestive disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The indications for the diagnosis and management of gastrointestinal CD based on recommendations for the screening and diagnosis of CD in the United States of America<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> refer to the work by Pinazo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which recommends a systematic study&#46; Other more detailed guidelines on the clinical diagnosis &#40;diagnosis and classification of the different disease stages&#41; are also needed&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The prevalence of digestive disorders in CD at the time of first care is high in this study&#46; According to classic studies&#44; up to 10&#37; of patients present with digestive involvement during the chronic phase of the disease&#44; but these data are based on series from endemic areas and usually only refer to megasyndromes&#46; Salvador et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> conducted an excellent review of the main clinical series of patients with chronic CD&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Other recent studies have found a greater incidence in digestive disorders &#40;in endemic areas up to 70&#37;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; in non-endemic areas up to 21&#37;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a>&#41;&#44; and some of them include structural involvement&#44; infectious comorbidities&#44; and&#47;or series from non-endemic areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;23</span></a> The high prevalence of CD-related digestive disorders may be the result of up-to-date radiological diagnostic techniques&#44; the introduction of systemic detection tests in clinical practice&#44; and&#47;or combined assessment criteria&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Variations in the results of different studies is probably also related to the different prevalence of Chagas disease according to geographical region&#46; This study included a large population and analyzed not only structural changes but also infectious comorbidity associated with CD&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The main gastrointestinal disorder in this study was related to infectious comorbidity&#46; These results must be analyzed with caution because some parasites found in this study are not considered pathogenic&#46; For example&#44; the pathogenicity in humans of <span class="elsevierStyleItalic">Endolimax</span> spp or <span class="elsevierStyleItalic">Blastocystis</span> spp is a controversial topic&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> However&#44; the presence of non-pathogenic parasites in feces is considered a good marker of fecal-oral contamination due to food or water &#40;potential exposure to other pathogenic parasites&#41; and patients are generally treated with antiparasitic drugs if they have symptoms&#46; The interactions between colonic bacterial communities and parasites considered nonpathogenic could alter the microbial profile and be responsible for some digestive symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In addition to this&#44; given that this study was conducted based on medical records&#44; it was not possible to distinguish species of <span class="elsevierStyleItalic">Entamoeba</span> spp &#40;<span class="elsevierStyleItalic">histolytica</span> vs&#46; other non-pathogenic species&#41; in most cases&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The prevalence of <span class="elsevierStyleItalic">Strongyloides stercoralis</span> infection in this study differed from others<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> because only results from feces were collected&#59; data from other serological tests were not described&#46; A high prevalence of <span class="elsevierStyleItalic">H&#46; pylori</span> infection has been reported in patients with CD in endemic regions &#40;up to 77&#37;&#41; and it is responsible for esophagitis&#44; chronic gastritis&#44; peptic ulcer&#44; and intestinal metaplasia&#46; Gastritis is associated with <span class="elsevierStyleItalic">H&#46; pylori</span> infection regardless of CD&#44; but differences in mononuclear and polymorphonuclear cell infiltration have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;28</span></a> Few studies have published the prevalence of <span class="elsevierStyleItalic">H&#46; pylori</span> infection in patients with CD&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> According to the results of this work&#44; the detection of <span class="elsevierStyleItalic">H&#46; pylori</span> in the systematic screening of patients with CD could be proposed&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The prevalence of Chagas-related structural involvement diagnosed through radiological procedures was also significant &#40;around one out of every five patients&#41; in this study&#46; Nevertheless&#44; as the study analyzed the results out of all tests conducted&#44; the real proportion could be lower if they had been systematically ordered &#40;including in asymptomatic patients&#41;&#46; Despite this&#44; a non-negligible percentage of abnormalities were also found in asymptomatic patients&#46; In addition&#44; it must be taken into account that manometric findings&#44; which are more sensitive for detecting Chagas abnormalities&#44; were not available in this study&#46; This finding is relevant given that imaging tests are often considered burdensome and are not without risk &#40;especially a barium enema&#41;&#46; It is common to avoid them to prevent cases of adverse events reported during the barium sulfate diagnostic procedure&#44; such as allergic reactions or bowel perforation&#46; However&#44; these complications are considered rare or very rare&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a> and thus they do not seem to be a sufficient reason for systematically refraining from conducting these tests in asymptomatic patients&#46; In this study&#44; no adverse event reports were collected&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Financial reasons are also typically used to justify not conducting radiological tests&#46; The approximate unit cost of an esophagogram and a barium enema is &#1028;55&#46;38 and &#1028;83&#46;07&#44; respectively&#44; in the Spanish National Health System&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> A cost-benefit analysis of the radiological screening for CD is needed&#46; At this point&#44; it is necessary to reflect on the potential benefit that a systematic radiological digestive assessment in all patients regardless of the presence of symptoms would have &#40;which could lead to greater knowledge of the disease&#39;s natural history as well as the detection of asymptomatic morphological abnormalities that could justify indicating trypanocidal therapy in order to halt disease progression and&#47;or symptoms development&#41; and the harm posed by the increase in costs&#44; the infrequent but possible side effects&#44; and the inevitable ethical question of whether to screen and establish a diagnosis for a disease with a small treatment arsenal&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In this study&#44; the presence of digestive symptoms or heart disease was associated with infectious comorbidity and thus&#44; they could be considered valuable clues for decision-making&#46; Some studies on CD conducted in Spain showed a prevalence of gastrointestinal involvement &#40;only structural changes&#41; of 0&#46;9&#37;&#8211;11&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;34&#44;35</span></a> The differences between these studies are linked to sample size and gastrointestinal assessment&#46; The prevalence of Chagas-related structural involvement is similar to what was described by Pinazo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; this series is retrospective and includes a greater proportion of asymptomatic patients&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitations</span><p id="par0255" class="elsevierStylePara elsevierViewall">The main limitations of this study are related to the nature of retrospective studies based on medical records&#46; The number of medical records excluded is noteworthy and not explained by the size of the pediatric population&#46; The lack of information on radiological and microbiological tests may be the main reason for excluding a large proportion of medical records&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Immigrants are a group of patients who face difficulties accessing the healthcare system and difficulties adhering to follow-up and treatment&#59; they are lost at a greater frequency in the first year of follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a> Cultural&#44; economic&#44; and social barriers impede continued follow-up on patients&#46; Therefore&#44; in this study&#44; they were likely diagnosed with CD but did not complete follow-up&#46; What&#8217;s more&#44; this situation could have worsened during the two years of the COVID-19 pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The differences in routine clinical practice and recommendations among centers made it so that the routine radiological or microbiological tests were not the same&#46; A definitive prevalence out of all patients in this study was not able to be obtained&#44; but rather a prevalence out of all patients who had the same tests&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">a&#41;</span><p id="par0270" class="elsevierStylePara elsevierViewall">In regard to radiological tests&#44; some centers where they were not routinely conducted only offered them to symptomatic patients&#46; It is reasonable to argue that structural changes in the gastrointestinal tract due to CD would produce more symptoms than no changes&#46; Therefore&#44; the hypothesis could be proposed that the prevalence of radiological changes would have been lower if all asymptomatic patients had been included in the analysis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">b&#41;</span><p id="par0275" class="elsevierStylePara elsevierViewall">The situation with microbiological tests is different&#46; Asymptomatic carriers for digestive parasites and <span class="elsevierStyleItalic">H&#46; pylori</span> have been described&#46; In this study&#44; the proportion of patients with infectious digestive comorbidity &#40;IDC&#41; may be higher &#40;mainly asymptomatic carriers of <span class="elsevierStyleItalic">H&#46; pylori</span> without HPA&#41;&#46; The latter situation represents approximately 75&#37; of these cases&#46; On the other hand&#44; it would be expected that variations in the prevalence of IDC in this study &#40;related to asymptomatic carriers of parasites&#41; would not be affected&#44; given that individuals not analyzed for parasites represented only 15&#37; of the sample&#46;</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">This study did not use a chronic cardiac CD classification system&#46; There are various classification systems for chronic CD based on the ECG&#44; chest x-ray&#44; echocardiogram&#44; and clinical symptoms&#46; They have disparities that hinder comparisons among clinical studies and management guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In addition&#44; whereas some changes on the ECG or ECHO are considered specific&#44; others may be related to cardiovascular risk factors&#46; However&#44; the association between these abnormal findings and Chagas-related digestive involvement may support the decision to order the pertinent digestive radiological studies in asymptomatic patients&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0285" class="elsevierStylePara elsevierViewall">The prevalence of CD-associated digestive disorders is high&#46; Therefore&#44; it is recommendable to rule out the presence of infectious diseases &#40;mainly parasitic diseases and <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#41;&#46; It would be desirable to rule out structural involvement in all symptomatic patients and it should be considered and offered to asymptomatic patients as well&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethics approval declaration</span><p id="par0290" class="elsevierStylePara elsevierViewall">This study was conducted pursuant to the Declaration of Helsinki on research in human subjects&#46; This research was approved by the G&#243;mez Ulla Hospital research committee &#40;DREC-HCDGU&#44; PADChI Study&#44; Code 65&#47;19&#41;&#46; The G&#243;mez Ulla Hospital research committee granted an exemption to obtaining informed consent&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0295" class="elsevierStylePara elsevierViewall">This research has not received specific funding from agencies in the public&#44; commercial&#44; or non-profit sectors&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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            1 => "<span class="elsevierStyleItalic">Trypanosoma cruzi</span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chagas disease &#40;CD&#41; is a parasitic disease caused by <span class="elsevierStyleItalic">Trypanosoma cruzi&#44;</span> in which up to 10&#8211;20&#37; of those affected may suffer digestive disorders&#46; Multiple studies have been carried out on CD in non-endemic countries&#44; mainly related to cardiological involvement&#46; However&#44; digestive disorders have not been analyzed in such depth&#46; The objective of the study was to determine the prevalence of digestive disorders in imported CD at the time of first care&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">An observational cross-sectional descriptive analysis of imported CD was performed&#46; Chagasic structural damage and infectious digestive comorbidity were evaluated&#46; The association between Chagasic structural damage and heart disease in Chagas patients was also investigated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">After reviewing a total of 1&#44;216 medical records&#44; those of 464 patients were selected for analysis&#46; Globally&#44; the prevalence of digestive disorders in imported Chagas was 57&#46;76&#37;&#44; 95&#37; CI &#40;53&#46;25&#8211;62&#46;27&#41;&#46; The prevalence of comorbidity of infectious diseases was 40&#46;73&#37; CI 95&#37; &#40;36&#46;25&#8211;45&#46;22&#41;&#46; Colonic abnormalities were found in 84 of 378 barium enema patients&#46; CD-related esophageal abnormalities were present in 63 of 380 patients studied with esophagogram&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The prevalence of digestive disorders associated with CD is high&#44; so the presence of infectious diseases &#40;mainly parasitic and <span class="elsevierStyleItalic">H&#46; pylori</span> infection&#41; should be ruled out&#46; It is important to exclude structural involvement in all symptomatic patients&#44; and asymptomatic patients should also be considered and offered&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
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            "titulo" => "Methods"
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          2 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Chagas &#40;EC&#41; es una enfermedad parasitaria causada por <span class="elsevierStyleItalic">Trypanosoma cruzi&#44;</span> en la que hasta un 10&#8211;20&#37; de los afectados pueden sufrir trastornos digestivos&#46; Se han realizado m&#250;ltiples estudios sobre la EC en pa&#237;ses no end&#233;micos&#44; principalmente relacionados con el compromiso cardiol&#243;gico&#46; Sin embargo&#44; los trastornos digestivos no se han analizado con tanta profundidad&#46; El objetivo del estudio fue determinar la prevalencia de los trastornos digestivos en la EC importada en el momento de la primera atenci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis descriptivo transversal observacional de la EC importada&#46; Se evalu&#243; el da&#241;o estructural chag&#225;sico y la comorbilidad digestiva infecciosa&#46; Tambi&#233;n se investig&#243; la asociaci&#243;n entre el da&#241;o estructural chag&#225;sico y la enfermedad card&#237;aca en pacientes con Chagas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Tras la revisi&#243;n de un total de 1&#46;216 historias cl&#237;nicas&#44; se seleccionaron para el an&#225;lisis las de 464 pacientes&#46; A nivel global&#44; la prevalencia de trastornos digestivos en Chagas importado fue del 57&#44;76&#37; IC95&#37; &#40;53&#44;25&#8211;62&#44;27&#41;&#46; La prevalencia de comorbilidad de enfermedades infecciosas fue de 40&#44;73&#37; IC95&#37; &#40;36&#44;25&#8211;45&#44;22&#41;&#46; Se encontraron anomal&#237;as col&#243;nicas en 84 de 378 pacientes con enema de bario&#46; Las anomal&#237;as esof&#225;gicas relacionadas con la EC estuvieron presentes en 63 de 380 pacientes estudiados con esofagograma&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de trastornos digestivos asociados a EC es alta&#44; por lo que conviene descartar la presencia de enfermedades infecciosas &#40;principalmente parasitarias e infecci&#243;n por <span class="elsevierStyleItalic">H&#46; pylori</span>&#41;&#46; Es importante excluir afectaci&#243;n estructural en todos los pacientes sintom&#225;ticos&#44; y tambi&#233;n se deber&#237;a considerar y ofrecer a pacientes asintom&#225;ticos&#46;</p></span>"
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                  \t\t\t\t">Esophageal disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Group 0&#58; no abnormalities in the barium enema&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Group 1&#58; patients with dolichocolon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Group 2&#58; patients with dolicomegacolon&#44; defined as&#58;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">a&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Descending colon &#62;6&#46;5&#8239;cm in diameter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">b&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Ascending colon &#62;8&#8239;cm in diameter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">c&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with a cecum &#62;12&#8239;cm in diameter&#46;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Rezende<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and Ximenes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> classification for the interpretation of the esophagogastroduodenal study and barium enema&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">323&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&#46;61&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Age groups &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>18&#8722;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>35&#8722;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>45&#8722;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">193&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>55&#8722;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Country of birth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Argentina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bolivia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">426&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ecuador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Honduras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Paraguay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of first-degree family members with Chagas disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">247&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prior treatment for Chagas disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unknown&#47;not reported&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">152&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Digestive abnormalities &#40;non-Chagas&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37;CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sociodemographic characteristics</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;67&#8722;1&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;761&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Age&#59; reference age group&#58; 18&#8722;34 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>35&#8722;44 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;15&#8722;4&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;774&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>45&#8722;54 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;29&#8722;6&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;695&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>55&#8722;64 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34&#8722;7&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;542&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;42&#8722;11&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;356&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of family members affected &#40;for each member&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&#8722;1&#46;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;379&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prior treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;1&#46;20&#8722;1&#46;37&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;898&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;101&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Presence of any cardiovascular risk factor&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Control and management of congenital Chagas disease in Europe and other non-endemic countries&#58; current policies and practices"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2023.02.008

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