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- Arq Bras Cardiol
- v.102(4); 2014 Apr
- PMC4028943
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Arq Bras Cardiol. 2014 Apr; 102(4): 383–390.
PMCID: PMC4028943
PMID: 24652056
Mariana A. Coutinho-Myrrha,1 Rosângela C. Dias,1,2 Aline A. Fernandes,1 Christiano G. Araújo,3 Mark A. Hlatky,4 Danielle G. Pereira,1,2 and Raquel R. Britto1,2
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Abstract
Background
The Duke Activity Status Index (DASI) assesses the functional capacity ofpatients with cardiovascular disease (CVD), but there is no Portugueseversion validated for CVD.
Objectives
To translate and adapt cross-culturally the DASI for the Portuguese-Brazillanguage, and to verify its psychometric properties in the assessment offunctional capacity of patients with CVD.
Methods
The DASI was translated into Portuguese, then checked by back-translationinto English and evaluated by an expert committee. The pre-test version wasfirst evaluated in 30 subjects. The psychometric properties and correlationwith exercise testing was performed in a second group of 67 subjects. Anexploratory factor analyses was performed in all 97 subjects to verify theconstruct validity of the DASI.
Results
The intraclass correlation coefficient for test-retest reliability was 0.87and for the inter-rater reliability was 0.84. Cronbach's α for internalconsistency was 0.93. The concurrent validity was verified by significantpositive correlations of DASI scores with the VO2max (r = 0.51, p< 0.001). The factor analysis yielded two factors, which explained 54% ofthe total variance, with factor 1 accounting for 40% of the variance.Application of the DASI required between one and three and a half minutesper patient.
Conclusions
The Brazilian version of the DASI appears to be a valid, reliable, fast andeasy to administer tool to assess functional capacity among patients withCVD.
Keywords: Cardiovascular diseases, Work capacity evaluation, Practice guidelines, Exercise test, Questionnaires, Validation studies
Introduction
Cardiovascular diseases (CVD) lead to physical disabilities and reduce patients'quality of life by their direct impact on functional capacity and performance.Assessment of functional capacity is important to investigate the impact of thedisease on a patient's life, to determine the degree of constraint imposed by CVD,as well as by being a factor in diagnosis, prognosis and a strong predictor ofmortality1.
The maximal exercise testing is the only accurate method to determine the aerobiccapacity1. However, it isnot always usable either due to patient physical condition or when it may expose agiven patient to higher-than-normal risk. Questionnaires are an inexpensive, simpleand safe tool to assess the functional or clinical status1,2 that mightbe used before the exercise test to determine a patient's ability to performappropriate effort3.
The Duke Activity Status Index (DASI) is a questionnaire, originally developed inEnglish4, to assess thefunctional capacity. DASI has been used mainly to evaluate patients withcardiovascular diseases, such as coronary artery disease, heart failure, myocardialischemia and infarction5,6. In clinical practice, DASI can beused to assess the effects of medical treatments and cardiacrehabilitation7 and toassist clinical decisions3,8. In controlled clinical trials,DASI can serve to evaluate interventions and as a component of the assessment of thetreatment cost/benefit8.
Considering that DASI is characterized as a good functional capacity questionnaire,the evidence of validity, the usefulness and large clinical and scientificapplicability, it appears to be a useful tool to evaluate cardiac patients1-3. So, to be used with Brazilian CVD patients it is necessary tovalidate DASI and verify its psychometric properties in this population9,10.
The aim of this study was to translate, culturally adapt and validate the DASI toBrazilian Portuguese and verify its psychometric properties in the assessment offunctional capacity of individuals with CVD.
Methods
Participants
The participants were of both sexes, diagnosed with CVD, older than 22 years old,with body mass index between 18.6 and 39.9 kg/m2, from Brazilian nationality and who had livedmost of their life in Brazil. The inclusion criteria were: diagnosis ofcardiovascular disease such as coronary artery disease, valvular heart disease,arrhythmia with at least one symptom11 such as chest pain, palpitations, fatigue, or dyspneaand physician referral to exercise testing. The excluded criteria were:cognitive deficit screened by Mini Mental State Examination according to thecutoff points recommended by Bertolucci et al12, emergency care or hospitalization two monthsbefore as well as acute illness, fever or severe physical limitation that wouldprevent from doing the exercise test13.
Data was collected between February and August 2012 and patients were recruitedat Stress Testing Laboratory of the University Hospital's Cardiology Service.The research was carried out according to the Declaration of Helsinki and wasapproved by the Ethics Committee of the institution. All subjects were informedabout the research objectives and signed a consent form.
Duke Activity Status Index (DASI)
The DASI was developed aiming at correcting failures presented by otherinstruments such as the New York Heart Association Scale (NYHA) and the CanadianCardiovascular Society (SCCS). It is a 12-item questionnaire that assesses dailyactivities such as personal care, ambulation, household tasks, sexual functionand recreation with respective metabolic costs. Each item has a specific weightbased on the metabolic cost (MET). The participants were asked to identify eachactivity they are able to do. The final score ranges between zero and 58.2points. The higher the score, the better the functional capacity4.
Translation and Cultural Adaptation
The process of translation and cultural adaptation followed the steps proposed byBeaton et al9. The originalversion (Table 1) was independentlytranslated into Brazilian Portuguese by two bilingual translators, qualified,whose mother tongue was Portuguese, generating versions T1 and T2. The firsttranslator had no knowledge about medical area and was not informed about thegoals and concepts studied. The second translator was a physiotherapist, PhD inRehabilitation Sciences, with knowledge about the concepts assessed. Thetranslators were instructed to make a report about doubts and difficulties.
Table 1
Original version of Duke Activity Status Index5
| Duke Activity Status IndexMark A. Hlatky et al5 | |
|---|---|
| Can you | Weight |
| 1. Take care of yourself, that is, eating, dressing, bathing orusing the toilet? | 2.75 |
| 2. Walk indoors, such as around your house? | 1.75 |
| 3. Walk a block or two on level ground? | 2.75 |
| 4. Climb a flight of stairs or walk up a hill? | 5.50 |
| 5. Run a short distance? | 8.00 |
| 6. Do light work around the house like dusting or washingdishes? | 2.70 |
| 7. Do moderate work around the house like vacuuming, sweepingfloors, or carrying in groceries? | 3.50 |
| 8. Do heavy work around the house like scrubbing floors orlifting or moving heavy furniture? | 8.00 |
| 9. Do yardwork like raking leaves, weeding, or pushing a powermower? | 4.50 |
| 10. Have sexual relations? | 5.25 |
| 11. Participate in moderate recreational activities like golf,bowling, dancing, doubles tennis, or throwing a baseball orfootball? | 6.00 |
| 12. Participate in strenuous sports like swimming, singlestennis, football, basketball, or skiing? | 7.50 |
| Total Score: | |
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DASI scoring: Positive responses are summed to get atotal score, which ranges from 0 to 58.2. Higher scores indicatehigher functional capacity.
A third bilingual translator, whose mother tongue is Portuguese, synthesized thetranslations T1 and T2, comparing them with the original version. Thus, it wasgenerated the consensus version (T-1.2). From this version, the back translationwas done into English by two other independent translators with no knowledgeabout the original version. These translators were English native speakers,lived in Brazil, did not belong to the medical area and were not informed aboutthe concepts assessed in the questionnaire.
Psychometric Validation
The translations were reviewed by an expert committee formed by amultidisciplinary team including the researchers, the translators, the fivetranslators and an healthcare professional an expert in research methodology andwho understands the concepts and goals of DASI. From all versions, based on thesociocultural context of Brazil, the committee assessed the clarity, relevance,coherence and significance of the items. All items of the consensus version wereevaluated and compared to the original version in order to achieve the semantic,idiomatic, conceptual and content equivalence.
The pre-test version was approved by all committee members, with items consideredclear and easy to understand even to a 12- year old person9. This version was submitted tosubjects with CVD to evaluate possible deviations and errors committed duringtranslation checking whether all items were clearly and unequivocallyunderstood. Participants were questioned about the clarity of the items and ifthey knew all the activities contained in the questionnaire.
The DASI was submited as an interview considering the lower education level ofthe population. However, the researchers maintained a neutral stance during thesubmission. Two trained raters, blinded as to the application of anotherevaluator, were given the questionnaire with an interval of one hour to assessinterrater reliability. The same examiner reapplied the questionnaire personallyor by phone with an interval between seven to ten days to assess the test-retestreliability. The time required for the questionnaire application wasrecorded.
Exercise Test Protocol
The exercise test protocol was the routinely used in the laboratory wherepatients were recruited. A cardiologist performed the tests and all equipmentsrequired to life support were available. The subjects were instructed tomaintain their usual medication, resting two hours before the test and avoidcaffeine, smoking and exercise on the test day. The exercise testing wasperformed according to the Bruce protocol13, using a treadmill (Micromed®,Brazil) following the recommendations of the Brazilian CardiacSociety14. A minimalhandrail support was allowed. During the test, including rest and recoveryperiods, heart rate (HR) and 12-lead electrocardiographic were continuouslymonitored by electrocardiograph (Micromed®, Brazil)in connection with the software (PC Ergo Elite 13) as well asblood pressure every three minutes. The test was finished upon subject request,on report of symptoms such as leg pain, tachycardia, angina or any otherdiscomfort and according to the absolute criteria for interruption14.
Unfortunately we did not have an oxygen consumption analyzer available, theoxygen uptake (VO2) was estimated using a software according to thefollowing formulas15:
VO2 (ml/kg.min)=(time-minutes from exercise test x2.33)+9.48 for men
VO2 (ml/kg.min)=(time-minutes from exercise test x 3.36)+1.06 forwomen
In order to avoid confounding factors, the physician conducting the exercise testwas blinded regarding the outcome of the DASI questionnaire.
Statistical Analysis
The SPSS version 15.0 was used to store and analyse data. The normal distributionof data was verified using the Kolmogorov-Smirnov test. Variables with normaldistribution were expressed as mean, standard deviation and confidence intervalof 95%. Variables with non-normal distribution were expressed as median andinterquartile range of 25-75%. A significance level of 5% was adopted for allstatistical tests.
The group that submitted the pre-test was compared with the group that performedthe exercise test by independent t-test. To assess the test-retest andinterrater reliabilities it was used the intraclass correlation coefficient(ICC) calculated for the total score of the questionnaire. Internal consistencywas assessed using α-Cronbach's coefficient. The assessment of concurrentcriterion validity was performed using the Spearman correlation between thefinal score of the DASI and maximal VO2 achieved in exercisetest.
Factor analysis was used to assess the construct validity16. We performed principalcomponents analysis with varimax rotation with Kaiser normalization. Theadequacy of the correlation matrix was verified by the Kaiser-Meyer-Olkin (KMO)criteria, which should be greater than 0.60 and Bartlett's test considering asignificance level of 0.05. As a criterion for extracting the number of factors,eigenvalues greater than or equal to one were considered relevant factors.Following rotation matrix, items with a factor loading greater than or equal to0.4 were added to the factor. The time required for the application of DASI wasexpressed as median, in minutes.
Results
Participants
Following Beaton et al9recommendations, 30 individuals participated in the pre-test. The test-retestand interrater reliabilities and internal consistency were observed in other 67subjects. The characteristics of these participants are presented in Table 2. The concurrent criterion validitywas performed in 62 subjects, since five were excluded due to non completion ofexercise test. The verification of construct validity was conducted with thetotal sample of 97 individuals. There was no statistically difference betweenindividuals who participated in the pre-test and those who participated in theevaluation of psychometric properties (p > 0.05). The sample consistedpredominantly of males and coronary artery disease patients. The majority of thesubjects had cardiovascular risk factors such as hypertension,hypercholesterolemia and smoking addiction.
Table 2
Demographic, clinical and functional capacity
| Variable | n = 67 |
|---|---|
| Male/Female | 41/26 (61.2% / 38.8%) |
| Age (years) | 56.88 ± 11.93 (53.97-59.79) |
| Weight (Kg) | 72.63 ± 15.61 (68.37-75.84) |
| Height (m) | 1.63 ± 0.09 (1.60-1.65) |
| Body Mass Index (Kg/m2) | 27.28 ± 4.76 (26.12-28.44) |
| Type of Cardiovascular Disease | |
| Coronary arterial disease | 27 (40.31%) |
| Acute myocardial infarction | 21 (31.34%) |
| Ischemic Cardiomiopathy | 8 (11.94%) |
| Valvulopathy | 9 (13.43%) |
| Arrhythmia | 2 (2.98%) |
| Risk Factors | |
| Hypertension | 53 (79.1%) |
| Diabetes | 11 (16.4%) |
| Hypercholesterolemia | 42 (62.7%) |
| Obesity | 17 (25.4%) |
| Smoker | 14 (20.9%) |
| Ex-smoker | 23 (34.3%) |
| Schooling | |
| Illiterate | 9 (13.4%) |
| 1 to 7 years | 34 (50.7%) |
| 8 years or more | 19 (28.4%) |
| College | 5 (7.5%) |
| Functional Capacity | |
| DASIa | 42.7 ± 1.95 (28.45-52.95) |
| VO2max(ml.kg-1.min-1)b | 26.17 ± 9.07 (23.85-28.46) |
| METmaxb | 7.47 ± 2.60 (6.81-8.13) |
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Data expressed as frequency (%), mean ± standard deviation(confidence interval 95%) or median ± standard error (interquartilerange of 25-75%);
adata expressed as median;
bn = 62; MET: maximal metabolic equivalent at exercise test;VO2max: maximal oxygen uptake at exercise test.
Translation and Cultural Adaptation
From the analysis and suggestions of the expert committee, aiming at gettinggreater equivalence of the translated version with the original, a betteradaptation of the questionnaire to Brazilian culture and a greater understandingof the items, changes were made in version T-1.2. In the item 7, the term"use vacuum cleaner" (usar o aspirador de pó) was replacedby "vacuuming" (passar o aspirador de pó), considered moreappropriate and used by the Brazilian population. In item 8, the term"scrubbing floor" (esfregar o chão) could be understood tomop the floor using a broom or other object in a standing position. To clarifythis activity, which should be held in the kneel down position to match thedesired metabolic expenditure (8 METS), was chosen the term "scrubbingthe floor with your hands using a brush" (esfregar o chão com asmãos usando uma escova). The term "moving heavy furniture"(deslocar móveis pesados) was also considered not clear. Thus, it was added"move heavy furniture of the place" (deslocar móveispesados do lugar). It was included the term "electric" to item9 to specify the equipment correctly and match the metabolic expenditure (4.5METS). Items 11 and 12 referred activities that are not usual in Brazil. Theseactivities have been replaced by volleyball, riding a bicycle, doing wateraerobics, soccer and running, which have equivalent metabolicexpenditure17.
All participants of the pre-test said that the questionnaire was easy to answer;the items were clear, they had no doubts during application and knew all theactivities listed. However, from that application, it was found that the term"walk" (caminhar) in items 2 and 3 was confused with habitual physical activityknown as "walk" (caminhada) to Brazilians. So, we decided to replace the word"walk" by "walking" (andar). This version was considered culturally adapted toBrazil, showing equivalence with the original version and was used for testingthe psychometric properties (Table3).
Table 3
Final Version Duke Activity Status Index Brazilian version
| Duke Activity Status Index VersãoBrasileira Coutinho-Myrrha MA et al | |||
|---|---|---|---|
| Você consegue | Peso (MET) | Sim | Não |
| 1. Cuidar de si mesmo, isto é, comer, vestir-se, tomar banho ouir ao banheiro? | 2,75 | ||
| 2. Andar em ambientes fechados, como em sua casa? | 1,75 | ||
| 3. Andar um quarteirão ou dois em terreno plano? | 2,75 | ||
| 4. Subir um lance de escadas ou subir um morro? | 5,50 | ||
| 5. Correr uma distância curta? | 8,00 | ||
| 6. Fazer tarefas domésticas leves como tirar pó ou lavar alouça? | 2,70 | ||
| 7. Fazer tarefas domésticas moderadas como passar o aspirador depó, varrer o chão ou carregar as compras de supermercado? | 3,50 | ||
| 8. Fazer tarefas domésticas pesadas como esfregar o chão com asmãos usando uma escova ou deslocar móveis pesados do lugar? | 8,00 | ||
| 9. Fazer trabalhos de jardinagem como recolher folhas, capinarou usar um cortador elétrico de grama? | 4,50 | ||
| 10. Ter relações sexuais? | 5,25 | ||
| 11. Participar de atividades recreativas moderadas como vôlei,boliche, dança, tênis em dupla, andar de bicicleta ou fazerhidroginástica? | 6,00 | ||
| 12. Participar de esportes extenuantes como natação, tênisindividual, futebol, basquetebol ou corrida? | 7,50 | ||
| Pontuação total: | |||
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Pontuação DASI: o peso das respostas positivas sãosomados para se obter uma pontuação total que varia de 0 a 58.2.Quanto maior a pontuação, maior a capacidade funcional.
Psychometric Validation
The ICC found for the test-retest reliability was 0.87 and 0.84 for interrater.We found a Cronbach's α of 0.93 for internal consistency. In the analysis ofconcurrent criterion validity, there were significant and positive correlationbetween VO2max and DASI score (r = 0.51, p < 0.001) as shown inFigure 1.
Figure 1
Correlation between DASI score and maximal functional capacity. DASI:Duke Activity Status Index; METmax: Maximal metabolic equivalent;VO2max: Maximal oxygen uptake.
The exploratory factor analysis to assess construct validity was conductedexcluding items 1 and 2 of the questionnaire, since all subjects in the sampleresponded that they were able to carry out the proposed activities. Therefore,there was no variance of these items. The significance value obtained by KMO(0.85) and Bartlett's test (p < 0.0001) were adequate to the use of factoranalysis for the data treatment. We extracted two factors. These factorsaccounted for 53.81% of total variance, with factor 1 accounting for 39.99% ofthe variance. The first factor was composed of items 5,8,9,11,12 and reflectsactivities with higher metabolic demand. The second factor was composed of items3,4,6,7,10 and reflects activities with a lower metabolic cost.
The questionnaire application varied between one and three and a half minutes,with a median of 1.57 ± 0.56 (1.37 to 2.05) minutes.
Discussion
This study translated the DASI questionnaire, adapted it culturally, and verified itspsychometric properties. The questionnaire had high internal consistency, goodtest-retest and interrater reliabilities, excellent concurrent criterion validityand it also was quick and easy to use in the target population.
It is important to emphasize the importance of multidisciplinary experts committee inthe process of translation and cultural adaptation. After evaluation of people fromdifferent areas, it was possible to make items clearer and more equivalent to theoriginal version. Moreover, the pre-test indicated a possible misinterpretation ofitems 2 and 3 that were corrected in the final version. The methodology provided thetranslation quality and safety. So, following the steps proposed for the translationand cultural adaptation studies it is essential for the final version to beequivalent to the original. The results of this study showed that the DASI, adaptedto Brazil, showed semantic, idiomatic and conceptual equivalence with the originalversion.
There were no statistically significant differences between the pre-test sample andthe sample in which the psychometric properties were verified. These samples shouldbe similar and composed by the target population, thus, ensuring that the translatedversion is suitable for this population.
It is important to verify the psychometric properties because the simple translationdoes not ensure the maintenance of such proprieties9. This evaluation demonstrated that DASI presents anadequate reliability and validity for assessing the functional capacity ofindividuals with CVD. The high value of CCI found for the test-retest reliabilitiesand interrater demonstrates the consistency of the measure. The questionnaire provedto be hom*ogeneous, measuring the same construct, with adequate internal consistency(α-Cronbach's values > 0.90). Moderate correlations were found between thequestionnaire score and variables obtained at maximal exercise test. This is afavorable outcome and expected because the DASI assesses the functional capacityperceived by the individual, being a subjective measure, while exercise testevaluates objectively the maximum capacity. So the concurrent criterion validity wassuitable. Moreover, other authors found a similar correlation between scores on theDASI and VO2peak in cardiac subjects (r = 0.6218 and r = 0.6419, p < 0.001).
Among other questionnaires that also evaluate functional capacity, such as theVeterans Specific Activity Questionnaire (VSAQ)20, the Specific Activity Questionnaire (SAQ)18 and the Specific Activity Scale ofGoldman (SAS)21, the DASI showedbetter correlation with VO2 obtained by using the exercise test18. The correlation between DASI andVO2peak showed good to excellent correlation when applied as aninterview (r = 0.81, p < 0.001) and moderate when self-administered (r = 0.58, p< 0.001), being better than the correlation between peak VO2 and SCCS(r = 0.49, p < 0.01) and SAS (r = 0.30, p < 0.01) in subjects withDCV4. The MET assessed byDASI before the exercise test, showed direct correlation with functional capacityassessed by Bruce protocol3,5. These studies emphasize theusefulness to choose the best exercise protocol3. The lower the DASI score before performing the exercisetest, the greater the possibility of being unable to perform some test protocol.
The exploratory factor analysis results indicated the presence of two factors and theitems were separated according to the metabolic cost (MET). Item 9 regardinggardening works, despite the correspondence to a low metabolic cost (4 METS), wasrelated to items corresponding to high MET (Factor 1). Gardening activities are notvery usual among Brazilians residing in an urban environment. So it may have been anoverestimation by the participants on the level of difficulty of this activity.During the evaluation of the expert committee it was discussed the possibility ofreplacing this item by another activity. However, we opted to maintain this item dueto the population residing in rural areas in Brazil (15.64%)22 and the assumption that thoseresiding in urban areas have access to such activities.
In previous studies, the DASI demonstrated to be a useful tool in clinical practiceand in research, being possible to discern different disease severity, assesseffects of medical treatment23,cardiac rehabilitation and provide relevant information to clinicaldecisions7,8. Despite the great clinical and scientific utility,the DASI may not be suitable to differentiate individuals with high functionalcapacity, due to a ceiling effect found in this and other studies24. This effect exists when more than15% of the sample reaches the total score10. In this study, 17.52% of the total sample (n = 97)obtained the total score. It was also observed, as the original study, that patientswith low capacity reported the maximal DASI score (see Figure 1, less than 20 ml.kg-1.min-1).So, future studies have to be done to investigate the relationship between reducedphysical capacity and patient perception.
Recent studies have applied this questionnaire in other populations, such as thosewith chronic obstructive pulmonary disease (COPD)25 and kidney disease26. Tavares et al27, in a parallel conducted study performed the culturaladaptation and evaluation of the reproducibility of the DASI to Brazil in a sampleof individuals with COPD. The authors found an ICC of 0.95 intraobserver andinterobserver agreement of 0.90 and a better correlation with the activity domain ofthe Saint George's Respiratory Questionnaire (SGRQ) (p < 0.001, r = -0.70).
It is recommended that health professionals assess and develop treatment plansaccording to the model proposed by the International Classification of Functioning,Disability and Health (ICF). It is important to focus on the implications of ahealth condition on an individual's life, adopting instruments based on a model thatnot only informs about conditions, but also on its impact on the peoples'lives28. The DASI providesthis information, specifying which activities are limited by disease and the impacton patient's life. In this study DASI presented appropriated characteristics to beconsidered a good tool in rehabilitation area29.
This study has several limitations. First, we did not use an individualized ramptreadmill protocol or directly measured the oxygen uptake. Second, although thequestionnaire was applied as an interview, the lower educational level of thesubjects could have increased the interpretation difficulties inherent to this kindof tool. Probably these limitations might have contributed to the smallercorrelation (0.51) with maximal capacity compared to the original study4 (0.81). Finally, we have toconsider that some questions are related to unspecific activities that could havevariations in terms of MET (for example the item 10 - "have sexual relations?").Future studies are necessary to clarify these points.
Conclusions
The present Portuguese version of DASI is adapted for Brazilian culture and appearsto be a valid, reliable, quick and easy instrument to assess the functional abilityof individuals with CVD.
This DASI Brazilian version can be used in clinical practice and also in researcharea to compare Brazilian studies with those from other countries using the sametool.
Acknowledgements
Research partially funded by Conselho Nacional de Desenvolvimento Científico eTecnológico (CNPq), Process 302913/2008-4 and 307597/2001-3 and Fundação de Amparo àPesquisa do Estado de Minas Gerais (FAPEMIG) Process PPM00478-11. Mariana A. C.Myrrha received master scholarship from Coordenação de Aperfeiçoamento de Pessoal deNível Superior (CAPES)
Footnotes
Author contributions
Conception and design of the research: Coutinho-Myrrha MA, Dias RC, Britto RR;Acquisition of data: Coutinho-Myrrha MA, Fernandes AA, Araújo CG; Analysis andinterpretation of the data and Writing of the manuscript: Coutinho-Myrrha MA,Dias RC, Fernandes AA, Pereira DG, Britto RR; Statistical analysis:Coutinho-Myrrha MA, Pereira DG, Britto RR; Obtaining funding: Britto RR;Critical revision of the manuscript for intellectual content: Dias RC, AraújoCG, Hlatky MA, Pereira DG.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
This study was funded by CNPq, FAPEMIG e CAPES.
Study Association
This article is part of the thesis of Doctoral submitted by Mariana A.Coutinho-Myrrha from Universidade Federal de Minas Gerais.
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